Introduction: Some studies have shown that patients consuming alternate medicine can suffer from complications like acute kidney injury (AKI) due to heavy metal poisoning. The use of traditional ayurvedic herbal remedies may be difficult to identify as a source of toxicity, especially if the treating doctor is not aware of this habit, unless a detailed history is taken. In this report, we describe a patient who had consumed ayurvedic supplements for treating fever and abdominal pain and presented to our emergency department (ED) with AKI.&nbsp;Case presentation: A 24-year-old male presented to the ED with complaints of abdominal pain, fever and loose stools. His blood tests revealed AKI and he was started on emergency hemodialysis. His renal function improved after only one cycle of dialysis and he was discharged in a stable condition.&nbsp;Conclusion: Acute lead toxicity should be suspected in patients with abdominal and neurological dysfunction who have a history of chronic ayurvedic medicine intake and thus should be promptly treated. Physicians should rule out potential toxicity from these supplements and have a heightened level of suspicion for lead toxicity in patients presenting with abdominal pain and AKI without any obvious cause

Moideen, Fabith

Moorthy, Saranya

Peringat, Jayameena

Samuel, Arpith Easo

English

Advanced Journal of Emergency medicine

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e8 Moorthy et al 
   
 1 Copyright © 2019 Tehran University of Medical Sciences  
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
Case Report DOI: 10.22114/ajem.v0i0.100 
Interstitial Nephritis Presenting as Acute Kidney Injury Following Ingestion of Alternative 
Medicine Containing Lead: A Case Report 
 
Saranya Moorthy1, Arpith Easo Samuel1*, Fabith Moideen1, Jayameena Peringat2 
 
1. Department of Emergency Medicine, Baby Memorial Hospital, Kerala, India. 
2. Department of Nephrology, Baby Memorial Hospital, Kerala, India. 
 
*Corresponding author: Arpith Easo Samuel; Email: arpitheasosamuel@gmail.com 
Published online: 2018-07-28 
Abstract  
Introduction: Some studies have shown that patients consuming alternate medicine can suffer from 
complications like acute kidney injury (AKI) due to heavy metal poisoning. The use of traditional ayurvedic 
herbal remedies may be difficult to identify as a source of toxicity, especially if the treating doctor is not 
aware of this habit, unless a detailed history is taken. In this report, we describe a patient who had consumed 
ayurvedic supplements for treating fever and abdominal pain and presented to our emergency department 
(ED) with AKI. 
Case presentation: A 24-year-old male presented to the ED with complaints of abdominal pain, fever and 
loose stools. His blood tests revealed AKI and he was started on emergency hemodialysis. His renal function 
improved after only one cycle of dialysis and he was discharged in a stable condition. 
Conclusion: Acute lead toxicity should be suspected in patients with abdominal and neurological 
dysfunction who have a history of chronic ayurvedic medicine intake and thus should be promptly treated. 
Physicians should rule out potential toxicity from these supplements and have a heightened level of suspicion 
for lead toxicity in patients presenting with abdominal pain and AKI without any obvious cause. 
Key words: Acute kidney injury; Alternate medicine; Acute tubulointerstitial nephritis; Lead 
Cite this article as: Moorthy S, Samuel AE, Moideen F, Peringat J. Interstitial Nephritis Presenting as Acute Kidney Injury Following 
Ingestion of Alternate Medicine Containing Lead: A Case Report. Adv J Emerg Med. 2019;3(1): e8. 
INTRODUCTION
Interstitial nephritis (also called tubulointerstitial 
nephritis) is inflammation of the interstitium 
surrounding the tubules of the kidneys. One of the 
causes of interstitial nephritis is exposure to 
heavy metals like lead, mercury, arsenic etc., 
either acutely or chronically. Chronic low-level 
exposure to lead can be considered to be a 
causative factor in cognitive dysfunction, 
neurobehavioral disorders, neurological damage, 
hypertension, and renal impairment (1). The 
extent of renal damage depends on the dose and 
duration of exposure. Here, we describe a case of 
interstitial nephritis following unintended lead 
consumption after which the patient presented 
with acute kidney injury (AKI).  
CASE PRESENTATION 
A 24-year-old man with complaints of fever, 
abdominal pain and 3 episodes of passing loose 
stools consulted an alternative medicine 
practitioner and was given ayurvedic medications. 
Following intake of the medicines, he had 
worsening diffuse abdominal pain and vomiting 
along with decreased urine output. He went to a 
local hospital on the 2nd day and was found to 
have deficient renal function (his serum creatinine 
level was 10.3 mg/dl). He was referred to our 
emergency department (ED) on the 3rd day for 
further management. He had no history of co-
morbidities or any known underlying disease.  
On examination, he was conscious, oriented, with 
a pulse rate of 64/min, blood pressure of 132/80 
mmHg, respiratory rate 24/min, and an O2 
saturation (SpO2) of 99% on room air. He also had 
some minor facial and pedal edema. Respiratory 
and cardiovascular system examinations were 
normal. Abdomen examination showed moderate 
tenderness in the left lower quadrant with no 
mass palpable and no flapping tremors.  
His electrocardiogram (ECG) showed sinus 
bradycardia (Figure 1). Non-enhanced computed 
tomography (CT) scan of the abdomen showed no 
obvious renal or ureteric calculi, nor any 
pelvicalyceal/ureteric dilatation on either side. He 
had minimal ascites and bilateral basal pleural 
effusion. Upon admission, his hemoglobin was 
13.5, blood urea 121, serum creatinine 11.33 
mg/dl, serum sodium 139 mmol/l, serum 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e8 Moorthy et al 
   
