Quinine-associated acute interstitial nephritis

A case of acute interstitial nephritis and granulomatous hepatitis induced by ingesting quinine

Quinine is used for the treatment of malarial infection, though not in common use. It is especially valuable for the parenteral treatment of severe illness owing to drug-resistant strains of Plasmodium falciparum. Quinine is also known to occasionally cause acute renal failure (ARF). Although quinine is listed in some reviews as a cause of acute interstitial nephritis, most cases of quinine-associated acute renal failure have been attributed to the hemolytic-uremic syndrome (HUS). Only two cases of acute renal failure due to acute interstitial nephritis associated with quinine have been reported [1, 2]. To our knowledge, there have been 6 reported cases of quinine-induced hepatic granuloma [3-8]. We report a case of quinine-induced acute interstitial nephritis (AIN) along with granulomatous hepatitis, both of which were confirmed on biopsy. A 50-year-old Nigerian man was admitted to the hospital with complaints of fever and general fatigue. He had been prescribed quinine as an antimalarial drug in a Nigerian hospital. The patient was febrile and showed nonoliguric ARF and liver dysfunction. In this case, liver injury showed gradual and spontaneous resolution after discontinuing quinine, and ARF resolved after treatment with oral prednisolone.

Renal-limited thrombotic microangiopathy and acute interstitial nephritis with a single dose of quinine

Quinine has been reported to cause acute kidney injury by various mechanisms. The response to quinine can result in a spectrum of problems ranging from isolated thrombocytopenia to thrombotic microangiopathy (TMA) to disseminated intravascular coagulation. Quinine has also been reported to cause acute interstitial nephritis (AIN). We report an unusual presentation where both of these entities of renal-limited TMA and AIN were precipitated by a single dose of quinine.

Cinchonism in a patient taking Quinine for leg cramps

Quinine is often used as a treatment for benign nocturnal cramps. The use of Quinine remains controversial with conflicting studies regarding its efficacy. Quinine has a side effect profile that cannot be ignored. Cinchonism, or quinine toxicity, includes nausea, vomiting, and tinnitus. Many other side effects have been reported in the literature. A case report demonstrating the side effects of quinine is presented. We briefly review the literature on quinine and alternative medications.

[Quinine-induced renal bilateral cortical necrosis]

Acute bilateral renal cortical necrosis is a rare cause of renal failure frequently induced by disseminated intravascular coagulation (Dic) following obstetrical complications, sepsis and drugs. We describe a case of Dic with bilateral cortical necrosis after ingestion of only one tablet of quinine. A 41-year-old woman was admitted for severe abdominal pain, melaena, fever and anuria two hours after quinine tablet intake for nocturnal leg cramps. Her medical history included angioneurotic edema caused by chloroquine for malaria prevention. Physical examination was normal. Laboratory data showed acute renal failure, hemolytic anemia without schistocytes and Dic. Platelet antibodies were negative. Ultrasonographic examination showed a complete defect of renal perfusion with permeable renal arteries. Results of abdominal CT scan and MAG3 scintigraphy led to the diagnosis of bilateral renal cortical necrosis. The patient underwent plasma exchanges with fresh frozen plasma which induced rapid resolution of Dic. She remained dependent on chronic hemodialysis. Quinine-induced microangiopathic hemolytic anemia and Dic is a rare described entity. These complications occur typically in quinine-sensitized subjects. The presence of acute renal failure is generally associated with poor prognosis in case of bilateral renal cortical necrosis. Caution is required for the prescription of quinine derivates, which should be avoided in patients experienced on adverse reaction to the drug.

Should people with nocturnal leg cramps drink tonic water and bitter lemon?

A literature search from 1993 to 1997 using MEDLINE and key-words beverages, muscle cramp, and quinine was performed. Three beverages containing quinine were examined in grocery stores. Analysis indicate that leg cramps are a common phenomenon associated with many comorbid disorders especially peripheral vascular and neurologic disorders. Thus, evaluation of a patient's complaining of leg cramps appropriately includes vascular, neurologic, and musculoskeletal examinations. Laboratory investigation of the symptom of leg cramps warrants as a minimum, assessment of thyroid function and determination of platelet counts and serum levels of electrolytes, calcium, and magnesium. A few small studies suggest that quinine is effective in decreasing the frequency of nocturnal leg cramps but not their severity or duration. Quinine consumed in commercial beverages has been reported to cause potentially fatal immunologically mediated hypersensitivity reactions. The concentration of quinine in commercial beverages varies greatly. Although commercial beverages containing quinine generally are labeled "Contains quinine," they typically lack both nutritional information about the amount of quinine and warnings of the health risks. It appears that 325 milligrams of quinine taken by mouth at bedtime typically relieves nocturnal leg cramps, but lower starting doses are appropriate for senior citizens and individuals with impaired renal function. In general, quinine in any form should be avoided by pregnant women and people with hepatic failure. Quinine consumed for the treatment of leg cramps should be prescribed and monitored by physicians, and people who consume quinine in commercial beverages must be warned of the health risks.

Polycystin: in vitro synthesis, in vivo tissue expression, and subcellular localization identifies a large membrane-associated protein

The primary structure of polycystin predicts a large integral membrane protein with multiple cell recognition motifs, but its function remains unknown. Insight into polycystin's normal function and its role in the development of autosomal dominant polycystic kidney disease (PKD1) requires the assembly of an extensive collection of molecular reagents to examine its expression and create model systems for functional studies. Development of these crucial reagents has been complicated due to the presence of transcriptionally active homologous loci. We have assembled the authentic full-length PKD1 cDNA and demonstrated expression of polycystin in vitro. Polyclonal antibodies directed against distinct extra- and intracellular domains specifically immunoprecipitated in vitro translated polycystin. The panel of antibodies was used to determine localization of polycystin in renal epithelial and endothelial cell lines and tissues of fetal, adult, and cystic origins. In normal adult kidney and maturing fetal nephrons, polycystin expression was confined to epithelial cells of the distal nephron and vascular endothelial cells. Expression in the proximal nephron was only observed after injury-induced cell proliferation. Polycystin expression was confined to ductal epithelium in liver, pancreas, and breast, and restricted to astrocytes in normal brain. We report clear evidence for the membrane localization of polycystin by both tissue sections and by confocal microscopy in cultured renal and endothelial cells. Interestingly, when cultured cells made cell-cell contact, polycystin was localized to the lateral membranes of cells in contact. These data suggest that polycystin is likely to have a widespread role in epithelial cell differentiation and maturation and in cell-cell interactions.