Acute Renal Failure Due to Acute Tubular Necrosis Caused by Direct Invasion of Orientia tsutsugamushi

Abstract

We describe a scrub typhus patient with acute renal failure for whom a diagnosis was made based on serology as well as immunohistochemical (IHC) staining and an electron microscopic examination (EM) of a renal biopsy specimen. For our case, we demonstrated by IHC staining and EM that renal failure was caused by acute tubular necrosis due to a direct invasion of Orientia tsutsugamushi. CASE REPORTA healthy-looking, 33-year-old male patient received a drug treatment for a 2-week history of cough and sputum. One day before admission to our hospital, he complained of abdominal pain and nausea after he played football. He was suspected of having renal failure on examination at a local clinic and was transferred to Chosun University Hospital in Gwang-ju, South Korea. At the time of admission, his vital signs were a blood pressure of 120 over 80 mm Hg, a pulse rate of 72 times/min, a respiratory rate of 20 breaths/min, and a body temperature of 37.2°C. A urinalysis showed no gross hematuria, with a urine output of 50 ml/h. His mental status was alert. There was no skin rash or lymphadenopathy. The patient's complete blood count showed a white blood cell count of 11,630/mm 3 , a hemoglobin count of 14.5 g/dl, and a platelet count of 243,000/ mm 3 . An arterial blood gas analysis showed a pH of 7. , 120 meq/liter; blood urea nitrogen, 39.3 mg/dl; and creatinine, 5.0 mg/dl. The biochemistry results showed a total protein level of 6.73 g/dl, albumin at 3.78 g/dl, aspartate transaminase at 30 IU/liter, alanine aminotransferase at 18 IU/liter, creatine phosphokinase at 446 U/liter, lactate dehydrogenase at 565 U/liter, myoglobin at 168.4 ng/ml, fibrin degradation products at 1 mg/ml (range, 0 to ϳ5.0 mg/ml), and a D-dimer concentration of 143.6 ng/ml (range, 0 to ϳ255 ng/ml). On urinalysis, hematuria (score, ϩ3) and proteinuria (score, ϩ4) were shown to be present. A microscopic urinalysis revealed 10 to 19 red blood cells/high-power field (HPF), 2% dysmorphic red blood cells/HPF, 1 to 4 white blood cells/HPF, and no cast/HPF. A urinalysis using urine collected during 24 h detected selective proteinuria (albumin, 895 mg/day). Serologic tests were all negative for rheumatoid factor, antinuclear antibody, antineutrophil cytoplasmic antibody, and cold agglutinin, human immunodeficiency virus, hepatitis B virus, and hepatitis C virus antibodies, and the VDRL test was negative. Antistreptolysin O and complement levels were all normal.A self-employed person, our patient presented with no typical symptoms of scrub typhus, including rash, fever, and headache.

Association of High Orientia tsutsugamushi DNA Loads with Disease of Greater Severity in Adults with Scrub Typhus

“…Renal impairment together with rare cases of renal failure is also recognized to occur during scrub typhus (27), and an elevated creatinine level has been reported to be an independent predictor of mortality (22). Histopathological examination of liver and kidney tissues from individuals with organ impairment during scrub typhus has demonstrated cellular damage that appears to be directly related to cellular invasion by O. tsutsugamushi (11).…”

Scrub Typhus in Northeastern Thailand: Eschar Distribution, Abnormal Electrocardiographic Findings, and Predictors of Fatal Outcome

“…AKI is a consequence of multiple factors like hypotension, direct renal invasion by O. tsutsugamushi, vasculitis, or rhabdomyolysis. 8,9,47,48 Half of patients with AKI were related to hypotension. AKI was a statistically significant predictor of mortality in our study and the study from India.…”

“…1 Presence of an eschar is a useful sign for diagnosing scrub typhus infection. Complications usually develop after the second week of illness, particularly in untreated cases, with systemic involvement 3 and disseminated vasculitis, 4 including septic shock, 5 acute respiratory distress syndrome (ARDS), 6,7 pneumonitis, 7 acute renal failure (ARF), 8,9 meningitis or meningoencephalitis, 10 myocarditis, 11 disseminated intravascular coagulation (DIC), 12 upper gastrointestinal bleeding, 13 and multiorgan dysfunctions (MODS). 1,4 Myocarditis is a rare complication, few reports showed abnormal electrocardiographic (ECG) findings in scrub typhus patients.…”

Clinical presentation of scrub typhus during a major outbreak in central Nepal

“…In this study, 35.8% of the patients developed AKI, which is consistent with findings in other studies where its incidence has been reported ranging from 10 to 60%. [32][33][34][35][36] Most of the patients had stage 1 and 2 AKI comprising of 66% and 33% respectively and only 1% of patients had stage 3 AKI.…”