IgA-dominant infection-associated glomerulonephritis in the pediatric population.

BACKGROUND: IgA-dominant infection-associated glomerulonephritis is well-documented in adults but has not been studied in depth in children. We assessed the incidence of pediatric IgA-dominant infection-associated glomerulonephritis and clinical and kidney biopsy findings. METHODS: Pediatric native kidney biopsies over a 10-year period with IgA dominance, strong C3, and findings indicative of infection-associated etiology were identified. RESULTS: We identified 9 cases of IgA-dominant infection-associated glomerulonephritis, 0.8% of pediatric native kidney biopsies. Seven patients presented with elevated creatinine. All had hematuria and proteinuria. Eight patients had clinical evidence of infection: one each with central port infection by methicillin-sensitive Staphylococcus aureus, recurrent streptococcal pharyngitis and recent otitis media, streptococcal pharyngitis demonstrated 8 months after biopsy, suspected streptococcal scalded skin syndrome, and viral gastroenteritis, and three with serologic evidence of Streptococcal infection but no identified site of infection. All but one patient experienced short-term normalization of creatinine and resolution of proteinuria, though two eventually progressed to kidney failure: one 3 years later due to progressive disease and one 11 years later due to focal segmental glomerulosclerosis without concurrent immune deposits. CONCLUSIONS: Pediatric IgA-dominant infection-associated glomerulonephritis is rare, and generally has a favorable prognosis, contrasting that seen in adults with severe comorbidities. A higher resolution version of the Graphical abstract is available as Supplementary.

Histomorphologic features of lung adenocarcinomas exhibiting ALK gene rearrangement.

With the advent of tyrosine kinase inhibitors, the identification of tumors with alterations in tyrosine kinase genes has become important to guide treatment. Lung adenocarcinomas harboring ALK translocations may be targeted with drugs such as crizotinib. We undertook a retrospective review of our institution's pathology records from January 2015 through September 2017 and identified 10 lung adenocarcinomas with ALK rearrangements. We reviewed the histomorphologic features and immunohistochemical results from these 10 cases. Morphologic features included patterns such as acinar, papillary, micropapillary, and solid, as well as features such as cribriform, signet ring, and extracellular mucin. Acinar (including simple and cribriform) was the most common pattern, followed by papillary. Solid and signet ring features were the least common. These findings were consistent with prior histomorphologic studies of ALK-positive lung adenocarcinomas. Certain histomorphologic patterns are associated with ALK positivity. However, histomorphologic features are neither absolutely sensitive nor absolutely specific in suggesting ALK rearrangement. Thus, identification of lung adenocarcinomas that may benefit from treatment with tyrosine kinase inhibitors requires comprehensive molecular testing.

Secondary involvement of the gastrointestinal tract by renal cell carcinoma.

Secondary involvement of the gastrointestinal (GI) tract by renal cell carcinoma is rare. We undertook a retrospective review of our institution's pathology records from January 2006 to July 2017 and identified eight cases of GI tract involvement by renal cell carcinoma. Sites of involvement included stomach, duodenum, jejunum, ileum, and cecum. Pertinent clinical information was obtained from electronic medical records. The interval from primary resection to identification of GI involvement was often prolonged, averaging 6 years, and mimicked primary GI tract malignancies, with presentations including GI bleeding, abdominal pain, and obstruction. One case presented asymptomatically on follow-up imaging. Histologic patterns of involvement varied from classic clear cell to purely sarcomatoid or complex unclassifiable morphology. Two patients with tumors exhibiting sarcomatoid morphology died within 2 years of primary resection and <1 year of GI involvement. The remaining patients survived a mean of 9 years (range, 5 to 22 years) at their last available follow-up.

Clinical uptake of antimicrobial stewardship recommendations following Nanosphere Verigene Blood Culture Gram-negative reporting.

We performed a retrospective chart review of patients to determine if the Verigene Gram-negative blood culture (BC-GN) results would lead to earlier deescalation of empiric therapy for inpatients with GN bacteremia with Citrobacter spp., Enterobacter spp., Klebsiella spp., and Escherichia coli to appropriate targeted coverage. A total of 899 records were reviewed from April 2014 to February 2016 from three institutions within the Baylor Scott & White Health network. The cases were reviewed for initial antibiotic coverage, timing of Verigene results, change in antibiotic coverage, and how these changes related to the timing of Verigene results. The lab reported the BC-GN results and final conventional susceptibility results within 2.5 ± 1.3 and 73.6 ± 40.0 hours from the Gram stain, respectively. Overall, 29.1% of patients were transitioned from empiric to targeted therapy at 12.2 ± 13.5 hours in response to BC-GN results, which was significantly earlier (P < 0.001) than results by conventional methods. After accounting for patients already on targeted therapy, polymicrobial infections, and patients deceased or lost to follow-up, we identified antibiotic stewardship opportunities in ∼28% of GN infections. Further subanalysis demonstrated site-specific differences in the uptake of stewardship recommendations, whereby 32.4%, 50.5%, and 15.0% of cases at different hospitals demonstrated the expected change in antibiotics. These results suggest that Verigene had the expected impact in a third of the cases and the results reporting algorithm minimized the real-time involvement of the pharmacist while maintaining optimal patient management. However, this impact varied substantially by clinical site and was tempered by variable initial antibiotic coverage and clinician response.