Cautionary Case: Over-Vigilance Harms Kidneys in PsA Patient

Maley JH, Kiskis EC. Perspective: Less Is More. Acute Renal Failure Following Treatment of a Common Culture Contaminant. A Teachable Moment.JAMA Intern Med. (2014) Published online October 20. doi:10.1001/jamainternmed.2014.5281

The nonspecific title may lead some readers to overlook this interesting case of a psoriatic arthritis patient denied her biologics and consigned to hospitalization --and worse--by overenthusiastic response to a pneumonia episode.

The woman in her 50s, who has psoriasis and psoriatic arthritis controlled with biologic therapy, was hospitalized with community-acquired pneumonia, treated with antibiotics, and discharged after recovery.

Before resuming systemic therapy, the rheumatologist ordered bronchoscopy with lavage to assure that the pneumonia was resolved. The test revealed Mycobacterium gordonae.

An infectious disease specialist withheld the biologics while starting the patient on antibiotics and chemotherapy. Two months later, she landed back in the hospital with a severe psoriasis flare.  A renal biopsy showed acute interstitial nephritis. Dialysis was started, antibiotics were discontinued, and she was discharged as her creatinine approached normal levels.

Guidelines recommend diagnostic bronchoscopy in life-threatening pneumonia that fails to respond to appropriate treatment, the authors point out. Her community-acquired pneumonia had resolved, they observe, remarking that it would have been quite justified to avoid the "invasive diagnostic procedure that led to the identification of a common culture contaminant,” prompting unnecessary treatment that caused a flare and acute renal failure.