Peripheral Neuropathies in Patients with Rhabdomyolysis: Clinical Characteristics and Electrodiagnostic Findings in the Acute/Subacute Stage

BACKGROUND: Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and characterized by myalgia and swelling of the affected muscles. Peripheral nerve injury rarely occurs in patients with rhabdomyolysis. METHODS: We reviewed the medical records of 8 consecutive patients with peripheral neuropathies associated with rhabdomyolysis. We assessed the clinical characteristics and electrodiagnostic findings of eight patients. RESULTS: In seven patients, rhabdomyolysis occurred after prolonged immobilization. In one patient, blunt trauma was a cause of rhabdomyolysis. All patients presented with weakness and paresthesia in lower extremities and electrodiagnostic tests showed peripheral nerve injury suggesting sciatic neuropathy or lumbosacral plexopathy. Although rhabdomyolysis itself recovered completely in all patients, neurologic deficits from neuropathy recovered partially and slowly. CONCLUSIONS: Sciatic nerve or lumbosacral plexus was injured in all eight patients. Among the various causes of rhabdomyolysis, prolonged immobilization is associated with development of peripheral neuropathy.

Acute Kidney Injury due to Rbadomyolysis Complicated with Zolpidem Overdose / 대한내과학회지

Zolpidem (Stilnox®, Handok, Seoul, Korea) is a hypnotic imidazopyridine that is often used to treat insomnia because it has less abuse and addiction potential than benzodiazepines. Its side effects include headache, dizziness, and nausea, but these are mild. Zolpidem intoxication rarely has severe complications. Here, we report a case of acute kidney injury due to rhabdomyolysis related to zolpidem. A 51-year-old man was admitted with drowsy mentality after taking an overdose of zolpidem in a suicide attempt. Laboratory findings showed a blood urea nitrogen of 59.9 mg/dL, serum creatinine of 5.8 mg/dL, and creatine phosphokinase of 16,210 IU/L. Acute kidney injury associated with rhabdomyolysis complicating zolpidem intoxication was diagnosed. The patient was managed with hemodialysis and recovered completely in terms of renal function and muscle enzyme levels.

A Case of Rhabdomyolysis Presenting with Acute Kidney Injury Complicating Carbon Monoxide Poisoning / 대한내과학회지

Carbon monoxide (CO) poisoning has increased rapidly in South Korea and may cause a variety of clinical effects. The most common complications are neurologic and neuropsychological disturbances. However, in rare cases, CO poisoning may also be associated with acute kidney injury and non-traumatic rhabdomyolysis. Here, we report a case of acute kidney injury and rhabdomyolysis complicating CO poisoning. A 32-year-old woman was admitted to our emergency department with dyspnea and confused consciousness after exposure to CO during a suicide attempt involving charcoal briquettes. Laboratory findings revealed a carboxyhemoglobin (COHb) level of 44.8%, a blood urea nitrogen level of 20.5 mg/dL, a serum creatinine level of 1.4 mg/dL, and a creatine phosphokinase level of 8,688.3 IU/L. Acute kidney injury and rhabdomyolysis complicating CO poisoning were diagnosed. This case was managed with normobaric oxygen therapy and hydration. The patient recovered completely with respect to renal function and muscle enzyme level, and COHb level returned to 0%.

A Case of Acute Kidney Injury in a Patient with Pulmonary Tuberculosis Receiving Ethambutol Therapy / 대한내과학회지

Ethambutol is commonly used as a first-line drug for the treatment of tuberculosis. The most serious adverse effect of ethambutol therapy is optic neuropathy. However, ethambutol-induced acute kidney injury is extremely rare. We report herein a case of acute kidney injury secondary to ethambutol-associated acute interstitial nephritis. A 65-year-old man with pulmonary tuberculosis presented with a > 7-day history of nausea and vomiting. He had begun antituberculosis medications including ethambutol 3 weeks previously. His laboratory findings showed elevated blood urea nitrogen and serum creatinine levels (32.6 and 3.6 mg/dL, respectively). Examination of percutaneous renal biopsy specimens showed diffuse interstitial mononuclear cell infiltration with mild interstitial edema. The patient was treated by cessation of ethambutol and supportive care. His renal function completely recovered (creatinine, 1.1 mg/dL) and his clinical symptoms improved.

