Fever, acute renal failure and pulmonary edema

A 39-year-old female presented with an 8-day history of fever, myalgia, back pain, nausea and vomiting, visual impairment, anuria and weight gain of 9 kg within 1 week. Neither cough nor dyspnea was reported. She had no previous medical history and no regular medication. She is a florist by profession and exposed to moss collected in the forest. She does regular mountain biking tours. On admission, she was severly ill. Jugular vein congestion was present; auscultation and percussion of the lungs were pathologic. The abdomen was tender and painful on palpation and suspicious for ascites. All other findings were unremarkable. Abnormal laboratory findings on admission were white blood count (WBC) 13/nL, platelets 84 /nL, lactate dehydrogenase (LDH) 285 U/L, creatinine 5.4 mg/ dL, urea 69 mg/dL, uric acid 6.5 mg/dL and C-reactive protein (CRP) 68 mg/L (normal < 5) as well as proteinuria and hematuria. All other values were unremarkable. Kidney ultrasound revealed bilateral kidney enlargement with hyperechogenic parenchyma. A chest X-ray and abdominal computed tomography (CT) (non-enhanced due to renal impairment) were performed with the findings presented in Figure 1–4.