Cat on a hot tin roof (a nephrology zebra)

Abstract

A 66-year-old man, the headmaster of a secondary school, was referred to the hospital for acute kidney injury (AKI). When questioned, he stated that he did not abuse alcohol, smoke tobacco or use intravenous or other illegal drugs. His medical history included HIV infection known since 1986, currently with undetectable viremia and CD4 + lymphocytes at 900/mm3. This HIV infection was complicated by a colic Kaposi’s sarcoma in 1993, now in complete remission, and stage III chronic kidney disease (CKD), which was associated with Tenofovir toxicity. His medical history included previous acute hepatitis B, prostate adenocarcinoma treated by radiotherapy followed by therapeutic ultrasound and currently in complete remission, basal cell carcinoma of the left forearm, hypertension and dyslipidemia. His current treatment includes Irbesartan, Hydrochlorothiazide, Modamide, Atorvastatin, Phosphoneuros and Juluca (Rilpivirine Chlorhydrate and Dolutegravir Sodium). The diagnosis of AKI, and the consequent referral, followed the results of a routine biological test, that showed a creatinine level of 284 μmol/L (3.2 mg/dL), increased from his baseline level of 136 μmol/L (1.5 mg/dL). The patient did not report any obvious precipitating element such as diarrhea or vomiting. The last therapy introduced was JULUCA, 6 months earlier. Questioning revealed that the patient had been to a party and had had homosexual intercourse with a chlamydiainfected partner a few days earlier. He reported having been deeply psychologically affected by the lock-down period (implemented by the French government in the context of the SARS-COV-2 epidemic). On physical examination, he was asymptomatic (temperature 37.3 °C, blood pressure 136/84 mm Hg, pulse 65 beats per minute, respiratory rate 18 breaths per minute). There were no clinical signs of dehydration or hyperhydration. Greenish anal discharge was noted. There was no sign of other clinical infection and the remainder of the examination was normal. Abdominal ultrasound revealed a right kidney of 11 cm and a left kidney of 11.7 cm, without dilatation of the urinary tract, but with right calyceal lithiasis. Hepatitis C serology, HIV RNA viral load, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium polymer chain reactions (PCR) on blood sample were all negative, as was SARS-COV 2 PCR on nasopharyngeal swab. The remaining biology is reported in Table 1.