Erratum: A Case of Acute Kidney Injury in a Patient with Pulmonary Tuberculosis Receiving Ethambutol Therapy / 대한내과학회지

We correct the revised date of this article.

A Case of Acute Bilateral Renal Infarction Associated with Protein S Deficiency / 대한신장학회지

Acute renal infarction usually occurs in patients with trauma, atrial fibrillation, atherosclerosis, vasculitis, and valvular heart disease. However, it may occur, though rarely, in patients with hypercoagulable states such as protein C and protein S deficiency. We report here a case of acute bilateral renal infarction associated with type II protein S deficiency without a demonstrable underlying cause. A 48-year-old male was presented to the emergency room with an abrupt, persistent pain at the left flank area. Three-dimensional abdominal computed tomography revealed wedge-shaped, well demarcated, low density lesions in both the kidneys, which were consistent with occlusions of segmental branches of both the renal arteries. Protein S activity by clot-based assay was 43% (73.7-146.3%). The patient was treated with intravenous heparin and later warfarin. He has remained symptom-free on warfarin therapy with preserved renal function during the follow-up of 5 weeks.

The Effect of Extract of Paeonia lactiflora on the Improvement of Ischemic Acute Renal Failure / 대한신장학회지

PURPOSE:The present study was undertaken to investigate whether the extract or the ethyl acetate fraction of Paeonia lactiflora, which improves cell survival under ischemic condition by inhibiting apoptosis, can prevent ischemic acute renal failure, using rats as an animal model. METHODS:In the control group, ischemia/reperfusion (I/R) injury was induced in male Sprague-Dawley rats by clamping of left renal pedicle for 45 minutes after removal of the right kidney, and subsequent reperfusion of the pedicle for 24 hours. In the experimental group, the water extract or ethyl acetate fraction of methanol extract Paeonia lactiflora was injected 1 hour prior to ischemia/reperfusion injury. We measured serum concentrations of creatinine at 24 hours after I/R injury. And the kidneys were extracted, fixed in a 10 % neutral-buffered formalin solution, embedded in paraffin and used for histopathological examination. RESULTS:Rats in the experimental group, treated with water extract or ethyl acetate fraction of methanol extract of Paeonia lactiflora, exhibited significant decrease in the serum concentrations of creatinine (approx. 2.0 mg/dL), compared with those in the control group (approx. 4.0 mg/dL). Finally, the cell morphology of the kidney of rats treated with ethyl acetate fraction of Paeonia lactiflora was well preserved, when judged from histopathological point of view. CONCLUSION:Pretreatment of rats with the water extract or ethyl acetate fraction of Paeonia lactiflora might be beneficial for the treatment of acute renal failure in humans.

A Case of Osteomyelitis of the Clavicle as a Complication of Subclavian Vein Catheterization in Hemodialysis Patient / 대한신장학회지

Osteomyelitis (OM) of the clavicle is a rare complication of the central venous catheterization and has been reported infrequently in the literature. We report here a case of OM of the left clavicle complicating right subclavian vein catheterization performed for hemodialysis (HD). A 41-year-old male patient on HD for 3 months complained of pain and mass over the left sternoclavicular joint. Computerized tomography showed a demarcated soft tissue mass. Bone scan demonstrated increased tracer uptake in the left clavicle compatible with OM. The patient underwent surgical exploration with removal of the necrotic bone and he was treated with antibiotics including vancomycin. Afterward he remained well on HD. In conclusion, OM should be considered in any dialysis patient who develops pain and signs of inflammation in the sternoclavicular area after central venous catheterization for HD.

