Absceso cerebral por Cladophialophora bantiana en un paciente con trasplante renal: reporte de un caso / Brain abscess caused by Cladophialophora bantiana after renal allograft loss: A case report

Resumen Las feohifomicosis cerebrales son infecciones graves causadas por mohos dematiáceos, entre los cuales Cladophialophora bantiana es una de las especies más comúnmente aislada. Esta tiene tropismo por el sistema nervioso central y frecuentemente produce abscesos cerebrales en pacientes inmunocompetentes; además, en los inmunocomprometidos también puede ocasionar infección diseminada. Pese a la disponibilidad de medicamentos antifúngicos de amplio espectro, a menudo se requiere también la intervención quirúrgica; de todas maneras, la mortalidad es elevada. El diagnóstico debe hacerse interviniendo para tomar la muestra y hacer el cultivo y las pruebas de sensibilidad. Se presenta aquí el caso de un paciente con trasplante renal que presentó un absceso cerebral por C. bantiana, el cual se extrajo mediante resección quirúrgica. El paciente recibió tratamiento con voriconazol, con adecuada respuesta, mejoría y sin secuelas neurológicas.

Abstract Cerebral feohifomycosis are severe infections caused by dematiaceous fungi. Cladophialophora bantiana is one of the most commonly isolated species; it has central nervous system tropism and it often manifests as a brain abscess in immunocompetent patients. In immunocompromised patients, it can lead to brain abscesses and disseminated infections. Despite the availability of broad-spectrum antifungal drugs, it is a must to perform surgical management, in addition to drug therapy. However, mortality is high. The diagnostic approach must be invasive to establish a timely diagnosis and direct treatment based on culture and susceptibility tests. We report a case of brain abscess caused by C. bantiana in an immunosuppressed patient who was treated with surgical resection and voriconazole with an adequate response to therapy and without neurological sequels.

Primary Hyperoxaluria in Korean Pediatric Patients

BACKGROUND: Primary hyperoxaluria (PH), a rare inborn error of glyoxylate meta bolism causing overproduction of oxalate, is classified into three genetic subgroups: type 1–3 (PH1–PH3) caused by AGXT, GRHPR , and HOGA1 gene mutations, respectively. We performed a retrospective case series study of Korean pediatric patients with PH.METHODS: In total, 11 unrelated pediatric patients were recruited and their phenotypes and genotypes were analyzed by a retrospective review of their medical records.RESULTS: Mutational analyses revealed biallelic AGXT mutations (PH1) in nine patients and a single heterozygous GRHPR and HOGA1 mutation in one patient each. The c.33dupC was the most common AGXT mutation with an allelic frequency of 44%. The median age of onset was 3 months (range, 2 months-3 years), and eight patients with PH1 presented with end stage renal disease (ESRD). Patients with two truncating mutations showed an earlier age of onset and more frequent retinal involvement than patients with one truncating mutation. Among eight PH1 patients presenting with ESRD, five patients were treated with intensive dialysis followed by liver transplantation (n=5) with/without subsequent kidney transplantation (n=3).CONCLUSION: Most patients presented with severe infantile forms of PH. Patients with two truncating mutations displayed more severe phenotypes than those of patients with one truncating mutation. Sequential liver and kidney transplantation was adopted for PH1 patients presenting with ESRD. A larger nation-wide multicenter study is needed to confirm the genotype-phenotype correlations and outcomes of organ transplantation.

Primary hiperoxaluria diagnosed after kidney transplantation: report of 2 cases and literature review / Hiperoxalúria primária diagnosticada após transplante renal: relato de dois casos e revisão da literatura

Abstract Primary hyperoxaluria (PH) is a very rare genetic disorder; it is characterized by total or partial deficiency of the enzymes related to the metabolism of glyoxylate, with an overproduction of calcium oxalate that is deposited in different organs, mainly the kidney, leading to recurrent lithiasis, nephrocalcinosis and end stage renal disease (ESRD). In patients with ESRD that receive kidney transplantation alone, the disease has a relapse of 100%, with graft loss in a high percentage of patients in the first 5 years of transplantation. Three molecular disorders have been described in PH: mutation of the gene alanin glioxalate aminotransferase (AGXT); glyoxalate reductase/hydroxy pyruvate reductase (GRHPR) and 4-OH-2-oxoglutarate aldolase (HOGA1). We present two cases of patients with a history of renal lithiasis who were diagnosed with primary hyperoxaluria in the post-transplant period, manifested by early graft failure, with evidence of calcium oxalate crystals in renal biopsy, hyperoxaluria, hyperoxalemia, and genetic test compatible; they were managed with proper diet, abundant oral liquids, pyridoxine, hydrochlorothiazide and potassium citrate; however, they had slow but progressive deterioration of their grafts function until they reached end-stage chronic renal disease.

