C-ANCA-positive glomerulonephritis associated with subacute infective endocarditis caused by Bartonella infection / 영남의대학술지

Glomerulonephritis (GN) is sometimes associated with infective endocarditis (IE). Bartonella endocarditis is difficult to diagnose because it is rare and cannot be detected by blood culture. This is the first report of cytoplasmic anti-neutrophil cytoplasmic antibody-positive subacute endocarditis-associated GN caused by Bartonella infection in South Korea. A 67-year-old man was hospitalized due to azotemia. He complained of weight loss and anorexia for 6 months. A diagnosis of IE was made based upon echocardiographic detection of vegetations on the mitral and aortic valves and a Bartonella antibody titer of 1:2,048. Renal histology identified focal crescentic GN. Azotemia and proteinuria improved after doxycycline and rifampin treatment combining with steroid therapy.

C-ANCA-positive glomerulonephritis associated with subacute infective endocarditis caused by Bartonella infection / 영남의대학술지

Glomerulonephritis (GN) is sometimes associated with infective endocarditis (IE). Bartonella endocarditis is difficult to diagnose because it is rare and cannot be detected by blood culture. This is the first report of cytoplasmic anti-neutrophil cytoplasmic antibody-positive subacute endocarditis-associated GN caused by Bartonella infection in South Korea. A 67-year-old man was hospitalized due to azotemia. He complained of weight loss and anorexia for 6 months. A diagnosis of IE was made based upon echocardiographic detection of vegetations on the mitral and aortic valves and a Bartonella antibody titer of 1:2,048. Renal histology identified focal crescentic GN. Azotemia and proteinuria improved after doxycycline and rifampin treatment combining with steroid therapy.

A Case of Oliguric Mannitol Induced Acute Kidney Injury Early Treated by Continuous Renal Replacement Therapy / 고신대학교의과대학학술지

We report oliguric mannitol-induced acute kidney injury (AKI) early treated by continuous renal replacement therapy. A 70-year-old woman was admitted to the Department of Neurology with diagnosis of acute intracranial hemorrhage. Mannitol was infused for intracranial pressure control. At admission third day, urine output was abruptly decreased to 57 ml during first 6 hours and blood urea nitrogen (BUN) and serum creatinine was increased to 54.2 mg/dL and 5.3 mg/dL respectively. Plasma osmolality was 340 mOsm/kg and osmolar gap was 70. Mannitol was immediately withdrawn and continuous renal replacement therapy (CRRT) was performed to remove mannitol rapidly. Urine output was increased 6 hours later after continuous veno-veno hemodiafiltration (CVVHDF) start. BUN and creatinine was decreased to 21.4 and 1.2 mg/dL at admission ninth day. Mannitol can develop oliguric AKI and CRRT may be of more benefit than conventional hemodialysis in the case of increased intracranial pressure.

Late Adverse Reaction to Iodixanol (Visipaque(R)) / 대한내과학회지

Late adverse reactions to iodinated contrast medium are defined as reactions occurring 1 hour to 1 week after contrast medium injection. The majority of late adverse reactions are cutaneous reactions, and include itching, maculopapular rash, urticaria, erythematous patches, and angioedema. We report a patient with an iodixanol (Visipaque(R))-induced late adverse reaction. She was admitted for evaluation of nephrotic range proteinuria and edema. Abdomen and chest enhanced computed tomography was performed as a malignancy work-up. Sixteen hours after radiocontrast exposure, her entire body felt itchy. A maculopapular rash was first detected on her back and abdomen 24 hours after exposure, and spread over her entire body, including her face. Her skin lesions resolved completely in 5 days after administering steroid and antihistamine. We should consider late adverse reactions of iodinated contrast medium when we detect skin lesions late after radiocontrast use.

