Pyrexia, anaemia and acute renal failure secondary to omeprazole

Abstract

SummaryWe present the case of a 77-year-old woman who initially presented with pyrexia of unknown origin, anaemia and mild renal impairment. When her omeprazole was stopped she improved rapidly. When omeprazole was re-started she developed fever and acute renal failure, which again settled quickly on discontinuation of omeprazole. This case demonstrates how drugs can cause severe multisystem disorders that may appear to be infective or inflammatory.Keywords: omeprazole; acute renal failure; anaemia; pyrexia; adverse drug reaction A 77-year-old woman initially presented with a one-week history of malaise, nausea, rigors and sweats with weight loss of 2.5 kg. She had nonpleuritic left-sided lower back pain and nonproductive cough for two days. Oral cefuroxime (250 mg bid) had been started before admission without improvement. She had had malaria and possible pyelonephritis in Africa. She was taking omeprazole 20 mg daily, prescribed empirically for dyspepsia for two months. She had never smoked.On admission she was pyrexial at 38.5°C and tachypnoeic. No other abnormality was found on clinical examination. The initial full blood count was normal with haemoglobin 12.0 g/dl and white cell count 9.9 x 109/l (eosinophils 2.6%). Renal function was impaired with serum creatinine 202 jmol/l. Other biochemistry was normal. The erythrocyte sedimentation rate (ESR) was markedly raised at 96 mm/h. A midstream specimen of urine sent before commencing antibiotics was normal but a repeat specimen demonstrated sterile pyuria. Blood cultures were negative at seven days. A chest X-ray was normal.Investigations to identify the cause of the pyrexia, including further cultures of blood, urine and stool, specimens for acid-fast bacilli, serology for Legionella and other atypical infections, Mantoux-testing and autoantibody screen, were negative. Ultrasound examination of the abdomen and computed tomography of the chest and abdomen were normal on two occasions, one month apart, as was echocardiography. Lumbar spine X-rays and skeletal scintigraphy were normal. There was no improvement after seven days treatment with intravenous cefuroxime 750 mg eighthourly.

Systematic review: proton pump inhibitor‐associated acute interstitial nephritis

“…Sixty cases met inclusion criteria. The nephritis diagnosis was confirmed by renal biopsy in 59 of the cases; 3, 4, 13, 17, 18, 21, 22, 24–27, 29, 30, 32, 35, 36, 45, 46, 48 one case demonstrated the effect upon re‐administering PPIs without any other factors associated 49 . Of these 60 cases, 47 were associated with omeprazole, six cases with pantoprazole, three with esomeprazole, two with lansoprazole and two with rabeprazole.…”

“…Three patients required dialysis treatment in the initial phases, but only one ended up on permanent dialysis. There were four cases of documented decreased renal function upon re‐administration of PPIs 24, 32, 35, 48 . There were no reports of death due to acute renal failure in the sample.…”

“…Following a recent rise in the use of PPIs, a number of individual case reports, case series and commentaries of PPI‐induced acute interstitial nephritis have been reported in the literature 9–49 . This has alerted the medical community to this serious complication and has placed PPIs among the principal causes of medication‐induced reversible acute renal failure.…”

Drug Fever due to a Single Dose of Pantoprazole

“…Hypersensitivity reactions towards PPI manifested as skin rash or as kidney injury occurring after prolonged intake of the drugs have been described [4,5,6]. There are very few reports on acute fever reactions upon administration of a PPI [7,8]. Here we report a case of acute drug-induced fever and inflammatory syndrome towards pantoprazole.…”

Proton Pump Inhibitors and Kidney Disease—GI Upset for the Nephrologist?

“…It was the first of many that raised the possibility of a causal association between PPI therapy and AKI. Following over a decade of isolated reports, 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 2 case series were published in 2006 that systematically investigated the association between PPI therapy and AIN through retrospective review of biopsy reports ( Table 1 ). 36 , 37 The first, a study from Australia, found 18 cases with biopsy-proven AIN in 2 hospitals over a 10-year period.…”