 2 Copyright © 2019 Tehran University of Medical Sciences  
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
potassium 3.9 mmol/l, total bilirubin 0.5 md/dl, 
and direct bilirubin 0.1 mg/dl. His ABG showed 
compensated metabolic acidosis with a pH of 7.36, 
PCO2 of 28 mmHg and HCO3 of 18meq/l.  
The patient was admitted to the nephrology 
department since he had metabolic disturbances 
and AKI. He was taken for emergency 
hemodialysis via a left double lumen femoral 
catheter. He started improving clinically after one 
session of dialysis and other supportive care. His 
renal function rapidly improved and his serum 
creatinine was 2.17 mg/dl on the fifth day of 
admission. The femoral catheter was then 
removed and he was discharged on day six. On 
follow up his serum creatinine was within normal 
limits (1.2 mg/dl). The ayurvedic supplement he 
had been taking was sent for toxicological analysis 
and showed the presence of a high concentration 
of lead which might have caused the interstitial 
nephritis leading to AKI in our patient. The serum 
level of lead was not measured in this patient  
DISCUSSIONS 
The kidney is an organ susceptible to heavy metal 
poisoning. Poisoning can occur acutely or due to 
chronic exposure. The most common renal lesions 
include acute tubular necrosis, cortical necrosis, 
and interstitial nephritis. Both acute and chronic 
exposure to heavy metals can cause 
tubulointerstitial injuries without any obvious 
morphological changes and they can occur within 
days of exposure to the offending drug (2). 
Chronic heavy metal exposure is an important but 
under-recognized cause of renal damage. The 
diagnosis is usually made by the finding of 
unexplained renal dysfunction and a history of 
exposure to a heavy metal (3). 
Acute lead poisoning has been reported frequently 
from India, the Middle Eastern countries and 
Mexico due to the popular usage of traditional and 
herbal medicines. This should be a matter of grave 
concern to patients who take such remedies, and 
to health professionals and health authorities in 
these countries (4).  
In cases of acute lead poisoning the patient may 
present with encephalopathy, seizures, altered 
mental status, papilloedema, ataxia, abdominal 
pain, and Fanconi’s syndrome. The combination of 
abdominal or neurologic dysfunction with 
hemolysis should raise suspicions about lead 
toxicity. Anemia and basophilic stippling may or 
may not be present, and patients with 
neurotoxicity may develop permanent central 
neurologic damage. Measurement of serum lead 
levels is necessary for a definitive diagnosis.  
There are various traditional medical methods, 
has been long used in all around the world (5). 
Among them, ayurvedic medicine originated in 
India more than 3,000 years ago and still has a 
role in the country’s health care systems. This 
traditional medical system promotes the use of 
herbal agents, minerals, and metal compounds, 
special diets, and other unique health practices. 
Ayurvedic medicine has not been widely studied 
and its safety assessment needs additional 
investigations. Some cases associated with its use, 
such as status epilepticus, fatal infant 
encephalopathy, congenital paralysis, 
sensorineural deafness, and developmental delay 
have been previously reported in this regard (6); 
and as in our case that presented with AKI 
following use of ayurvedic herbal medicines, 
induced lead toxicity. 
 