Late Adverse Reaction to Iodixanol (Visipaque(R)) / 대한내과학회지

Late adverse reactions to iodinated contrast medium are defined as reactions occurring 1 hour to 1 week after contrast medium injection. The majority of late adverse reactions are cutaneous reactions, and include itching, maculopapular rash, urticaria, erythematous patches, and angioedema. We report a patient with an iodixanol (Visipaque(R))-induced late adverse reaction. She was admitted for evaluation of nephrotic range proteinuria and edema. Abdomen and chest enhanced computed tomography was performed as a malignancy work-up. Sixteen hours after radiocontrast exposure, her entire body felt itchy. A maculopapular rash was first detected on her back and abdomen 24 hours after exposure, and spread over her entire body, including her face. Her skin lesions resolved completely in 5 days after administering steroid and antihistamine. We should consider late adverse reactions of iodinated contrast medium when we detect skin lesions late after radiocontrast use.

Treatment of Pseudoaneurysm Caused by Insertion of Dual Lumen Catheter for Hemodialysis: A Case Report / 대한신장학회지

In patients with end-stage renal disease, cannulation of the central venous system with large-bore dual-lumen catheters is often necessary until a functioning vascular access can be created. However, the technique of placing a dual-lumen catheter can make complication. The right internal jugular vein is the preferred site of hemodialysis catheter placement because its complication rate was lower compared with the subclavian and left internal jugular veins. Common complications include severe bleeding, hematoma formation, pneumothorax and hemothorax, atrial or ventricular arrhythmias, malposition of the catheter, air embolism, secondary infections, and intraarterial placement of the catheter. We report an unusual case of pseudoaneurysm of the superior thyroidal artery complicating an attempt of internal jugular-vein catheterization which was successfully treated by endovascular coil embolization.

Aspergillus flavus Peritonitis Detected by Fungal Balls in the Blood Culture Bottles: A Case Report / 대한신장학회지

Fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients is rare. But, it is a serious complication of CAPD because of high morbidity and mortality. It is very important to diagnose and treat such infections promptly, as otherwise it has a poor prognosis. We experienced a case of peritonitis in a CAPD patient that was caused by Aspergillus flavus detected by fungal balls in blood culture bottles and treated successfully by administering anti-fungal agents and removing the peritoneal dialysis catheter.

Renal Pelvic Hematoma Induced by Delayed Re-bleeding After Renal Biopsy / 대한신장학회지

Renal biopsy is a useful method for the diagnosis of kidney disease. Complications may occur and are usually associated with bleeding. However, delayed recurrent bleeding is so rare. We report a case of renal pelvic hematoma and hydronephrosis occurred by delayed re-bleeding after percutaneous needle renal biopsy. A 42-year-old woman was admitted to our institution via emergency room with gross hematuria and left flank pain, which had started on that day. Renal biopsy had been done 8 days earlier. Computed tomography (CT) angiography revealed left hydronephrosis caused by pelvic hematoma and we observed bloody urine in the left ureteral orifice on cystoscopy. Hydration, diuresis and double J stent insertion restored hydronephrosis and hematuria was disappeared. Even though renal pelvic hematoma by delayed bleeding occurs rarely after percutaneous needle kidney biopsy, we should consider this complication when delayed recurrent gross hematuria occurs after kidney biopsy.

A case of peritonitis caused by Pantoea agglomerans in a patient undergoing continuous ambulatory peritoneal dialysis / 대한내과학회지

Microorganisms belonging to the genus Pantoea rarely cause infection in normal hosts, but are common in hospitalized or immunocompromised patients. Pantoea agglomerans has frequently been associated with exogenous sources such as plants, soil, water, and foodstuffs. Until now, only one case of P. agglomerans associated peritonitis has been reported in an adult patient undergoing continuous ambulatory peritoneal dialysis (CAPD). We report a case of peritonitis due to P. agglomerans in a 55 year old man with maintenance CAPD. Antibiotic therapy with intraperitoneal cefazolin and gentamicin led to clinical improvement.

