2019 Research Forum

Applicant: Prabina Shrestha MS IV Principal Investigator & Faculty Sponsor: Davis Aguirre MD An Atypical Presentation of Severe Non-Traumatic Rhabdomyolysis Resulting in Multi-Organ Failure

David Aguirre MD, Afshar Houtan MD R1, Prabina Shrestha MS IV

INTRODUCTION 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, requiring hemodialysis and high dose prednisone showing rhabdomyolysis on biopsy. 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 that required hemodialysis. DISCUSSION 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. She had previously gone to an outside hospital where CT of the abdomen was negative for pancreatitis and US of the abdomen showed fatty liver. 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. Given the severe multiorgan disease process in a previously healthy person, autoimmune etiology was likely. Pulmonary service was consulted and it agreed to perform a diagnostic bronchoscopy on the patient. However, the pathology was negative for malignancy or infection. Nephrology service was consulted and started 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. Given the negative workup, a renal biopsy was performed for definitive diagnosis. The renal biopsy showed acute tubular necrosis secondary to rhabdomyolysis and mild arteriosclerosis. The patient was 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. CONCLUSION 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.

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