Effect of antitumor agents on the survival of human hepatocellular carcinoma cells under hypoxic conditions / 대한내과학회지

BACKGROUND: In a previous study, we have shown that quinolones, antibiotics inhibiting topoisomerases, improve survival of tumor cells under hypoxic conditions. In this study, we tested whether antitumor agents such as doxorubicin that inhibit topoisomerases can also improve survival of tumor cells under hypoxic conditions. METHODS: Human hepatocellular carcinoma cells (HepG2) were grown in 4 mL of the culture medium at 2.5x10(5) cells/60 mm culture dish under normoxic conditions for 2 days before being transferred to fresh culture medium with different concentrations of doxorubicin or other antitumor agents under normoxic or hypoxic (1% oxygen concentration in air) conditions. Cell viability and the concentration of glucose and lactic acid in the medium were measured during cell culture. At the same time, the cells in the 60 mm dishes were lysed, and chromosomal DNA was isolated and loaded onto a 1.5% agarose gel for the DNA fragmentation assay. RESULTS: Doxorubicin inhibited cell growth under normoxic condition in a concentration-dependent manner for the 0~100 microgram/mL concentration range. However, doxorubicin improved cell viability under hypoxic conditions for a 0.1~10 microgram/mL concentration range by inhibiting apoptosis. Similar phenomena were observed for other antitumor agents that inhibit topoisomerases. CONCLUSIONS: Solid tumors usually have hypoxic regions in the tumor, under which conditions antitumor agents that inhibit topoisomerases may function to delay tumor cell death. This can reduce the efficacy of the antitumor agents.

Focal Segmental Glomerulosclerosis in a Patient with Behcet's Disease: A Case Report and Review of Literature / 대한신장학회잡지

No abstract available.

A Case of Pure Red Cell Aplasia Due to Parvovirus B19 Infection in a Renal Transplant Recipient / 대한신장학회잡지

We report a case of pure red cell aplasia due to parvovirus B19 infection in a renal transplant recipient. The patient was a 32-year-old male with end stage renal disease due to chronic glomerulonephritis, who had been undergoing regular hemodialysis. He received a living nonrelated renal transplant and immumosuppressive therapy including prednisolone, tacrolimus, and mycophenolate mofetil. One week after kidney transplantation, severe anemia was persisted despite recombinant human erythropoietin administration and packed red blood cell transfusion. His bone marrow aspiration smear demonstrated erythroid hypoplasia and giant pronormoblasts with prominent intranuclear inclusions. Both serum and bone marrow were positive for parvovirus B19 DNA polymerase chain reaction and anti-parvovirus B19 IgM. He was treated with intravenous immunoglobulin and conversion of tacrolimus to cyclosporine. His hemoglobin level was completely recovered three months later.

A Case of Goodpature's Syndrome with Perinuclear-Antineutrophil Cytoplasmic Antibody / 대한신장학회잡지

No abstract available.

Nephrotic Syndrome, Hepatitis and Gastric Involvement in Secondary Syphilis / 대한신장학회잡지

Syphilis, caused by the spirochete Treponema pallidum, is a chronic systemic infectious disease. Nephrotic syndrome, hepatitis, or gastric involvement resulting from secondary syphilis are well-documented complications, but very rare. Moreover, the simultaneous occurrence of these complications in the same patient is extremely rare. This report describes 43-year-old male patient with syphilis presented with features of nephrotic syndrome, acute hepatitis, and gastric involvement. A diagnosis of secondary syphilis was made by skin lesions and serologic tests for syphilis. After a diagnosis of syphilis, we supposed that nephrotic syndrome and hepatitis were the complications of secondary syphilis and performed kidney and liver biopsies. A kidney biopsy revealed membranous nephropathy characterized by subepithelial hump-like electron-dense deposits and effacement of epithelial foot-processes on electron microscopy. A liver biopsy showed a feature of lobular hepatitis with a few granulomas. Esophagogastroduodenoscopy (EGD) showed multiple shallow ulcers with varying degrees of nodular mucosa at gastric antrum. The patient was treated with intramuscular benzathine penicillin G, 2.4 million units. Proteinuria, skin lesion, hepatitis, and EGD finding were resolved rapidly after penicillin therapy. In conclusion, syphilis should be considered in the differential diagnosis of the nephrotic syndrome, hepatitis, and gastric involvement occurring separately or simultaneously.

