2019 Research Forum

David Aguirre MD, Afshar Houtan MD R1, Prabina Shrestha MS IV An Atypical Presentation Of Severe Non-Traumatic Rhabdomyolysis Resulting In Multi-Organ Dysfunction Purpose To bring awareness about the different presentation of acute kidney injury with a significant increase in creatinine from baseline of 1.09 to 11.40 with acute tubular necrosis and non- traumatic rhabdomyolysis.

A 37 year old Hispanic female with no significant past medical history presenting with acute kidney injury (AKI), pancreatitis, and bilateral multi-lobar pulmonary infiltrates of unknown etiology. Introduction Hospital Course Patient is a 37 year female with no significant past medical history who presented to the emergency department complaining of a four day history of constant epigastric pain, 10/10 in severity, associated with nausea, headache, non-bloody vomiting, productive cough with yellow sputum, and chest pain on inspiration. Notable labs were lipase: 8120, AST/ALT: 3079/789, BUN 85, and creatinine 11.40. The urinalysis was notable for RBC>50 and protein 300mg/dl. Chest x- ray was notable for bilateral multi-lobar patchy infiltrates. The patient was hemodynamically stable, not requiring oxygen despite the diffuse bilateral pulmonary infiltrates, and her pain was controlled with medication. A diagnostic bronchoscopy was performed on the patient. However, it was negative for malignancy or infection. Nephrology recommended dialysis. Both specialties agreed with an autoimmune etiology and wanted to start high dose steroids. Autoimmune panel, viral panel, and toxin panel were ordered. ANA, double stranded DNA, Smith Ab, Sjogren Ab, P-ANCA, C-ANCA, cardiolipin, and beta2glycoprotein were negative. Parvo B19 and anti- streptolysin was negative. IGG subclass 4 was negative. Salicylate, acetaminophen, HIV, and hepatitis panel were negative. Only C3 was borderline low at 80. A renal biopsy was performed and showed 1. Acute tubular necrosis with myoglobin cast 2. Mild arteriosclerosis Comment: There are many myoglobin case, consistent with significant parenchymal scarring. There is no evidence of minimal change disease or crescentic glomerulonephritis. rhabdomyolysis associated kidney injury. There is no glomerulosclerosis or

Conclusions Acute kidney injury from non-traumatic rhabdomyolysis and diffuse pulmonary infiltrates requiring steroids and hemodialysis is a rare phenomenon. Given her extensive negative workout, this patient is still being evaluated as an outpatient to find the underlying etiology for her condition. Patient received 3 months of dialysis and completed a tapering dose of high dose steroids. Patient followed up in Nephorology clinic and her creatinine returned to baseline of < 1.0. Patient has been cleared from Nephrology clinic. Because of her return to baseline kidney function, ATN and Rhabdomyolysis has completely resolved and the kidney has completed the recovery phase. Acknowledgements 1. Janga, Kalyana C et al. “Nontraumatic Exertional Rhabdomyolysis Leading to Acute Kidney Injury in a Sickle Trait Positive Individual on Renal Biopsy.” Case reports in nephrology vol. 2018 5841216. 15 Apr. 2018, doi:10.1155/2018/5841216 2. Cucchiari, David et al. “Exertional rhabdomyolysis leading to acute kidney injury: when genetic defects are diagnosed in adult life.” CEN case reports vol. 7,1 (2017): 62-65. doi:10.1007/s13730-017-0292-z 3. Repizo, Liliany P et al. “Biopsy proven acute tubular necrosis due to rhabdomyolysis in a dengue fever patient: a case report and review of literature.” Revista do Instituto de Medicina Tropical de Sao Paulo vol. 56,1 (2014): 85-8. doi:10.1590/S0036- 46652014000100014 The patient continued on dialysis and prednisone and showed improvement in her multiorgan dysfunction. Her abdominal pain and pulmonary infiltrates had resolved. Her creatinine improved to 5.12. She was discharged with prednisone and outpatient dialysis. Course Continued

Figure 2 : CT Sagittal view showing bilateral pulmonary infiltrates on HD 1

Figure 3: CT Axial view showing bilateral pulmonary infiltrates on HD 1

Figure 1: Chest X-ray with pulmonary infiltrates on Hospital Day 1

Figure 4: CT of the kidneys showing no inflammation or infection

Figure 5: CT Liver and Pancreas showing no inflammation

Figure 6: Chest X-ray showing improvement following high dose steroid and dialysis

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