Rifampicin: An Infrequent Cause of AKI

Introduction: Rifampicin is used to treat Mycobacterium infection. Hypersensitivity reaction to rifampicin resulting in acute kidney injury (AKI) is infrequent. Here we describe rifampicin hypersensitivity in a patient presenting with AKI who was treated for Mycobacterium marinum infection. Case Description: A 43 year old male was treated with Rifampicin for Mycobacterium marinum infection 3 years ago. He recently injured his hand and took two pills of Rifampicin leftover from 3 years ago to prevent another infection. He took them about 12 hours apart and a few hours after taking the second pill he developed severe nausea, vomiting, flank pain and dark colored urine. He presented to emergency department and labs showed elevated LDH(lactate dehydrogenase) and bilirubin, thrombocytopenia, anemia and elevated creatinine. He was transferred to our hospital for further management. Upon arrival creatinine was 7.5mg/dl. Bilirubin had normalized and haptoglobin was in normal range. ADAMTS13 level was 56%. Peripheral smear did not show schistocytes. He underwent kidney biopsy which showed moderate acute tubular injury and focal thrombotic microangiopathy. It was determined that he had AKI from type 2 hypersensitivity to Rifampicin. His creatinine continued to worsen to 18mg/dl before improving. He did not require renal replacement therapy. On follow up three weeks later, his creatinine had improved to 1.7mg/dl. Discussion: Rifampicin hypersensitivity can manifest with hepatitis, hemolytic anemia and AKI. It is most often seen when the drug is re-administered or used intermittently. The outcome of AKI is usually favorable after discontinuation of the drug, with most patients achieving full recovery within 90 days. As the hypersensitivity reaction is infrequent, prompt recognition and withdrawal of drug is important to prevent irreversible injury.Renal biopsy showing Acute Tubular Injury.