Hypothyroidism is a wide clinical spectrum disorder and only a few cases in literature show this. Rhabdomyolysis and acute renal impairment can be seen concurrently in a hypothyroid state. We report a case of severe hypothyroidism with poor drug compliance leading to rhabdomyolysis and acute kidney injury. • Hypothyroidism is a rare cause of acute kidney injury. • In this case report, we studied a rare occurrence of acute renal impairment due to hypothyroidism with poor drug compliance, which induced rhabdomyolysis. • Our report emphasized that thyroid status should be evaluated in patients with unexplained acute renal impairment or presenting with the symptoms of muscle involvement. Case presentation A 53-year-old male was admitted to a hospital with 15 days history of dyspnoea, weakness and oliguria, and muscle pain. His medical history included pulmonary thromboembolic, hypertension and cardiac arrhythmia. He had undergone total thyroidectomy for papillary thyroid cancer two years ago. His medication consisted of metoprolol, enoxaparin and l-thyroxine with no use in the past 4 weeks. Physical examination revealed dry and pale skin and slow speech. His pulse rate was 55 beats/minute and blood pressure was 130/90 mm Hg. Electrocardiography has shown bigemine ventricular extra systole. Laboratory investigations showed the following values: creatine phosphokinase, 1560 U/L (reference range, 52-336 U/L); creatinine, 2.1 mg/dL (0.2-1.0 mg/dL); potassium, 5.3 mEq/L (3.5-5.0 mEq/L); thyroid-stimulating hormone (TSH) 43.2 µIU/mL (0.4-4.8 uIU/mL), free thyroxine (fT4) <0.3 ng/dL (1.71-2.8 ng/dL) and free triiodothyronine (fT3) 0.48 pg/mL (1.57-4.71 pg/ mL). Haematological tests showed haemoglobin 9.4 g/dL (12-16), white cell count 9000 µL and platelet counts were in normal range. His urine was bloody in appearance and urine analysis showed blood reaction with dipstick test, but no erythrocytes were found on microscopic examination. Fraction excretion of Na and urinary Na were high (2.6% and 46 mEq/L, respectively). Renal tract ultrasonography was normal. No signs suggested the presence of an associated infectious or systemic inflammatory disease. In addition, other causes resulting in rhabdomyolysis such as muscular trauma, drugs and toxins were excluded with history and laboratory investigations. His condition was diagnosed as acute kidney injury secondary to hypothyroidism-induced rhabdomyolysis. This case was also consulted with the department of cardiology physicians who started him on metoprolol 25 mg before beginning thyroid replacement therapy. Cardiac status remained stable: l-thyroxine 25 microgram/day was prescribed, then 2 weeks later it was continued with l-thyroxine 50 microgram/day. His fluid deficiency was treated aggressively. His symptoms resolved over the following 3 weeks.

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Persistent proteinuria is the most important predictor of underlying renal disease after delivery. All patients with preeclampsia should be evaluated with respect to continuing proteinuria, persistent hematuria, or impaired renal functions after postpartum period and a percutaneous renal biopsy should be performed in those patients who have positive signs of underlying renal disease.

Acute kidney injury (AKI) is rarely reported in the clinical course of H1N1 infection and this condition is strongly related with increasing of mortality risk. However, there are no sufficient data about the development of AKI due to H1N1 infections. The recent reports were documented for elevation of creatinine phosphokinase levels in the course of influenza infection, but rhabdomyolysis was rarely reported. Herein, we present a 28-year-old female patient and a 19-year-old male patient with AKI in the course of H1N1 influenza infection due to rhabdomyolysis.

Hydatid disease, which affects the kidney, is not rare, and we suggest that urinalysis and, if indicated, renal biopsy should be performed for hepatic hydatid disease diagnosis.