Resumo A hiperoxalúria primária (HP) é um distúrbio genético muito raro, caracterizado por deficiência total ou parcial das enzimas relacionadas ao metabolismo do glioxilato, superprodução de oxalato de cálcio que se deposita em vários órgãos (principalmente os rins) resultando em litíase recorrente, nefrocalcinose e doença renal terminal (DRT). Nos pacientes com DRT que recebem transplante renal, a doença apresenta recidiva em 100% dos casos, com perda do enxerto nos primeiros cinco anos após o transplante num elevado percentual de pacientes. Três distúrbios moleculares foram descritos na HP: mutação dos genes da alanina-glioxilato aminotransferase (AGXT), glioxilato redutase/hidroxipiruvato redutase (GRHPR) e 4-OH-2-oxoglutarato aldolase (HOGA1). Apresentamos dois casos de pacientes com histórico de litíase renal diagnosticados com hiperoxalúria primária no período pós-transplante, manifestada na forma de perda precoce do enxerto com evidências de cristais de oxalato de cálcio na biópsia renal, hiperoxalúria, hiperoxalemia e testes genéticos compatíveis. Os pacientes foram tratados com abordagem nutricional, líquidos orais em abundância, piridoxina, hidroclorotiazida e citrato de potássio. Contudo, os pacientes apresentaram deterioração lenta e gradual da função do enxerto e evoluíram para doença renal terminal.

Oliguria and acute renal dysfunction in a six-month-old infant / 中国当代儿科杂志

The infant (a girl aged 6 months) was admitted to the hospital because of oliguria and acute renal dysfunction. The laboratory examination results showed serious metabolic acidosis and increased blood urea nitrogen and serum creatinine levels. The patient continued to be anuric after 10 days of treatment with continuous renal replacement therapy (CRRT). she died a day later. The family history showed that the patient's sister died of acute renal failure 6 months after birth. The genomic sequencing results showed AGXT mutation in the patient and confirmed the diagnosis of primary hyperoxaluria type 1 (PH1). Her parents were heterozygous carriers. PH1 should be considered when the children have abnormal renal function or recurrent renal calculi or have a family history of these symptoms. AGXT gene analysis is an important method for PH1 diagnosis.

Type 1 primary hyperoxaluria in a male infant

No abstract available.

A rare case of hyperoxaluria presenting with acute liver injury and stone-free kidney injury

A 49-year-old woman visited the clinic because of acute hepatitis and acute kidney injury with decreased urine output presenting microscopic hematuria and proteinuria. An abdominal computed tomography revealed a localized, hypoattenuated lesion in a hepatic lateral segment, and kidney biopsy showed oxalate crystal deposition with tubular necrosis. In addition, the patient's 24-hour urinary excretion of oxalate was increased. Her kidney and liver injury improved after sessions of hemodialysis, and urinary oxalate excretion was normalized. Major mutations in primary hyperoxaluria have not been proven. A full sequencing of target genes may be helpful to diagnose a rare form of primary hyperoxaluria.

Hiperoxaluria primaria en tres hermanos / Primary hyperoxaluria in three brothers