Figure 1: The patient’s electrocardiogram on arrival to emergency department 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e8 Moorthy et al 
   
 3 Copyright © 2019 Tehran University of Medical Sciences  
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
CONCLUSIONS 
Acute lead toxicity should be suspected in patients 
with abdominal and neurological dysfunction who 
have a history of chronic ayurvedic medicine 
intake and they should be promptly treated. In our 
opinion, physicians should rule out potential 
toxicity from these supplements and have a 
heightened level of suspicion for lead toxicity in 
any patients with abdominal pain and AKI without 
an obvious cause.  
ACKNOWLEDGMENTS 
We thank the residents, nurses, and paramedical 
staff of the Department of Emergency Medicine 
and Nephrology at Baby Memorial Hospital, 
Kerala, India. 
AUTHORS’ CONTRIBUTION 
All authors passed four criteria for authorship 
contribution based on recommendations of the 
International Committee of Medical Journal 
Editors. 
CONFLICTS OF INTEREST 
The authors have no conflicts of interest to report. 
Any conflicts that the editor considers relevant to 
the content of the manuscript have been disclosed. 
FUNDING 
No funding from any source was received or used 
for this case report. 
REFERENCES
1. Lin JL, Lin-Tan DT, Hsu KH, Yu CC. Environmental lead exposure and progression of chronic renal 
diseases in patients without diabetes. N Engl J Med. 2003;348(4):277-86. 
2. Jha V, Rathi M. Natural medicines causing acute kidney injury. Semin Nephrol. 2008;28(4):416-28. 
3. Sathe K, Ali U, Ohri A. Acute renal failure secondary to ingestion of ayurvedic medicine containing 
mercury. Indian J Nephrol. 2013;23(4):301-3. 
4. Tait PA, Vora A, James S, Fitzgerald DJ, Pester BA. Severe congenital lead poisoning in a preterm infant 
due to a herbal remedy. Med J Aust. 2002;177(4):193-5. 
5. Karimpour Reihan S, Firuzei E, Khosravi M, Abbaszadeh M. Coagulation Disorder following Red Clover 
(Trifolium Pratense) Misuse: a Case Report. Adv J Emerg Med. 2018;2(2):e20. 
6. Saper RB, Kales SN, Paquin J, Burns MJ, Eisenberg DM, Davis RB, et al. Heavy metal content of 
ayurvedic herbal medicine products. JAMA. 2004;292(23):2868-73. 
 


Interstitial Nephritis Presenting as Acute Kidney Injury Following Ingestion of Alternative Medicine Containing Lead: A Case Report

Frontiers in Emergency Medicine (E-Journal)

