Acute hemolysis and renal failure following discontinuous use of rifampin

Rifampin is frequently used in the treatment of mycobacterial infections. Intermittent or discontinuous therapy with rifampin has been associated with systemic symptoms referred to as the "flu syndrome" and, less frequently, acute hemolysis and acute renal failure. We report the case of a 73-year-old woman who experienced acute hemolysis and renal failure while being treated with rifampin and ethambutol for a respiratory infection caused by Mycobacterium fortuitum and M. avium-intracellulare. This patient had interrupted her therapy for periods of one week or more due to a rash and flu-like symptoms, which she ascribed to her medications. A review of the literature indicated that these adverse effects of rifampin appear to be immunologically mediated and that the symptoms of the flu syndrome may be due to mild intravascular hemolysis. Intermittent therapy with rifampin should be avoided and noncompliant patients should be given alternative treatment when possible.