La hiperoxaluria es responsable de 2%-20% de las causas metabólicas de litiasis en niños y adolescentes. Esta puede ser secundaria o primaria(HP), en este último caso es tipo I o tipo II, de herencia autosómica recesiva. El objetivo es analizar diagnóstico y evolución en dos hermanos con HP tipo I y un tercero con alta probabilidad. El primer caso presentó a los 9 años un cólico nefrítico con litiasis múltiples bilaterales y una IRA leve. Presentaba hiperoxaluria de 214 mg/1,73 m2. Se descartaron causas secundarias. El estudio genético demostró dos copias de la mutación IIe244Thr. Los otros dos pacientes se presentaron en forma similar, a edades de 8 y 17 años. La piridoxina a altas dosis descendió los niveles de oxaluria como está descrito en un tercio de los casos. El tiempo de evolución es 7,3 y 1 año respectivamente. Persisten actualmente con litiasis bilaterales, sin nefrocalcinosis ni alteraciones del medio interno. La severidad de la HP tipo I es variable, hay formas de presentación temprana con litiasis recurrente y falla renal crónica en la infancia o en la adolescencia; otras de inicio tardío en edad adulta. Se trata de una enfermedad grave, progresiva, cuyo diagnóstico temprano con estudio metabólico completo puede mejorar el pronóstico,fundamentalmente en aquellos que responden a la piridoxina. El manejo de la litiasis y sus complicaciones es fundamental para evitar la IRC. Cuando ésta se desarrolla, la diálisis agresiva y el trasplante hepatorrenal son las opciones terapéuticas. Es el primer informe de casos confirmados de hiperoxaluria primaria en nuestro país...

Primary hyperoxaluria type 1 in Tunisian children

Primary hyperoxaliuria type 1 is an autosomal-recessive disorder characterized by increasing urinary excretion of calcium oxalate, recurrent urolithiasis, nephrocalcinosis, and accumulation of insoluble oxalate throughout the body. This inborn error of metabolism appears to be a common cause of end stage renal disease in Tunisia. To review the clinical, biological and radiological futures of primary hyperoxaluria type 1 and to correlate these aspects with the development of end-stage renal disease. we retrospectively reviewed 44 children with Primary hyperoxaliuria type I who were treated in our department during a period of 15 years between 1995 and 2009. The diagnosis was established by quantitative urinary oxalate excretion. In patient with renal impairment, the diagnosis was made by infrared spectroscopy of stone or by renal biopsy. Male to female ratio was 1.2. The median age at diagnosis was 5.75 years. About 43% of those were diagnosed before the age of 5 years. Initial symptoms were dominated by uraemia. Four patients were asymptomatic and diagnosed by sibling screening of known patients. Nephrocalcinosis was present in all patients. It is cortical in 34%, medullary in 32% and global in 34%. At diagnosis, twelve children were in end-stage renal disease [27%]. Pyridoxine response, which is defined by a reduction in urine oxalate excretion of 60% or more, was found in 27%. In the majority of patients, the clinical expression of Primary hyperoxaliuria type 1 is characterized by nephrocalcinosis, urolithiasis and renal failure. Pyridoxine sensitivity is associated with better outcome

Liver-kidney transplantation in primary hyperoxaluria type-1: case report and literature review

Primary hyperoxaluria type-1 [PH1] is a rare inherited autosomal recessive disorder in which a deficiency of the hepatic enzyme alanine-glyoxylate aminotransferase leads to endogenous oxalate overproduction, renal failure, systemic oxalate deposition and death. As hemodialysis provides insufficient oxalate clearance, patients ultimately require both liver and kidney transplantation for correction of the metabolic abnormality and oxalate excretion. Herein, we describe a young adult male with end-stage renal disease and systemic oxalosis causing progressive disabling multi-organ dysfunction while awaiting transplantation. We review the literature regarding liver-kidney transplantation and suggest that for patients with PH1, a standardized assessment of organ dysfunction and functional impairment may improve identification of patients requiring urgent transplantation thereby reducing the morbidity and mortality that can occur with delayed transplantation

A Case of Primary Hyperoxaluria with Renal Allograft Dysfunction / 대한신장학회지

Primary hyperoxaluria is a rare disorder of glyoxylate metabolism in which hepatic enzyme deficiencies result in overproduction of oxalate. The resulting elevation of urinary oxalate excretion leads to recurrent urolithiasis and progressive nephrocalcinosis. End-stage renal disease frequently occurs and is accompanied by systemic oxalate deposition along with its harmful effects. With the rarity and various clinical heterogeneity of the disease, the high proportion of patients in whom diagnosis is made after advanced renal failure have developed it. On account of its high rate of graft loss associated with primary hyperoxaluria, isolated kidney transplantation has been replaced by combined liver/kidney transplantation. In this report, we describe a case of primary hyperoxaluria with kidney graft failure who had a history of recurrent renal stones.

Primary hyperoxaluria type 1 with a novel mutation.

