A prisoner with acute renal failure

Blood tests showed acute renal failure with a plasma creatinine of 932 mmol/L. He had peripheral leucocytosis with neutrophilia (14.3 × 10^sup 9^/L) and eosinophilia (8.4 × 10^sup 9^/L). He also had increased alkaline phosphatase (198 U/L), alanine transaminase (78 U/L), and gamma glutamyl transferase concentrations (391 U/L)] with a prolonged INR (1.7), which we interpreted as signs of acute hepatitis. C-reactive protein was increased (265 mg/L) with a normal erythrocyte sedimentation rate (12 mm/h). The patient had proteinuria (urine proteinxreatinine ratio 12800 mg/mmoL), and urine microscopy showed more than 108 white cells and dysmorphic red blood cells/L. Abdominal CT showed bilateral swollen kidneys with poor corticomedullary differentiation but normal vascularity and renal venous flow. The liver and gallbladder were normal. Antinuclear antibody and extractable nuclear antigen, antineutrophil cytoplasmic antibody, antimyeloperoxidase and antiproteinase-3, were not detected by ELISA. Serum complement concentrations were increased and antibodies against hepatitis B and C, HIV, and other viral pathogens, leptospira, and parasites were negative. A percutaneous renal biopsy showed acute granulomatous vasculitis with focal segmental glomerular crescents and tubulointerstitial inflammation and lymphocytic and eosinophilic infiltrates (figure).