To the Editor,
I would like to report a patient who developed fever and renal function impairment after mesalamine administration for ulcerative colitis, which disappeared when mesalamine was stopped.
A 22-year-old female patient was admitted to our hospital with bloody diarrhea lasting for 6 weeks, erythema nodosum, and bilateral arthritis in the knees. Until the diagnosis, metronidazole 1500 mg/day (IV) was ordered, but the symptoms did not resolve, and on the seventh day, a colonoscopic evaluation was planned. The colonoscopic and pathological examination was compatible with ulcerative colitis, and the sacroiliac MRI scan revealed bilateral sacroiliitis. She was diagnosed as ulcerative colitis and enteropathic arthritis. Firstly, 60 mg/day methylprednisolone was ordered, and 4 days later, 2000 mg/day of mesalamine was added to the treatment protocol. After the addition of mesalamine, a fever of 39.5°C developed. First, she was evaluated for additional infections, but an infectious reason could not be found. Parallel to the fever, renal function impairment also occurred. Although the basal creatinine level was 0.87 mg/dL, it increased up to 2.46 mg/dL in 4 days. After the cessation of mesalamine treatment, the fever disappeared, and the creatinine level came to normal levels. Now, she is on a treatment protocol with azathioprine 150 mg/day, and the steroid has been tapered slowly and stopped.
Mesalamine-induced fever, hypersensitivity pneumonitis, pericarditis, interstitial nephritis, acute and chronic renal failure, and exacerbation of symptoms have been reported before (1–8). But, to our knowledge, both fever and acute reversible renal failure in the same patient have not been reported before.
Sulfasalazine and mesalamine are frequently used in the daily practice of rheumatology and gastroenterology. On the other hand, although it is a very safe drug when compared to most others, it may also have some unexpected side effects. In a patient with ulcerative colitis, the disease itself, amebic colitis, arthritis due to enteropathic arthritis, and nosocomial infections may all cause fever. But, if a patient develops fever under steroid therapy, the prescribed drugs may also be checked.
In conclusion, all drugs have rare side effects, and this must not discourage clinicians in preferring them.
Footnotes
Ethics Committee Approval: N/A.
Informed Consent: Written informed consent was obtained from patient who participated in this study.
Peer-review: Externally peer-reviewed.
Conflict of Interest: No conflict of interest was declared by the authors
Financial Disclosure: The author declared that this study has received no financial support.
References
- 1.Hatemi I, Goksu A, Dobrucali A. Mesalazine induced drug fever. J Gastrointestin Liver Dis. 2010;19:222–3. [PubMed] [Google Scholar]
- 2.World MJ, Stevens PE, Ashton MA, Rainford DJ. Mesalazine-associated interstitial nephritis. Nephrol Dial Transplant. 1996;11:614–21. doi: 10.1093/oxfordjournals.ndt.a027349. http://dx.doi.org/10.1093/oxfordjournals.ndt.a027349. [DOI] [PubMed] [Google Scholar]
- 3.Laboudi A, Makdassi R, Cordonnier C, Fournier A, Choukroun G. Chronic interstitial nephritis induced by 5-aminosalicylic acid: a new case report. Nephrologie. 2002;23:343–7. [PubMed] [Google Scholar]
- 4.Tadic M, Grgurevic I, Scukanec-Spoljar M, Bozic B, Marusic S, Horvatic I, et al. Acute interstitial nephritis due to mesalazine. Nephrology (Carlton) 2005;10:103–5. doi: 10.1111/j.1440-1797.2005.00376.x. http://dx.doi.org/10.1111/j.1440-1797.2005.00376.x. [DOI] [PubMed] [Google Scholar]
- 5.Shimizu T, Hayashi M, Shimizu N, Kinebuchi S, Toyama J. A case of mesalazine-induced lung injury improved by only discontinuation of mesalazine. Nihon Kokyuki Gakkai Zasshi. 2009;47:543–7. [PubMed] [Google Scholar]
- 6.Park JE, Hwangbo Y, Chang R, Chang YW, Jang JY, Kim BH, et al. Mesalazine-induced eosinophilic pneumonia in a patient with Crohn’s disease. Korean J Gastroenterol. 2009;53:116–20. [PubMed] [Google Scholar]
- 7.Perrot S, Aslangul E, Szwebel T, Gadhoum H, Romnicianu S, Le Jeunne C. Sulfasalazine-induced pericarditis in a patient with ulcerative colitis without recurrence when switching to mesalazine. Int J Colorectal Dis. 2007;22:1119–21. doi: 10.1007/s00384-007-0310-2. http://dx.doi.org/10.1007/s00384-007-0310-2. [DOI] [PubMed] [Google Scholar]
- 8.Yamauchi K, Takeda H, Kobayashi K, Watanabe K, Machida Y, Suzuki H. A case of mesalazine-induced pleuritis with hemophagocytic findings. Nihon Kokyuki Gakkai Zasshi. 2005;43:518–22. [PubMed] [Google Scholar]