ABSTRACT
Sarcoidosis presents in a variety of ways, but historically, renal involvement has been considered rare with an incidence of 0.7% and is seldom the presenting feature of the illness. Concomitant involvement of kidney and bone marrow is extremely rare. Atypical forms of presentation, such as in this case, may pose a true diagnostic challenge. A 20-year-old African-American male presented to the emergency department with vague symptoms including fatigue, malaise, anorexia, right-sided lower back pain, and nausea. Acute kidney injury was clearly evident, creatinine was 19.78 mg/dL (normal range 0.60-1.20 mg/dL), and BUN was 124.0 mg/dL (normal range 5.0-25.0 mg/dL). Laboratory results were also remarkable for leukopenia, microcytic anemia, hyperkalemia, anion gap metabolic acidosis, and non-PTH dependent hypercalcemia. Interestingly, urinalysis was equivocal and both chest x-ray (CXR) and abdominopelvic computed tomography (CT) scan were unrevealing. The patient was admitted to the hospital and required renal replacement therapy to stabilize his clinical condition while planning for a renal biopsy that was later performed. While awaiting pathological results, pancytopenia developed, and a bone marrow biopsy was then obtained. On further investigation, angiotensin-converting enzyme (ACE) turned out to be significantly elevated suggesting sarcoidosis. Renal biopsy showed moderate acute tubular injury, tubulitis, extensive interstitial edema, and infiltration by numerous non-caseating granulomas, which confirmed the diagnosis of sarcoidosis. Bone marrow histopathology revealed hypocellularity but no granulomatous infiltration. The patient remained largely asymptomatic throughout his hospital stay, with no signs or symptoms suggesting the involvement of other organs. High-dose corticosteroids were started and continued outpatient after discharge while still on hemodialysis. Pancytopenia resolved while on glucocorticoids and improvement in renal function was such that after roughly two months of steroids, renal replacement therapy was no longer necessary. Overall, kidney injury severe enough to require hemodialysis associated with pancytopenia in a previously healthy 20-year-old constitutes a rather rare sarcoidosis presentation. This highlights the importance of considering sarcoidosis as a possible cause of kidney and bone marrow dysfunction and emphasizes the need for timely biopsy to facilitate accurate diagnosis and early initiation of appropriate therapy to avoid delayed or inadequate care, especially considering that even severe damage is potentially reversible when identified early and treated promptly.
ABSTRACT
Purpose Many health care providers adopted telehealth during the coronavirus disease 2019 (COVID-19) pandemic. This unprecedented transformation in medical practice posed challenges to both physicians and patients. However, little is known about the adaptation of attendings, residents, and patients to this new normal. Thus, a survey was sent out to investigate the feedback of both physicians and patients on telehealth. Methods Surveys were administered via phone call to patients and electronic survey to physicians at an internal medicine resident clinic in one tertiary community hospital from April to June 2020. Demographic information and assessment of overall experience, satisfaction, and concerns of telehealth were collected. Statistical analyses were performed to compare feedback between patients and physicians. Results Fifty patients and 45 physicians participated in the study. Eighty-four percent of patients were first- or second-time users, and 50% of patients were older than 60 years. Eighty-four percent of patients were very or extremely satisfied with telehealth, while 72% wanted to continue telehealth in the future. Ninety-four percent of patients believed that their concerns were adequately addressed, but 14% experiencing technical issues. Physicians' feedback to telehealth was less positive than the patients'. More than 60% of physicians experienced technical issues, and nearly 60% of physicians were neutral or not satisfied with telehealth. Nearly 50% of physicians had difficulty transitioning to telehealth, while only 29% believed that their patients' complaints were adequately addressed. Most physicians had to schedule in-person visits after telehealth. Patients were more satisfied with telehealth than physicians (84% vs. 42%; p<0.001) and were more likely to believe that their concerns were properly addressed by telehealth (94% vs. 29%; p<0.001). Conclusion This survey revealed that patients were more satisfied with telehealth than physicians. Further research with a larger sample should be considered to confirm this conclusion, and subjective studies are needed to determine the imbalance of satisfaction.