Expression of Transforming Growth Factor-beta1 in Spontaneously Developed Diabetic Rats / 대한신장학회잡지

BACKGROUND: Diabetic nephropathy is a common cause of end-stage renal disease by means of glomerular and interstitial fibrosis. Increases in extracellular matrix (ECM) and changes in its components have been documented in the glomeruli of diabetic nephropathy. Fibrogenic cytokines, particularly transforming growth factor (TGF)-beta1, play a central role in progressive renal fibrosis. Activated TGF-beta1 is known to increase the production of ECM as collagen and fibronectin. Otsuka Long-Evans Tokushima Fatty (OLETF) rat is an inbred strain that spontaneously develops non-insulin-dependent diabets mellitus which progresses to diabetic glomerulosclerosis. This study is examined the time points and localization of TGF-beta1 in diabetic glomerulosclerosis of OLETF rats. METHODS: OLETF rats, a chronic model for human type 2 diabetes mellitus, and age-matched control (LETO) rats were used. Blood was assayed for glouse and body weight were measured. From rats aged 30 to 60 weeks, animals were sacrificed under ether anesthesia, and both kidneys were removed. Portions of these tissues were processed for light microscopy and immunohistochemistry of TGF-beta1. TGF-beta1 mRNA levels were measured by reverse transcription polymerase chain reaction. RESULTS: The body weights of OLETF rats were significantly greater than those of LETO rats from the age of 30 to 40 weeks, but those of OLETF rats gradually decreased after 40 weeks of age. There were no differences in body weights between these two strains at 50 weeks of age. Blood glucose levels of OLETF rats increased significantly with aging and were significantly higher than those of LETO rats after 32 weeks of age. There was no significant fibrosis in kidney of OLETF and LETO rats at all ages examined. The TGF-beta1 protein was detected in the glomerular endothelial cells and tubular epithelial cells of OLETF rats at 35 to 38 weeks of age. The TGF-beta1 protein in tubular epithelial cells of OLETF rats was strongly expressed at 60 weeks of age, whereas the glomerular endothelial cells scarcely detected the expression of TGF-beta1 protein. In LETO rat kidneys, the TGF-beta1 protein is detected in the glomerular endothelial cells at 35 weeks of ages, but is not detected in any other cells. The TGF-beta1 mRNA of OLETF rats were increased at 32 weeks of age, higher than that of control LETO rats. CONCLUSION: Until 60 weeks of age, glomerular sclerosis became very weakly in OLETF rats. However, in 30-week-old OLETF rats, the blood gloucose levels and TGF-beta1 protein increased significantly. The TGF-beta1 protein was detected in the glomerular endothelial cells and tubular epithelial cells of OLETF rats at 37 weeks of age.

Acute renal failure by intermittent rifampin administration in leprosy patient / 대한내과학회지

A 74-years-old female with leprosy was hospitalized because of nausea, vomiting, and oliguria after ingestion of rifampin 600 mg once for one day. At this time, after taking the second dose of rifampin, she presented with anemia, hepatic dysfunction and oliguric renal failure. Renal biopsy specimen showed acute interstitial nephritis and tubular necrosis without immunoglobulin deposition on immunofluorescence examination. Peripheral blood smear showed fragmented red blood cells (RBCs) and direct Coombs' test was positive. Indirect antiglobulin test with patient's serum using RBCs sensitized in vitro with rifampin showed positive finding. The renal failure and systemic symptoms were improved after discontinuation of rifampin, high dose prednisolone administration and several sessions of hemodialysis.

A Case of Crescentric Glomerulonephritis Superimposed on Preexisting Membranous Nephropathy / 대한신장학회잡지

Membranous nephropathy (MGN) is a common cause for nephrotic syndrome in adults. Renal failure usually develops gradually in patients with MGN and rapid deterioration of renal function is a rare complication. Moreover, the development of crescentric glomerulonephritis (CGN) as a cause of acute renal failure (ARF) in patients with preexisting MGN is very rare. We report 20-year-old male patient with MGN who presented with ARF due to superimposed CGN. He had been diagnosed as idiopathic MGN and his renal function was maintained within normal range. After 13 months of conservative treatment, ARF was developed and renal biopsy was performed to differentiate the possible causes of ARF. Renal biopsy revealed diffuse crescents formation on preexisting MGN. Anti-GBM antibody and ANCA were not detected. This patient was treated with combination therapy including methylprednisolone pulse therapy followed by high dose steroid and cyclophosphamide. His renal function was improved significantly 2 weeks after treatment. In conclusion, when unexplained ARF in patient with MGN develops, prompt investigation for superimposed conditions including CGN is necessary and repeat renal biopsy should be considered.

