Interstitial Nephritis, Thrombocytopenia, Hepatitis, and Elevated Serum Amylase Levels in a Patient Receiving Clarithromycin Therapy

We describe a patient who developed acute interstitial nephritis shortly after starting treatment with clarithromycin (Biaxin; Abbott Laboratories, Chicago, IL). It was accompanied by thrombocytopenia, hepatitis, and an elevated amylase level. Nephritis cleared with administration of prednisolone. This may be the first case of combined interstitial nephritis, thrombocytopenia, hepatitis, and elevated amylase levels after use of clarithromycin. These features point to an allergic reaction. A 77-year-old man presented on 7 January 1997 with a 2-week history of cough, sputum production, and nasal stuffiness. He had been seen on 30 December 1996 for similar symptoms and had been prescribed trimethoprim-sulfamethoxazole (80/400 mg b.i.d.) without significant improvement in his condition. Physical examination revealed the following: temperature, 37.1°C (98.9°F); pulse rate, 81; blood pressure, 182/98 mm Hg; and respiratory rate, 12. Expiratory wheezes were heard over the chest. A clinical diagnosis of sinusitis and bronchitis was made (no laboratory studies were done), and the patient was prescribed clarithromycin (250 mg b.i.d.) on 7 January 1997. Five days later, he presented again with a 24-h history of abdominal pain and intermittent fever. The patient had a history of hypertension for which he was receiving treatment with captopril (50 mg t.i.d.) and furosemide (40 mg q.d.); he was also being treated with an albuterol inhaler (p.r.n.), vitamin C (1,000 mg/d), nasal inhalation of beclomethasone diproprionate, and Actifed (Warner-Lambert, Morris Plains, NJ). He appeared acutely ill. His temperature was 36°C (96.8°F) (later rising to 37.6°C [99.7°F]); pulse rate, 110; respiratory rate, 22; and blood pressure, 129/77 mm Hg. He had crackles at the base of the left lung and diffuse abdominal tenderness. Laboratory studies disclosed the following values: hemoglobin, 15.2 g/dL; WBCs, 11.2/mm3 (37% segmented neutrophils, 48% band forms, 3% lymphocytes; vacuolization of neutrophils was present); blood urea nitrogen, 30 mg/dL; and creatinine, 3.4 mg/dL. Urinalysis revealed the following: SG, 1.025; blood, 21; bilirubin, 21; protein level, >300 mg/dL; ketones and glucose, negative; casts, negative; WBCs, 25 per high-power field; red blood cells, too numerous to count; bacteria, negative; nitrite, positive; and leukocyte esterase, 11. Other laboratory studies revealed the following values: amylase, 324 U/L (normal range, 25–125 U/L); aspartate aminotransferase, 109 U/L (10–42 U/L); lactate dehydrogenase, 431 U/L (91–180 U/L); creatine kinase, 410 U/L (22–240 U/L); creatine kinase MB isoenzyme, 6.3 ng/mL (0–7.5 ng/mL); bilirubin, 1.7 mg/dL; albumin, 3.1 g/dL (3.5–5.0 g/dL); alkaline phosphatase, 76 U/L (32–92 U/L); total protein, 7.2 g/dL (6.7–8.6 g/dL); calcium, 8.9 mg/dL; and phosphate, 2.2 mg/dL (2.5–4.6 mg/dL). Chest radiography did not reveal any infiltrates. Blood cultures were sterile.