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e8 Moorthy et al     1 Copyright © 2019 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). Case Report DOI: 10.22114/ajem.v0i0.100 Interstitial Nephritis Presenting as Acute Kidney Injury Following Ingestion of Alternative Medicine Containing Lead: A Case Report  Saranya Moorthy1, Arpith Easo Samuel1*, Fabith Moideen1, Jayameena Peringat2  1. Department of Emergency Medicine, Baby Memorial Hospital, Kerala, India. 2. Department of Nephrology, Baby Memorial Hospital, Kerala, India.  *Corresponding author: Arpith Easo Samuel; Email: arpitheasosamuel@gmail.com Published online: 2018-07-28 Abstract  Introduction: Some studies have shown that patients consuming alternate medicine can suffer from complications like acute kidney injury (AKI) due to heavy metal poisoning. The use of traditional ayurvedic herbal remedies may be difficult to identify as a source of toxicity, especially if the treating doctor is not aware of this habit, unless a detailed history is taken. In this report, we describe a patient who had consumed ayurvedic supplements for treating fever and abdominal pain and presented to our emergency department (ED) with AKI. Case presentation: A 24-year-old male presented to the ED with complaints of abdominal pain, fever and loose stools. His blood tests revealed AKI and he was started on emergency hemodialysis. His renal function improved after only one cycle of dialysis and he was discharged in a stable condition. Conclusion: Acute lead toxicity should be suspected in patients with abdominal and neurological dysfunction who have a history of chronic ayurvedic medicine intake and thus should be promptly treated. Physicians should rule out potential toxicity from these supplements and have a heightened level of suspicion for lead toxicity in patients presenting with abdominal pain and AKI without any obvious cause. Key words: Acute kidney injury; Alternate medicine; Acute tubulointerstitial nephritis; Lead Cite this article as: Moorthy S, Samuel AE, Moideen F, Peringat J. Interstitial Nephritis Presenting as Acute Kidney Injury Following Ingestion of Alternate Medicine Containing Lead: A Case Report. Adv J Emerg Med. 2019;3(1): e8. INTRODUCTIONInterstitial nephritis (also called tubulointerstitial nephritis) is inflammation of the interstitium surrounding the tubules of the kidneys. One of the causes of interstitial nephritis is exposure to heavy metals like lead, mercury, arsenic etc., either acutely or chronically. Chronic low-level exposure to lead can be considered to be a causative factor in cognitive dysfunction, neurobehavioral disorders, neurological damage, hypertension, and renal impairment (1). The extent of renal damage depends on the dose and duration of exposure. Here, we describe a case of interstitial nephritis following unintended lead consumption after which the patient presented with acute kidney injury (AKI).  CASE PRESENTATION A 24-year-old man with complaints of fever, abdominal pain and 3 episodes of passing loose stools consulted an alternative medicine practitioner and was given ayurvedic medications. Following intake of the medicines, he had worsening diffuse abdominal pain and vomiting along with decreased urine output. He went to a local hospital on the 2nd day and was found to have deficient renal function (his serum creatinine level was 10.3 mg/dl). He was referred to our emergency department (ED) on the 3rd day for further management. He had no history of co-morbidities or any known underlying disease.  On examination, he was conscious, oriented, with a pulse rate of 64/min, blood pressure of 132/80 mmHg, respiratory rate 24/min, and an O2 saturation (SpO2) of 99% on room air. He also had some minor facial and pedal edema. Respiratory and cardiovascular system examinations were normal. Abdomen examination showed moderate tenderness in the left lower quadrant with no mass palpable and no flapping tremors.  His electrocardiogram (ECG) showed sinus bradycardia (Figure 1). Non-enhanced computed tomography (CT) scan of the abdomen showed no obvious renal or ureteric calculi, nor any pelvicalyceal/ureteric dilatation on either side. He had minimal ascites and bilateral basal pleural effusion. Upon admission, his hemoglobin was 13.5, blood urea 121, serum creatinine 11.33 mg/dl, serum sodium 139 mmol/l, serum ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e8 Moorthy et al     2 Copyright © 2019 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). potassium 3.9 mmol/l, total bilirubin 0.5 md/dl, and direct bilirubin 0.1 mg/dl. His ABG showed compensated metabolic acidosis with a pH of 7.36, PCO2 of 28 mmHg and HCO3 of 18meq/l.  