DELAYED REACTION AND ACUTE INTERSTITIAL NEPHRITIS INDUCED BY PIPERACILLIN: A CASE REPORT T. Yau MD MPH, J. E. Abdalla MD MS, R. McCarron MD Department of Medicine, LSU Health Sciences Center, New Orleans, LA
INTRODUCTION: Hypersensitivity to penicillin can present as either an IgE mediated immediate reaction such as anaphylaxis and angioedema or a delayed reaction which is thought to be related to cell mediated mechanisms. We present an interesting case illustrating a complication from Piperacillin use.
CASE: A 60-year-old woman with hypertension, uncontrolled type 2 diabetes mellitus, and morbid obesity (BMI of 51) presented with a 2-week history of left leg cellulitis. She was previously evaluated at an outside hospital (OSH) Emergency Department (ED) and was discharged with ciprofloxacin and clindamycin. However, she returned to the OSH ED for a 1-day history of worsening left leg cellulitis was found to have an abscess. Vancomycin and piperacillin-tazobactam were initiated and the abscess was drained. On hospital day 2, she developed an acute kidney injury (AKI) with a creatinine of 2.7 (baseline of 0.8). Vancomycin and piperacillin-tazobactam were discontinued and she was started on ceftriaxone. The next day, she developed a generalized, morbilliform, pruritic rash on her neck, chest, abdomen, and back. Her kidney function progressively worsened resulting in nephrotic range proteinuria. Renal ultrasound revealed decreased bilateral perfusion but showed no radiological evidence of hydronephrosis. There was no eosinophilia or urine eosinophil noted. She also had positive ANAwith 1:160 speckled titer, but negative Anti-dsDNA, Anti-SSa and Anti-SSB, ANCA, ASO, and complement levels. Ceftriaxone was replaced by aztreonam due to the concern for acute interstitial nephritis (AIN). She required intermittent hemodialysis and was started on a high dose steroid taper. Following discharge, her kidney function recovered, and she was weaned off dialysis. DISCUSSION: The classic cutaneous manifestations from a hypersensitivity to penicillin use include a morbilliform or maculopapular rash that occurs within one to two weeks after antibiotic therapy. Resolution is expected one to two weeks after discontinuation of the culprit antibiotics. Penicillin is one of the most recognized causes of AIN. Drug induced AIN is thought to be a hypersensitivity that involves both humoral and cell mediated mechanisms.
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