Acute Renal Failure and Mediterranean Spotted Fever

Dr. Donato Donati, MD, Divisione di Nefrologia, Ospedale Multizonale – USSL n.3, Via le Borri, 57, I-21100 Varese (Italy) Sir, Herein we report a rather unusual case of acute renal failure associated with Mediterranean spotted fever. The patient was a 58-year-old male living in the countryside of Central Italy. He was a heavy drinker (about 250 g of ethanol/day) but he had always been in perfect health. He presented with fever (40 °C), chills and diffuse maculo-papular exantema which had appeared 5 days before admission to the hospital. On admission, he was in good general condition, well oriented in space and time and the only subjective complaint was a moderate headache. Blood pressure was 150/90, heart rate ranged around 96/min, no sign of dehydration was clinically evident in spite of the high body temperature. Pulmonary auscultation revealed rales in the basal right side where X-ray examination showed a pneumonitis focus. Serum creatinine was 3.2 mg/dl, urea 112 mg/dl, acute phase proteins were elevated, hematocrit was 40%, hemoglobin 14 g/dl, blood leukocytes were 9,210/mm3 (84% of neutrophiles), serum hepatic cytolysis enzymes were elevated, fibrinogen/fibrin degradation products were normal and the research of pathologic seric and urinary myoglobin was negative. The patient was oliguric and the few urine contained hemoglobin and 1.5 g/l of protein. Urinary sodium was 38 mEq/1, urinary potassium was 11 mEq/1. Urinary sediment showed 15–20 erythrocytes pmf, 20–25 leukocytes pmf and a number of casts, mainly hemoglobinic ones. On ultrasound, both kidneys were normal in shape and size. Acute renal failure rapidly developed, the patient became absolutely anuric and hemodialysis was started 8 days after admission. Table 1. Skin biopsy Endothelial hyperplasia Perivascular lymphocytic infiltrates Renal biopsy Tubules: segmental necrosis and proximal tubule epithelium, hemoglobin casts, intact membranes Glomeruli: intact Interstitium: edema and inflammation Vasa: no lesions Immunofluorescent staining, negative: IgG, IgA, IgM, C3, fibrinogen