Advanced Chronic Kidney Disease (CKD) in a Patient With Alstrom Syndrome.

Alstrom syndrome is an autosomal recessive disease. It affects multiple systems, including cardiovascular, renal, endocrine, and eyes. Our patient is a 25-year-old female who presented with elevated creatinine. Her past medical history was significant for hypothyroidism, polycystic ovarian syndrome, blindness, cataracts, hearing loss, and heart problems. She had genetic testing done that revealed that she was homozygous for the ALMS1 gene and was diagnosed with Alstrom syndrome. She was followed by nephrology in the clinic and had chronic kidney disease (CKD) stage V. The patient traveled to Italy and was lost to follow-up.

Looks can be Deceiving: A Challenging Case of Anti-Neutrophil Cytoplasmic Autoantibody Associated Vasculitis.

[Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis] (AAV) is an autoimmune disease characterized by systemic vascular inflammation. We present a case of a 76-year-old man who presented with shortness of breath, fatigue, and weakness. He was eventually diagnosed with hydralazine-induced ANCA-associated renal limited glomerulonephritis. The presentation of this case was unique for a few reasons; the patient showed an initial improvement in kidney function, was non-oliguric, and had no systemic signs of vasculitis. This led to the patient being discharged prematurely with the diagnosis of acute tubular necrosis. We discuss educational features of this case and warn future clinicians about the possibility of waxing and waning renal function in these patients, as well as the importance of having a higher index of suspicion for glomerulonephritis in patients who take hydralazine.

Hypokalemic Periodic Paralysis Precipitated by Thyrotoxicosis and Renal Tubular Acidosis.

BACKGROUND: Hypokalemic periodic paralysis is a rare neuromuscular disorder characterized by transient episodes of flaccid paralysis due to a defect in muscle ion channels. Most cases are hereditary, but it can be acquired. We present a case of acquired hypokalemic periodic paralysis associated with hyperthyroidism and renal tubular acidosis. Clinical Case. A 38-year-old female with a history of Graves' disease presented to the emergency department with generalized weakness and associated nausea, vomiting, and weight loss. Examination was significant for diffuse weakness in all extremities. Labs showed hypokalemia, hyperthyroidism, and nonanion gap metabolic acidosis with a positive urine anion gap. She was treated for hypokalemic periodic paralysis and renal tubular acidosis. Potassium replacement, propranolol, methimazole, and sodium bicarbonate were initiated. Her potassium gradually corrected with resolution of her symptoms. Further investigation revealed a history of dry eyes, dry mouth, and recurrent dental carries. She had positive ANA, SS-A, and SS-B antibodies. She was diagnosed with Sjögren's syndrome, which may have been associated with her Graves' disease and thus contributed to both her RTA and hyperthyroidism. CONCLUSION: Early recognition and treatment of thyrotoxic periodic paralysis are important to prevent cardiac complications. Management includes potassium replacement with careful monitoring to prevent rebound hyperkalemia. The definitive treatment is to achieve euthyroid status.

Intoxication with Fireball Whiskey causing severe lactic acidosis.

Propylene glycol is a viscous, colorless liquid that has been approved by the US Food and Drug Administration for use as a preservative in foods and as a solvent in pharmaceuticals. Compared with methanol and ethylene glycol, it is regarded as a relatively safe alcohol. There have been several reports of severe lactic acidosis in the setting of iatrogenic unintentional overdosing of medications that use propylene glycol as a diluent, including lorazepam and diazepam. The laboratory findings may include high metabolic acidosis and high osmolal gap. Propylene glycol is also one of the ingredients used in Fireball Whiskey. We present two cases of severe lactic acidosis in the setting of Fireball Whiskey use.

Worsening of renal function and uncontrolled hypertension from intravitreal bevacizumab injections.

Vascular endothelial growth factor (VEGF) inhibitors are used in the treatment of various cancers as well as diabetic retinopathy. The systemic use of these drugs has been associated with adverse effects such as worsening hypertension, proteinuria, and renal function. There have been some reported cases of worsening hypertension, thrombotic microangiopathy, or glomerular disease after intravitreal injections of bevacizumab, aflibercept, and ranibizumab. We present a case of a patient who was taking intravitreal bevacizumab injections for diabetic retinopathy and was hospitalized with worsening renal function, high blood pressure, and nephrotic-range proteinuria in the setting of tight glycemic control.

Rhabdomyolysis After Total Abdominal Hysterectomy Requiring Urgent Hemodialysis Due to Hyperkalemia.

