Nephrology Image: Shocking urine

A 53-year-old man with diabetes mellitus who underwent decreased donor kidney transplant 9 months prior presented with cough and dyspnea. Chest computed tomography scan demonstrated multiple bilateral cavitary lesions with surrounding ground glass opacities. Bronchoscopy and bronchoalveolar lavage culture demonstrated Nocardia nova. High-dose oral sulfamethoxazole-trimethoprim (1600–320mg every 8h) was initiated. Over the next 3 days the patient developed oliguria and serum creatinine increased from 2.0mg/dl to a peak of 3.3mg/dl. Automated urinalysis revealed the following: pH 6.0, small blood, and few amorphous crystals. The nephrologist who performed urine microscopy noted 0–1 amorphous crystals per high-power field with a ‘shock of wheat’ appearance (Figure 1). These were consistent with sulfamethoxazole crystals. The drug was discontinued and meropenem and minocycline were substituted. Hemodialysis was initiated for diuretic unresponsive hypervolemia in the setting of acute kidney injury (AKI). The patient began to recover kidney function after 72h, and dialysis was discontinued with serum creatinine returning to baseline.