Transaxillary Renal Artery Angioplasty and Stenting in a Single-Kidney Patient with Leriches Syndrome / 대한신장학회지

We report a case of renovascular hypertension (RVH) by severe left renal artery stenosis (RAS) that was successfully treated by percutaneous intervention in a single-kidney patient with Leriches syndrome. A 51-year-old man was admitted to our hospital due to uncontrolled hypertension on medications with maximal doses. CT angiography showed complete occlusion of the infrarenal abdominal aorta, the absence of the right kidney and the approximately 80% stenosis of the proximal left renal artery. The proximal left RAS was considered as an important factor in uncontrolled secondary hypertension and aggravation of his renal function. We made an attempt to relieve the RAS by transaxillary renal artery angioplasty and stenting because of the total occlusion of the bilateral iliac artery. His renal function was remarkably improved and his hypertension was well controlled with less antihypertensive medications after the procedure.

Peritonitis and Intra-abdominal Abscess by Trichoderma longibrachiatum in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) / 대한신장학회지

Peritonitis by Trichoderma longibrachiatum in patients undergoing CAPD has been reported rarely in the literature. We describe a case of peritonitis and intra-abodominal abscess caused by an unusual fungus, Trichoderma longibrachiatum, in a patient undergoing CAPD. The patient was successfully treated with catheter removal, anti-fungal agents and appropriate drainage.

Abdominal Actinomycosis Associated with a Sigmoid Colon Perforation in a Patient with a Ventriculoperitoneal Shunt

Abdominal actinomycosis causing hydronephrosis in a patient with a ventriculoperitoneal shunt is very rare. A 27- year-old female patient was admitted complaining of lower abdominal pain. She had undergone ventriculoperitoneal shunt surgery 10 years ago. Abdominal Ultrasonography and a CT scan demonstrated an inflammatory mass in the lower left quadrant of the abdomen causing obstructive hydroureter and hydronephrosis. Laparotomy revealed a diffusely infiltrating mass involving the small bowel, mesentery, and sigmoid colon, and a 1cm perforation in the sigmoid colon. Actinomycosis was diagnosed upon histological examination. After treatment with antibiotics and surgery, the patient's condition improved.

Acute Bilateral Renal Cortical Necrosis Associated with Diclofenac Sodium / 대한신장학회잡지

Acute bilateral renal cortical necrosis is relatively unusual cause of acute renal failure (ARF). We report a rare case of acute bilateral renal cortical necrosis associated with diclofenac sodium. A 57-year-old man visited to our hospital with progressive oligoanuria for three days. Four days earlier, after diclofenac sodium 150 mg was injected intramuscularly at local hospital, he experienced anaphylactic shock. Our laboratory findings revealed the existence of fibrin split, thrombocytopenia, coagulopathy, and microangiopathic hemolytic anemia (MAHA). These findings were compatible with disseminated intravascular coagulation (DIC). The radiocontrast enhancement CT scan showed a bilateral lack of enhancement of the renal cortex after contrast infusion, enhancement of renal medulla, and the absence of renal excretion of the contrast dye. Renal biopsy showed a cortical necrosis with congested acellular glomuruli and necrotic tubules. Empiric treatment including hemodialysis was commenced. Although his renal function was not completely recovered, he is now being followed up at this hospital without dialysis.

Acquired Pure Red Cell Aplasia due to Anti-Erythropoietin Antibodies in a Patient Undergoing Hemodialysis / 대한혈액학회지

A 63-year-old man was placed on hemodialysis for the end-stage of renal disease secondary to renal artery stenosis. He was also regularly given epoetin, subcutaneously, for anemia associated with his renal disease. Rapidly progressing erythropoietin (EPO) resistant anemia and reticulocytopenia developed after 1 year of hemodialysis. The patient required frequent red blood cell transfusions. The bone marrow examination demonstrated selective erythroid hypoplasia. A detailed search for the cause of the erythroblastopenia revealed nothing, with the exception of anti-EPO antibodies (Ab). Pure red cell aplasia (PRCA) was suspected due to the anti-EPO Ab. With the immunosuppressive agent and change to the epoetin-therapy, the patient recovered his hemoglobin and reticulocyte counts. Particular attention should be paid for the possibility of PRCA due to anti-EPO Ab in patients undergoing rHuEPO therapy, with an unexplained recombinant human erythropoietin (rHuEPO) resistant anemia, especially via the subcutaneous route.