Primary hyperoxaluria type 1 [PH1] is an autosomal recessive disorder caused by a deficiency of alanine-glyoxylate aminotransferase AGT, which is encoded by the AGXT gene. We report an Indian family with two affected siblings having a novel mutation in the AGXT gene inherited from the parents. The index case progressed to end stage renal disease at 5 months of age. His 4 month old sibling is presently under follow up with preserved renal function.

Primary hyperoxaluria.

A 5-month-old female infant who had chronic diarrhea and acute renal failure was referred to Chulalongkorn Hospital for further investigation and management. Laboratory investigation revealed elevated blood urea nitrogen and creatinine level, hypocalcemia, hyperphosphatemia, and hyponatremia. Ultrasonography of the kidneys showed normal size with bilateral hyperechoic kidneys. Eyes examination was compatible with oxalosis maculopathy. Urine organic acid analysis revealed peak of oxalate and glycolate. Clinical impression concluded acute renal failure from hyperoxaluria. The patient underwent continuous venovenous hemodiafiltration (CVVH-DF) with regional citrate anticoagulation and expired on day 13 after admission. Pathological examination of kidney necropsy revealed diffuse intraluminal deposition of oxalate crystals within the renal parenchyma. Primary hyperoxaluria is a very rare disease and has rarely been reported in Thailand. In the presented case, the diagnosis was delayed due to uncommon presentation and unavailability of diagnostic laboratory.

Hiperoxaluria primaria con pancitopenia: a propósito de un caso / Primary hyperoxaluria and pancitopenia: A case report

Se presenta el caso de un varón, de 15 años de edad, con diagnóstico de litiasis renal desde la infancia que evolucionó a Insuficiencia Renal Crónica, requiriendo hemodiálisis. Seis meses antes del reporte se agregan dolores articulares, con signos flogósicos en rodilla derecha, compromiso progresivo del estado general, pérdida de peso y anemia. Al examen físico se encuentra a un paciente emaciado, pálido, con múltiples adenopatías cervicales, y presencia de hepato-esplenomegalia. Se realizan exámenes evidenciándose: pancitopenia, con mayor compromiso de la serie roja (hemoglobina 7,3mg/dL, leucocitos 2600/uL, y plaquetas 123 000/uL). Los valores de transaminasas y bilirrubinas fueron normales así como los dosajes de Fierro, Transferrina, Acido Fólico y Vitamina B12. La ecografía abdominal revela riñones calcificados y atróficos y los Rx de abdómen demuestran nefrocalcinosis y litiasis renal. La biopsia de medula ósea evidenció un extenso depósito de cristales de oxalato de calcio, dispuestos en forma radiada, con casi completa obliteración de la medula ósea con un número variable de células multinucleadas y fibrosis moderada. El aspirado de medula ósea no mostró cristales de oxalato de calcio. este reporte hace una revisión sobre hiperoxaluria primaria, y resalta la importancia de reconocer la enfermedad como causa de falla renal en un paciente con historia clínica de litiasis renal y nefrocalcinosis.

Primary hyperoxaluria type-1: an unprecedented presentation at birth.

This report describes a male baby with primary hyperoxaluria type-1, presenting at 5 hours of age with cyanotic episodes, hypotonia, unexplained techypnea and tachycardia. This infant also had renal calcinosis, and middle cerebral arterial infarct with unilateral enlargement of ventricle and left porencephalic cyst on CT scan. The infant improved with diuretics, water supplementation, pyridoxine, and Albright solution.

End-stage Renal Disease Caused by Primary Hyperoxaluria / 대한신장학회잡지

Primary hyperoxaluria is a rare autosomal recessive inherited metabolic disease which results from endogenous overproduction of oxalic acid. It causes variant phenotypes from renal failure in infancy to mere urolithiasis in late adulthood. We report a case of primary hyperoxaluria in a 11-year-old boy. He presented with recurrent multiple renal stones since 3 years of age. He had renal failure and markedly increased hyperoxaluria (568.26 microgram/mg of creatinine (normal: 0.04-0.15)) and his stones consisted of a mixture of calcium oxalate (30%) and calcium phosphate (10%) in contrast to pure calcium oxalate monohydrate in the other primary hyperoxaluria type 1 patients. A renal biopsy showed interstitial cellular infiltration with crystals which are birefringent under polarized light within the tubules. His general conditions were improved after hemodialysis treatment. For definite cure of disease, combined liver-kidney transplantation is considered.