A Case of Medullary Cystic Disease which Progressed to End Stage Renal Disease during Pregnancy / 대한신장학회잡지

Medullary cystic disease (MCD) and familial juvenile nephronophthisis are inherited diseases characterized by development of small cysts at the cortico- medullary borders of the kidneys. Both diseases consist of microscopic or gross cysts of the renal medullae associated with atrophy of nephrons, anemia, renal insufficiency, polyuria, and salt-wasting. We report a 27-year-old pregnant female patient with MCD which caused acute renal failure progressing to end stage renal disease during the second trimester. Hypertension, oliguria, preeclampsia, placenta abruptio, and disseminated intravascular coagulation were also accompanied. Radiologically, abdominal ultrasonography and computed tomogram showed many cysts confined only to the renal medullae, which are typical findings consistent with MCD. In spite of conservative therapy, her renal function deteriorated rapidly and uremic symptoms including pulmonary edema were aggravated. She was started on hemodialysis and she has received regular hemodialysis without recovery of renal function.

A Case of Rapidly Progressive Glomerulonephitis Associated with Anti-Glomerular Basement Membrane Antibody and p-Antineutrophilic Cytoplasmic Antibody / 대한신장학회잡지

Rapidly progressive glomerulonephritis(RPGN) is clinical syndrome characterized by rapid loss of renal function within several weeks to months, with histologic finding of extensive crescent formation. We report a case of RPGN associated with anti-glomerular basement membrane antibody(anti-GBM Ab) and perinuclear-antineutrophilic cytoplasmic antibody(p- ANCA), which rapidly progressed to chronic renal failure. A 44-year-old male was referred to our hospital for evaluation of pitting edema and proteinuria. Both anti-GBM Ab and p-ANCA were detected in serum. Percutaneous renal biopsy showed many crescents with some fibrinoid materials and heavy deposits of IgG. He was treated with pulse methylprednisolone, followed by oral corticosteroid and cyclophosphamide. In spite of immunosuppressive therapy, his renal function deteriorated rapidly and uremic symptoms including pulmonary edema were aggravated. He was started on hemodialysis and he has received regular hemodialysis without recovery of renal function. Further studies will be needed to determine the clinical significance of combined anti- GBM Ab and ANCA.

A Case of the Membranous Glomerulonephritis Associated with Squamous Cell Lung Cancer / 결핵

The nephrotic syndrome that occurs in the absence of renal vein thrombosis, amyloidosis, neoplastic infiltration of the kidneys is an unusual but a well recognized paraneoplastic syndrome. The most frequently reported neoplasms associated with nephrotic syndrome are Hodgkin's disease and various carcinomas. The most common renal lesions are membranous glomerulonephritis(MGN) associated with carcinomas and minimal change lesions associated with Hodgkin's disease. Approximately 40% to 45% of patients clinically manifest the MGN symptoms prior to the diagnosis of the tumor, 40% simultaneously with the tumor and the remaining 15% to 20% following the tumor. Therefore, evaluating the underlying malignancy in patients with MGN is important. Here we report a patient with squamous cell lung cancer, which was detected 12 months after a MGN had been diagnosed, with a review of the relevant literature.

A Case of Collapsing Glomerulopathy Discovered in End Stage Renal Disease(ESRD) with Normal Sized Kidney / 대한신장학회잡지

Collapsing glomerulopathy is recently described as the disease which causes rapidly progressive renal failure. Clinically, the disease starts with constitutional symptoms, and then nephrotic syndrome with marked proteinuria and hypertension follows. Eventually the disease rapidly progresses to the ESRD within several weeks to months. Its typical renal biopsy findings are extensive glomerular capillary collapse, visceral epithelial cell hypertrophy and hyperplasia, and variable degree of tubulointerstitial inflammation. Such findings closely resemble those of HIV associated nephropathy(HIVAN) except endothelial inclusion body in HIVAN. Here we present, for the first time in Korea, a 16 yrs-old female patient with ESRD in a normal sized kidney. Nephrotic syndrome and hypertension were also accompanied. Serologically, she had no evidence of HIV infection. Though her symptom duration was somewhat shorter than that previously reported, her renal biopsy findings were those of collapsing glomerulopathy as previously described. Her renal function did not return to normal, and now she is on regular hemodialysis, waiting for renal transplantation.