A Case of Hypothyroidism and Type 2 Diabetes Associated with Type V Hyperlipoproteinemia and Eruptive Xanthomas

Primary hypothyroidism and type 2 diabetes are both typically associated with the increased level of triglycerides. To date, there have been only a few case reports of type 2 diabetes patients with both type V hyperlipoproteinemia and eruptive xanthomas, but there have been no reports of hypothyroidism patients associated with eruptive xanthomas. We report here on a case of a 48-yr old female patient who was diagnosed with type 2 diabetes and primary hypothyroidism associated with both type V hyperlipoproteinemia and eruptive xanthomas. We found rouleaux formation of RBCs in peripheral blood smear, elevated TSH, and low free T4 level, and dyslipidemia (total cholesterol 18.1 mM/L, triglyceride 61.64 mM/L, HDL 3.0 mM/L, and LDL 2.54 mM/L). She has taken fenofibrate, levothyroxine, and oral hypoglycemic agent for 4 months. After treatment, both TSH level and lipid concentration returned to normal range, and her yellowish skin nodules have also disappeared.

Spontaneous Splenic Rupture in a Hemodialysis Patient

Spontaneous splenic rupture (SSR) in a patient undergoing hemodialysis has been described as an extremely rare and potentially fatal complication. We report here spontaneous splenic rupture in a 52-year-old woman undergoing regular hemodialysis for end-stage renal disease (ESRD). She complained of colicky abdominal pain in the left upper quadrant area and dizziness when she assumed an upright posture. Her vital signs revealed low blood pressure and tachycardia, which was suggestive of hypovolemic shock. Abdomen CT scan showed splenic hematoma and hemoperitoneum. However, she had no history of any event triggering the splenic rupture. An exploratory laparotomy showed a ruptured spleen and an emergency splenectomy was performed. We suggest that spontaneous spleen rupture may be attributed to uremic coagulopathy and heparin-induced coagulopathy.

The Change of Lung Diffusing Capacity for Dialysis Duration and Membranes in Maintenance Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Pulmonary fibrosis is the most common pulmonary complication in patients with end stage renal disease undergoing hemodialysis. The diffusing capacity is sensitive and reliable methods for diagnosis for pulmonary fibrosis. The aim of this study was to investigate the change of diffusing capacity for dialysis duration and membranes (synthetic vs cellulosynthetic) in maintenance hemodialysis patients. METHODS: We evaluated prospectively pulmonary diffusing capacity (DLCO/VA) of the patients who had been receiving regular hemodialysis for a period of at least 3 months at Gyeongsang National University Hospital from April 1, 2002 to June 30, 2003. Seventy one patients were divided into two groups by dialysis duration: less than 24 months; more than 24 months. Also, we divided patients into two groups by dialysis membrane: cellulosynthetic membrane (Hemophan); synthetic membrane (Polysulfone). RESULTS: The diffusing capacity and dialysis durations were presented for negative correlation [r= -0.321 (p=0.01) in DLCO/VA]. According to dialysis membranes, DLCO/VA values were significantly decreased in patients in Hemophan group rather than Polysulfone Group [92.4+/-20.5% vs 107.5+/-19.3%, (p= 0.01)]. According to dialysis durtation and membranes, DLCO/VA values were significantly decreased in patients in Hemophan group rather than Polysulfone group at duration for more than 24 months [84.9+/-20.1% vs 105.2+/-20.8%, (p=0.003)]. CONCLUSION: Patients undergoing long-term maintenance hemodialysis showed a gradual reduction in lung diffusing capacity for dialysis duration. Our results suggested that lung diffusing capacity was more severely reduced in hemodialysis patients using bioincompatible membrane rather than biocompatible membrane.

