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Some studies indicate that DIAIN is the lesion responsible for renal failure in about 15&#37; of biopsies with ARF&#46; Furthermore&#44; in many cases of DIAIN&#44; no biopsy is performed and diagnosis is based on clinical data and recent administration of a new drug which&#44; as described below&#44; is sometimes not very easy to identify&#46;<span class="elsevierStyleSup">3-5</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">28-year-old male&#44; admitted with pain at the dimples of Venus&#44; fatigue and nausea&#44; with preserved diuresis&#46;</p><p class="elsevierStylePara">The patient had used intranasal cocaine &#40;1g&#41; five days before admission&#46; He denied having taken non-steroidal anti-inflammatory drugs or other medication&#46; The physical examination showed a good general condition&#44; with slightly high blood pressure of 147&#47;97mmHg and without fever&#44; rash or arthralgia&#46;</p><p class="elsevierStylePara">Cardiovascular and respiratory examinations were normal&#46; The abdomen was soft&#44; depressible and painless and the liver was palpable 1cm below the costal margin and there was slight pain on bilateral palpation of lower back&#46;</p><p class="elsevierStylePara">The initial blood test showed an unremarkable complete blood count &#40;without eosinophilia&#41;&#44; normal liver function and albumin within the normal range&#44; serum creatinine&#58; 160&#956;mol&#47;l&#44; urea&#58; 7&#46;5mmol&#47;l&#44; potassium&#58; 3&#46;9mmol&#47;l&#44; sodium&#58; 139mmol&#47;l chloride 101mmol&#47;l&#46; Total creatine phosphokinase was normal &#40;3&#46;3&#956;kat&#47;l&#41; with normal MB fraction&#46; Urine sediment showed 2 leukocytes and 3 erythrocytes per high power field and no dysmorphic erythrocytes or eosinophils&#46; Urine biochemistry&#58; sodium&#58; 46mmol&#47;l&#44; potassium&#58; 33mmol&#47;l and chloride&#58; 63mmol&#47;l&#44; protein ratio&#58; creatinine 5g&#47;mol&#44; negative urine culture&#46;</p><p class="elsevierStylePara">Protein electrophoresis&#44; immunoglobulins&#44; complement&#44; levels of angiotensin converting enzyme and antinuclear antibody titres were normal&#46; Serology for human immunodeficiency virus&#44; Epstein-Barr virus&#44; cytomegalovirus&#44; hepatitis A&#44; B&#44; and C and mycoplasma did not detect active infection&#46; The ultrasound showed normal-sized&#44; diffusely echogenic kidneys with appropriate arterial and venous flow&#46;</p><p class="elsevierStylePara">The electrocardiogram was normal&#46; The chest x-ray showed a cardiothoracic ratio &#60;0&#46;5 and lung fields without infiltrates&#46;</p><p class="elsevierStylePara">After admission&#44; urinary output remained at 50 to 75ml&#47;h and creatinine remained unchanged&#46; The patient underwent a renal biopsy&#46;</p><p class="elsevierStylePara">Histological findings are as follows&#58; optical microscopy showed a total of 13 glomeruli&#44; all normal&#44; without sclerosis&#44; proliferation or necrotic lesions &#40;Figure 1&#41;&#46; Basement membranes and the glomerular mesangium were normal&#46; The interstitium displayed moderate mononuclear inflammatory infiltrate with abundant eosinophils &#40;Figure 2&#41;&#44; with presence of focal tubulitis and atrophy &#40;Figure 2&#41;&#46; The arterioles did not display remarkable lesions and immune deposits were not shown in the immunofluorescence&#46;</p><p class="elsevierStylePara">The findings were compatible with the pathological diagnosis of acute tubulointerstitial nephritis &#40;ATN&#41;&#46;</p><p class="elsevierStylePara">This fact&#44; along with the clinical characteristics and recent use of cocaine led us to define this case as cocaine-induced AIN&#46;</p><p class="elsevierStylePara">The patient obviously suspended drug use and was treated with oral prednisone &#40;initial dose 1mg&#47;kg&#47;day&#41;&#44; which was progressively decreased and discontinued after 12 weeks&#46;</p><p class="elsevierStylePara">In the subsequent follow-up&#44; his progression was good with a gradual improvement in renal function until complete recovery in the month in which treatment started&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We report the case of