A 63-year-old woman with a past medical history of invasive ductal carcinoma of the breast, status post lumpectomy and chemoradiation, 15 cm left inguinal-femoral enlarged lymph node consistent with high-grade serous carcinoma of the ovary and 4.7 cm right adnexal mass underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node dissection with cystoscopy and bilateral ureteral catheter placement. There was no intraoperative complication. After surgery, patient's urine output decreased, and she developed acute kidney injury (AKI). Initially, it was thought that her reduced output might be due to surgery/anesthesia. She also developed arm and leg weakness raising suspicion for stroke. The neurological workup was unremarkable for any acute abnormality. Her creatinine kinase (CK) level was >20,000 u/l consistent with rhabdomyolysis. She was hydrated aggressively and required hemodialysis due to hyperkalemia. During the hospital course, her kidney function improved, and rhabdomyolysis resolved, and she did not require dialysis after discharge.

Rasburicase-Induced Methemoglobinemia.

Methemoglobinemia occurs as iron in heme is oxidized to its ferric state, resulting in a decreased ability of hemoglobin to bind and release oxygen. Rasburicase is a recombinant urate-oxidase enzyme used in the prevention of tumor lysis syndrome. Methemoglobinemia can occur as a rare complication of treatment with rasburicase, primarily in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Methylene blue, an agent used for treating methemoglobinemia, should be avoided in patients with G6PD deficiency. In patients with G6PD deficiency, methylene blue is inadequately reduced to its active form, which then causes the methylene blue to further the oxidize the hemoglobin to methemoglobin that can result in hemolysis.

Contrast Extravasation Mimicking Subarachnoid Hemorrhage After Cardiac Catheterization.

Neurological complications after coronary angiography are rare but associated with significant mortality and morbidity. These include ischemic and hemorrhagic strokes, and transient ischemic attacks. Rarely, contrast media can cross the blood brain barrier causing transient neurological symptoms including confusion and seizures. On imaging, it can mimic a subarachnoid hemorrhage (SAH). Blood can be differentiated from contrast media using MRI. We present a patient who developed confusion after undergoing cardiac angiography and the initial CT of the brain showed SAH. However, MRI of the brain did not reveal any hemorrhage indicating contrast staining.

Ethylene Glycol Poisoning with a Near-Normal Osmolal Gap: A Diagnostic Challenge.

Ethylene glycol is a colorless, odorless, sweet-tasting liquid commonly found in antifreeze, as well as in industrial agents. It is regarded as one of the toxic alcohols. Ethylene glycol poisoning usually occurs due to ingestion, and its toxicity is mediated by its metabolites, glycolic acid, and oxalate. These metabolites can cause neurological symptoms, gastrointestinal symptoms, and/or renal failure if not diagnosed and treated promptly. The diagnosis can be very challenging as the test used to detect ethylene glycol in the blood may not be readily available or due to an inaccurate history. The treatment of ethylene glycol poisoning consists of supportive care, sodium bicarbonate, and the use of an antidote (ethanol or fomepizole) which inhibits alcohol dehydrogenase and thereby prevents the formation of toxic metabolites. Patients with advanced poisonings may also require dialysis. The diagnosis is usually suggested by a high anion gap metabolic acidosis and an elevated osmolal gap in the setting of a suspected ingestion. Rarely, the osmolal gap may be close to normal which can delay the diagnosis or lead to a misdiagnosis. We report a case of ethylene glycol ingestion with a near-normal osmolal gap.

Chronic Kidney Disease and Calciphylaxis: A Literature Review.

Calcific uremic arteriolopathy (CUA), also known as calciphylaxis, is a rare complication of chronic kidney disease (CKD). Its incidence is increasing due to a better understanding and diagnosis by physicians. Calciphylaxis is a fatal complication of many metabolic disorders. If not managed properly, it can lead to death within a year. This review is an effort to highlight the importance of research on prompt diagnosis and treatment guidelines for calciphylaxis, as it poses a challenge due to its diverse clinical presentation and high mortality rate.

Pain Management in Metastatic Bone Disease: A Literature Review.

Cancer means an uncontrolled division of abnormal cells in the body. It is a leading cause of death today. Not only the disease itself but its complications are also adding to the increase in mortality rate. One of the major complications is the pain due to metastasis of cancer. Pain is a complex symptom which has physical, psychological, and emotional impacts that influence the daily activities as well as social life. Pain acts as an alarm sign, telling the body that something is wrong. Pain can manifest in a multitude fashion. Management of bone pain due to metastasis involves different modes with some specific treatments according to the type of primary cancer. Over the years various treatment modalities have been tried and tested to improve the pain management including the use of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, bisphosphonates, tricyclic antidepressants, corticosteroids, growth factors and signaling molecules, ET-1 receptor antagonists, radiotherapy as well as surgical management. The topic of discussion will cover each one of these in detail.