A day in the zoo

A 32-year-old woman was referred with a diagnosis of acute kidney injury (AKI). She had initially presented to a regional district hospital with a short history of feeling generally unwell with flu-like symptoms, headache as well as conjunctivitis and photophobia. She had no previous medical history whatsoever and was on no medication. She then developed thrombocytopenia (platelet count 37 × 10/L [normal 140–440 × 10/L]), AKI (serum creatinine 449 μmol/L [normal 45–84 μmol/L]) and mildly deranged liver function tests (ALT 81 U/L [<41 U/L]). Lactate dehydrogenase was elevated at 900 U/L (240–480 U/L). Hepatitis and HIV serology were negative. A haematologist did not see any fragmented red blood cells in repeated films of peripheral blood, which were also negative for malaria and ehrlichiosis. Intravenous ceftriaxone was begun to cover meningoencephalitis although a subsequent sample of cerebrospinal fluid was normal. A computed tomography of the brain was also normal. On arrival here, her vital signs were stable and she was no longer photophobic. There was no neck stiffness. The remainder of the clinical examination was essentially unremarkable. The patient had not travelled abroad and all her family were well. She worked as a zookeeper in a wildlife park. During the last weeks, she had worked with a variety of captive birds, kangaroos, and primates, such as lemurs (Figure 1). The patient did not recall exposure to sick animals but had cleaned kennels recently. Urine dipstick was positive for blood and leucocytes but negative for protein and nitrite. Virology and autoimmune screen was negative. Ultrasound showed normal sized kidneys with no evidence of obstruction. Plans were made for an urgent renal biopsy but serum creatinine improved to 221 μmol/L on Day 4.