Stenotrophomonas Maltophilia Infection in Patients Receiving Continuous Ambulatory Peritoneal Dialysis

BACKGROUND: Stenotrophomonas maltophilia is a gram-negative bacillus that has become increasingly recognized as an important nosocomial pathogen, particularly in individuals with severe debilitation or immunosuppression. S. maltophilia is also characterized by its resistance to multiple antibiotics. S. maltophilia peritonitis in CAPD (continuous ambulatory peritoneal dialysis) patients is associated with a poor prognosis and loss of CAPD catheter. No report concerning this entity has been presented in Korea. Therefore, we describe and discuss five cases of the S. maltophilia infection associated with CAPD in three patients with peritonitis and two with exit-site infections. METHODS: We performed a retrospective search for episodes of S. maltophilia infections related to CAPD in our renal unit. The baseline levels of hemoglobin, albumin, cholesterol, BUN and creatinine were compared with age, sex and, if possible, the underlying disease-matched controls. RESULTS: All the patients with S. maltophilia peritonitis had diabetes mellitus as the underlying disease. The individual patients also had other significant combined morbidities, such as panhypopituitarism, COPD chronic obstructive pulmonary disease, cerebrovascular accident and myocardial infarction. The level of hemoglobin in these patients was significantly lower than in the controls, and the mean values of serum albumin, creatinine and BUN were also low. CONCLUSION: Immune dysfunction due to uremia, anemia, malnutrition, other comorbidities (e.g. diabetes mellitus), and also, an indwelling peritoneal catheter may be predisposing factors for the S. maltophilia infection in CAPD patients. Once the S. maltophilia infection is diagnosed in CAPD patient, the patient should be treated based on the understanding of this particular organism.

A Case of Minimal Change Disease with Chronic Tubulointerstitial Nephritis by Lithium Nephrotoxicity / 대한신장학회잡지

Lithium is commonly employed in the treatment of bipolar disorders. The commonly reported nephrotoxic effects of lithium therapy are nephrogenic diabetes insipidus and chronic tubulointerstitial nephropathy with little or no proteinuria. Mild proteinuria is a common manifestation of most renal injuries including nephrotoxicity by lithium. But nephrotic syndrome related with lithium therapy is very rare and only one case of membranous glomerulonephritis has been reported in Korea by this time. We report a lithium toxicity case manifested by nephrotic syndrome, nephrogenic diabetes inspidus and chronic renal insufficiency in a 44-year-old man who had been taking lithium for 13 years for bipolar disorder. Kidney pathology showed minimal change disease and chronic tubulointerstitial nephritis which can be seen in chronic lithium toxicity. Polyuria and massive proteinuria disappeared with the withdrawal of lithium. Renal function was gradually improved but not to norma range. Careful and regular monitoring on the renal function in all patients on lithium treatment will be needed.

A Case of Trichosporon beigelii Peritonitis in CAPD / 대한신장학회잡지

Fungal peritonitis is one of the leading causes of patient dropout from continuous ambulatory peritoneal dialysis (CAPD) therapy. Although the most causative agents of peritonitis associated with CAPD are bacteria, fungi are implicated in up to 10% of cases. The most common organism of fungal peritonitis is Candida specises, but Trichosporon beigelii was reported as a rare causative agent of fungal peritonitis. We experienced a case of CAPD peritonitis by Trichosporon beigelii, which was treated with CAPD catheter removal, and antifungal agents with amphotericin B and fluconazole. Thus, we report our experience of CAPD peritonitis caused by Trichosporon beigelii and review of the literature.