a patient with ARF&#44; with acute tubulointerstitial lesion associated with DIAIN&#44; in which no related agent was identified&#44; except for cocaine&#46; Currently people are starting to become aware of cocaine-induced ARF in adults&#59; in fact&#44; the two most common causes are rhabdomyolysis and malignant high blood pressure induced by intense arterial vasoconstriction&#46;</p><p class="elsevierStylePara">There are few reported cases of cocaine-related DIAIN&#46;<span class="elsevierStyleSup">2&#44;6</span> The mechanism remains unclear&#44; and it remains to be demonstrated whether this entity is related to cocaine <span class="elsevierStyleItalic">per se</span> or natural impurities&#44; adulterants or diluents&#46;<span class="elsevierStyleSup">7</span> In fact&#44; in the case of crack&#44; contamination is highly likely&#46;</p><p class="elsevierStylePara">In this case the patient may have been sensitised to cocaine or its additives by previous consumption&#46; Hypersensitivity to the drug is the most likely cause in our patient&#46;<span class="elsevierStyleSup">7&#44;8</span></p><p class="elsevierStylePara">Our patient did not have any &#8220;classic&#8221; symptoms of ARF&#44; such as fever&#44; rash&#44; or eosinophilia&#44; but recent studies suggest that AIN is a heterogeneous disorder and&#44; therefore&#44; these &#8220;classic&#8221; symptoms are only seen in fewer than 30&#37; of cases&#46;<span class="elsevierStyleSup">8</span> Eosinophiluria is usually interpreted as a feature of DIAIN&#59; however&#44; it has very low sensitivity &#40;67&#37;&#41;&#46; The eosinophiluria specificity for the diagnosis of AIN is 87&#37;&#44; but it may be present in other diseases that may also present with acute renal failure&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">The pathogenesis of AIN involves an idiosyncratic allergic reaction to drug exposure&#46; It often involves a type IV hypersensitivity T cell response&#46; Molecular mimicry or direct binding of the drug to the tubular basement membrane are the main mechanisms involved&#44;<span class="elsevierStyleSup">9</span> and this maybe the underlying process in our case&#46;</p><p class="elsevierStylePara">Early recognition of DIAIN is crucial because patients may ultimately develop chronic kidney disease&#46;</p><p class="elsevierStylePara">The key element of treatment is the interruption of the causative agent&#46; However&#44; as DIAIN is an inflammatory allergic process&#44; it is necessary to consider the use of immunosuppressive agents&#44; including corticosteroids&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">In corticoresistant AIN&#44; there are reports of cases that suggest the benefit of cyclophosphamide and cyclosporine&#44; as well as potential beneficial effects of mycophenolate mofetil&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">Growing evidence based on different studies suggests that steroids lead to a quicker and more complete recovery of renal function&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">As a consequence of interstitial infiltration typical of AIN&#44; a rapid progression towards interstitial fibrosis can occur in a few weeks&#46; Based on these data&#44; we used corticosteroids at the time of diagnosis to prevent potential progression to irreversible interstitial fibrosis&#46; The result was positive and displayed rapid normalisation of renal function&#46;</p><p class="elsevierStylePara">DIAIN should be recognised as a potential cause of acute renal failure in cocaine users and the history of potential use should be carefully investigated in patients with AIN with no obvious cause&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11809&#95;16025&#95;49164&#95;en&#95;f111809&#46;jpg" class="elsevierStyleCrossRefs"><img src="11809_16025_49164_en_f111809.jpg" alt="Renal biopsy&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Renal biopsy&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11809&#95;16025&#95;49165&#95;en&#95;f211809&#46;jpg" class="elsevierStyleCrossRefs"><img src="11809_16025_49165_en_f211809.jpg" alt="Renal biopsy&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Renal biopsy&#46;</p>"
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