Case 6: Skin Discoloration, Methemoglobinemia, and Acute Interstitial Nephritis in a 15-year-old Girl

Mihir R. Atreya; Najla Al Jaberi; Donna. J. Claes; Oded Volovelsky

doi:10.1542/pir.2016-0238

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Mihir R. Atreya, MD, MPH*
Najla Al Jaberi, MD*
Donna. J. Claes, MD, MS, BS Pharm^†
Oded Volovelsky, MD, PhD^†

^*Department of Pediatrics and
^†Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

AUTHOR DISCLOSURE
Drs Atreya, Al Jaberi, Claes, and Volovelsky have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 15-year-old girl who has a history of recurrent urinary tract infections (UTIs) presents to the emergency department with a 3-day history of decreased urine output, nausea, vomiting, shortness of breath, and concerns about appearing yellow. She reports that 1 month ago she was treated for a UTI with a 10-day course of trimethoprim-sulfamethoxazole. Because of persistent urinary pain, she has taken phenazopyridine for the past 7 days (200 mg 3 times daily).

On initial physical examination, she has a temperature of 97.8°F (36.6°C), heart rate of 94 beats/min, respiratory rate of 24 breaths/min, blood pressure of 112/78 mm Hg, and reassuring capillary refill. The only other finding of note is a yellowish-orange discoloration of her skin. Pulse oximetry reveals an Spo₂ of 87%, which does not improve with supplemental oxygen. Arterial oxygen saturation is normal and venous co-oximetry reveals methemoglobinemia (methemoglobin value of 18.5% [0.18]; normal range: 0.5%-1.5% [0.01-0.01]). Urine microscopy shows large white blood cells and trace bacteria. Blood chemistry documents a marked elevation of serum creatinine to 2.92 …