Relato de caso: Oxalose / A case report: oxalosis

Neste artigo é relatado um provável caso de hiperoxalúria primária tipo 1 que evoluiu precocemente para insuficiência renal crônica (IRC) terminal, com o objetivo de chamar atenção para uma enfermidade rara que exige tratamento agressivo e precoce. O paciente iniciou sintomatologia aos dois meses, com diarréia associada a aumento de escórias, anemia, edema, hipertensão arterial, distúrbios metabólicas e descompensação hemodinâmica, necessitando de diálise peritoneal. A propedêutica revelou nefrocalcinose e depósitos de cristais de oxalato de cálcio no parênquima renal, estabelecendo-se o diagnóstico de oxalose. Evoluiu com IRC, episódios de peritonite, desnutrição e atraso no desenvolvimento. Foi tentado o uso de piridoxina, sem sucesso. Está atualmente em diálise peritoneal ambulatorial contínua. O tratamento definitivo da oxalose consiste no transplante hepatorrenal, realizado o mais precocemente possível. Sendo assim, tal conhecimento por parte dos nefrologistas é relevante para o diagnóstico etiológico de IRC na infância.

Pediatric Liver Transplantation for Metabolic Liver Disease / 대한이식학회지

PURPOSE: Metabolic liver disease may progress to liver cirrhosis or fulminant hepatic failure. Liver transplantation has been indicated in children with metabolic liver disease as an established curative treatment modality. METHODS: Between October 1986 and December 1999, 139 pediatric liver transplantations were performed in 119 patients. Twenty nine liver transplantations were underwent in 24 patients (16 males/8 females, mean age +/-SD: 8.2+/-5.6 yr, ranging 3 months-17 yrs) for metabolic liver disease (20.2%). Of 24 patients, 3 cases (12.5%) with primary hyperoxaluria type 1 underwent combined liver/kidney transplantations. Multiple liver transplantations were performed in 3 patients (1 patient: 3 times, 2 patients: 2 times). Twenty five orthotopic liver transplants were performed in 22 patients (91.7%), while 3 cases of auxiliary heterotopic liver transplants were done in 2 patients (8.3%). The mean follow-up period was 48.2+/-37.2 months (ranging 6-133 months). RESULTS: Patient and graft survival in metabolic disease at 1 year were 91.5%, 89.1%, in non-metabolic disease, 74.1%, 71.2%, respectively. Twelve patients (50%) suffered at least one episode of acute rejection after transplantation. The one-year-patient survival of rejection group was 91.7%, non-rejection group, 91.7%. Mortality developed in 6 patients (25%) after transplantation. The causes of death were sepsis (n=3), hepatic failure (n=2) and chronic rejection (n=1). CONCLUSION: The result of liver transplantation in metabolic liver disease seems to be better than non-metabolic liver disease (p>0.05). No difference was found between rejection and non-rejection group in one-year-patient survival (91.7% vs. 91.7%).

Dilemma of oxalosis in end stage renal failure: isolated kidney allograft or hemodialysis

We report the case of a 10-year-old girl who received a cadaveric kidney transplant for oxalosis after a period of 12 months on hemodialysis. The donor was a 6-year-old child. Cold ischemia was four hours. Diuresis occurred immediately in the operating room. Mean daily diuresis was maintained at 8 liters: first by I.V perfusion, then by nocturnal continuous nasogastric hydration. In addition to the usual immunosuppressive drugs, she received pyridoxine, sodium citrate, phosphate, hydrochlorothiazide and magnesium. Daily hemodialysis was performed from day 1 to day 9 and four additional sessions every other day. The postoperative course was satisfactory. Oxaluria was elevated initially at 1074 mg/24h [normal<50mg/24h] one year later mean daily diuresis is still 8 liters, renal function is normal and oxaluria is at 296mg/24h. repeated graft sonography showed no nephrocalcinosis, but mild oxalate deposits are noted on renal biopsy. Isolated renal transplantation was successful in our patient. It allowed us to stop hemodialysis and to avoid extra-renal accumulation of oxalate. Despite this success, we are convinced that long term prognosis is uncertain and liver transplantation should be realized to correct definitely the biochemical defect