Acute renal failure following Entamoeba histolytica treatment in a 9-year-old girl

A 9-year-old girl entered to the emergency department with fever, dysentery, neurological signs, and renal failure following an epidemic of amebiasis. She had used 5 days metronidazole (30 mg/kg/daily) before she was affected to hemolytic uremic syndrome (HUS) and seizure, blindness, and ataxia. We hold using of metronidazole and by supportive therapy all symptoms alleviated and she left hospital in 8 ^th day, after 1-month she was healthy without need to use any drug. amebiasis may cause to HUS by different mechanisms, but metronidazole as a causing and defining of symptoms in HUS should be considered.

Keywords: Entamoeba histolytica , hemolytic uremic syndrome, metronidazole

Hemolytic uremic syndrome (HUS) is primarily a disease of infancy and early childhood and is classically characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. ^[1] Many infectious agents and noninfectious include drugs may cause HUS. ^[2]

In this case report, we present a 9-year-old girl affected to D+ HUS following an epidemic amebiasis and used metronidazole 5 days before her constellation of clinical features that were predominantly neurological and renal type. In spite of active infection include of fever and tenesmus, metronidazole using was held, and supportive care was begun, her neurological and general condition came to better.

A 9-year-old girl and her family developed severe watery diarrhea changed to dysentery due to drinking of contaminated nonboiled water. The trophozoites were found in stool examination and medical therapy include metronidazole and iodoquinol started 8 days before her admission, in 5 ^th day after therapy her urine output decreased and constitutional symptoms appeared, these problems lasted 3 days until she was brought to our hospital. On entering to the emergency department, she had an episode of tonic-clonic seizure, which controlled by phenobarbital. Her visual power decreased to 1 m along diplopia, ataxia and astrexis, her urine output was <50 ml/day (0.1 cc/kg/h) she had fluctuating fever, melena and bright bloody vomiting, her laboratory finding was shown in [Table 1].

Immediately, after admission with respect to her uremia symptoms dialysis by aim to decrease urea up to 30% in every session has been considered. Her blood pressure (BP) at first visit was 100/60, which increased to 150/95 controlled by medical therapy and hemodialysis. Her visual power resolved gradually by hemodialysis and her ataxia resolved up to 7 ^th day in 8 ^th day she left hospital in good condition she was in stable condition after 2 months, her creatinine reached to 1 mg/dl and hemoglobin increased to 10.5 and her BP remain on 100/50 without antihypertensive drug.

Hemolytic uremic syndrome is primarily a disease of infancy and early childhood and is classically characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. ^[1] Many infectious agents and noninfectious include drugs may cause HUS. ^[2] Entamoeba histolytica has also been known as an etiologic factor for HUS in developing countries. ^[2],[3],[4]

There is not precise pathological definition between Entamoeba and renal disease at the moment, ^[5],[6],[7]] some theories explained appearance of holes called amoebapore which were made by adhering of some molecules to lecithin cell walls and killing cell or by similar mechanism like as Shiga toxin, which in amebiasis it will be done by cystine protease enzyme that ultimately increase production of tumor necrosis factor-α by macrophage and leading to cell death ^{[8],[9],[10],[11]} and some virulent forms may exhibit their cytotoxic effects by involving in immune system. ^[12]

Our case was a 9-year-old girl affected to HUS during an epidemic amebiasis. Her clinical features began by gastroenteritis 8 day before her admission and used metronidazole and iodoquinol like as other people decrease urinary output and paleness appeared 3 days before admission and her neurologic signs and symptoms appeared just before her admission when she visited signs of active infection such as fever and dysentery was prominent in her.

There are reports describe the association of HUS and metroniodazole using by oral or intravenous route in patients with or without a history of diarrhea that in 2 out of 6 patients who used metronidazole persistent hypertension, and renal failure occurred. They used metronidazle from 1 day to 18 days and one case who used higher dose for a prolonged time has been died due to severe neurological complications. ^[13],[14] In our case who used metronidazole for 5 days by oral route in usual dose prescribed for amebiasis (30 mg/kg/daily), she showed her general complaints and renal failure after 5 days, in entrance in spite of she was being febrile toxic and suffered to dysentery we preferred to hold using metronidazole by her because of that it is showed by reports that metronidazole may aggravated neurological problems ^[13],[14] or may lead to HUS in someone. ^[13] With supporting therapy and holding metronidazle not only her infection has not been aggravated but her neurological symptom went to better and she left our hospital without renal failure or hypertension.

Finding of relations of E. histolytica and HUS are growing and it is not clear this pathogen act on by self or in association of Escherichia coli (reservoir and transport of E. coli by E. histolytica). In addition, role of metronidazole should be defined as an inciting to HUS appearing and definition of some signs and symptoms. May have it a negative role like as using antibiotic in D+ HUS due to E. coli or positive role whenever HUS is caused by Shigella? ^[15] However as our report metronidazole not only will not prevent HUS due to amebiasis, but may establish a dangerous condition mainly by neurological signs, its withholding not being problematic, but promote alleviation of symptoms, especially neurological ones.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.145015

[Table 1]