The patient was admitted to the nephrology department since he had metabolic disturbances and AKI. He was taken for emergency hemodialysis via a left double lumen femoral catheter. He started improving clinically after one session of dialysis and other supportive care. His renal function rapidly improved and his serum creatinine was 2.17 mg/dl on the fifth day of admission. The femoral catheter was then removed and he was discharged on day six. On follow up his serum creatinine was within normal limits (1.2 mg/dl). The ayurvedic supplement he had been taking was sent for toxicological analysis and showed the presence of a high concentration of lead which might have caused the interstitial nephritis leading to AKI in our patient. The serum level of lead was not measured in this patient  DISCUSSIONS The kidney is an organ susceptible to heavy metal poisoning. Poisoning can occur acutely or due to chronic exposure. The most common renal lesions include acute tubular necrosis, cortical necrosis, and interstitial nephritis. Both acute and chronic exposure to heavy metals can cause tubulointerstitial injuries without any obvious morphological changes and they can occur within days of exposure to the offending drug (2). Chronic heavy metal exposure is an important but under-recognized cause of renal damage. The diagnosis is usually made by the finding of unexplained renal dysfunction and a history of exposure to a heavy metal (3). Acute lead poisoning has been reported frequently from India, the Middle Eastern countries and Mexico due to the popular usage of traditional and herbal medicines. This should be a matter of grave concern to patients who take such remedies, and to health professionals and health authorities in these countries (4).  In cases of acute lead poisoning the patient may present with encephalopathy, seizures, altered mental status, papilloedema, ataxia, abdominal pain, and Fanconi’s syndrome. The combination of abdominal or neurologic dysfunction with hemolysis should raise suspicions about lead toxicity. Anemia and basophilic stippling may or may not be present, and patients with neurotoxicity may develop permanent central neurologic damage. Measurement of serum lead levels is necessary for a definitive diagnosis.  There are various traditional medical methods, has been long used in all around the world (5). Among them, ayurvedic medicine originated in India more than 3,000 years ago and still has a role in the country’s health care systems. This traditional medical system promotes the use of herbal agents, minerals, and metal compounds, special diets, and other unique health practices. Ayurvedic medicine has not been widely studied and its safety assessment needs additional investigations. Some cases associated with its use, such as status epilepticus, fatal infant encephalopathy, congenital paralysis, sensorineural deafness, and developmental delay have been previously reported in this regard (6); and as in our case that presented with AKI following use of ayurvedic herbal medicines, induced lead toxicity.  Figure 1: The patient’s electrocardiogram on arrival to emergency department ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e8 Moorthy et al     3 Copyright © 2019 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). CONCLUSIONS Acute lead toxicity should be suspected in patients with abdominal and neurological dysfunction who have a history of chronic ayurvedic medicine intake and they should be promptly treated. In our opinion, physicians should rule out potential toxicity from these supplements and have a heightened level of suspicion for lead toxicity in any patients with abdominal pain and AKI without an obvious cause.  ACKNOWLEDGMENTS We thank the residents, nurses, and paramedical staff of the Department of Emergency Medicine and Nephrology at Baby Memorial Hospital, Kerala, India. AUTHORS’ CONTRIBUTION All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. CONFLICTS OF INTEREST The authors have no conflicts of interest to report. Any conflicts that the editor considers relevant to the content of the manuscript have been disclosed. FUNDING No funding from any source was received or used for this case report. REFERENCES1. Lin JL, Lin-Tan DT, Hsu KH, Yu CC. Environmental lead exposure and progression of chronic renal diseases in patients without diabetes. N Engl J Med. 2003;348(4):277-86. 2. Jha V, Rathi M. Natural medicines causing acute kidney injury. Semin Nephrol. 2008;28(4):416-28. 3. Sathe K, Ali U, Ohri A. Acute renal failure secondary to ingestion of ayurvedic medicine containing mercury. Indian J Nephrol. 2013;23(4):301-3. 4. Tait PA, Vora A, James S, Fitzgerald DJ, Pester BA. Severe congenital lead poisoning in a preterm infant due to a herbal remedy. Med J Aust. 2002;177(4):193-5. 5. Karimpour Reihan S, Firuzei E, Khosravi M, Abbaszadeh M. Coagulation Disorder following Red Clover (Trifolium Pratense) Misuse: a Case Report. Adv J Emerg Med. 2018;2(2):e20. 6. Saper RB, Kales SN, Paquin J, Burns MJ, Eisenberg DM, Davis RB, et al. Heavy metal content of ayurvedic herbal medicine products. JAMA. 2004;292(23):2868-73.  

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Interstitial Nephritis Presenting as Acute Kidney Injury Following Ingestion of Alternative Medicine Containing Lead: A Case Report

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