Diagnosing Etiology by Urine Microscopy in Sudden Spurt of Acute Kidney Injury Cases: Going Back to the Basics

Cases: Going Back to the BasicsTo the Editor: Recently, a sudden rise in acute kidney injury in children has been reported from Indonesia, Gambia, and a few other countries. 1The suspected cause of these cases appeared to be from adulteration of cough, cold, and fever medications with diethylene glycol and ethylene glycol in place of the more expensive, nontoxic solvent glycerol. 1,2The metabolite of these adulterants leads to the formation of oxalic acid and calcium oxalate monohydrate or dihydrate crystals leading to oliguric and anuric acute kidney injury and cerebral edema. 3,4e describe here a recent representative case, one of many of such cases in Uzbekistan, and the role of urine microscopy in diagnosing the etiology in such cases.This 5-year-old girl presented to the hospital with a history of flu-like symptoms with high grade fever, cough, and cold for 4 days, altered sensorium and complete anuria since day 1.All such children had taken paracetamol and cough syrup of the same brand.The medications for fever and cough were taken 3 times a day, 4 days before anuria and altered mental status.The child required daily hemodialysis and mechanical ventilation.Laboratory evaluation showed disproportionate severe metabolic acidosis, high osmolar gap, evidence of severe acute kidney injury, and elevated aspartate aminotransferase, alanine transaminase and lactate dehydrogenase >10 times the normal range.The child's urine examination is shown in Figure 1.Typical clinical presentation, laboratory evidence of high osmolar gap, and the urine microscopy confirmed the diagnosis of suspected diethylene glycol adulteration.This child needed hemodialysis and supportive care for anuric acute kidney injury, which resolved in 4 weeks with a normal serum creatinine and no proteinuria on followup at 6 months.Calcium oxalate crystals may appear in urine as rods or in a classic "dumbbell" appearance in the monohydrate form, whereas the dihydrate crystals appear as envelope like structures, as seen in our representative case (Figure 1).The calcium oxalate crystals are not

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