Factors Associated With Urgent-Start Peritoneal Dialysis Catheter Complications in ESRD.

INTRODUCTION: Urgent-start peritoneal dialysis (PD) in patients with newly diagnosed end-stage renal disease (ESRD) is a well-tolerated alternative to hemodialysis (HD). The primary aim of this study was to identify the demographic and clinical characteristics of ESRD patients, as well as the presurgical, surgical, and postsurgical factors associated with urgent-start PD complications. METHODS: A retrospective cross-sectional observational study was performed on 102 patients with ESRD who merited urgent-start PD from January 2015 to June 2019. The primary clinical outcome measures were catheter leakage, dysfunction, and peritonitis, whereas the secondary outcomes were catheter removal, repositioning, and death. Statistical inferences were made with the χ2 or Fisher's exact test and independent samples t tests. RESULTS: One hundred two subjects (65 men, 63.7%) 56.2 ± 15.1 years old were included in this study; 64 of the subjects had diabetes and hypertension (62.7%). Catheter leakage occurred in 8 patients (7.8%), catheter dysfunction in 27 patients (26.5%), and peritonitis in 14 patients (13.7%); meanwhile, catheter removal occurred in 6 patients (5.9%), catheter repositioning in 21 patients (20.6%), and death in 3 patients (2.9%). Peritonitis was associated with younger age (i.e., 47.0 ± 16.8 vs. 57.6 ± 14.4 years; P = 0.014; 95% confidence interval [CI]: 2.2-19.1; odds ratio [OR] 0.96; P = 0.018; 95% CI: 0.92-099), higher creatinine levels upon admission (i.e., 20.2 ± 9.8 vs. 14.1 ± 8.3; P = 0.014; 95% CI: -10.9 to -1.2), and heart failure (OR 4.79; P = 0.043; 95% CI: 1.05-21.88). Patients with abdominal hernia were 7.5 times more likely to have their catheter leak (OR 7.5; P = 0.036; 95% CI: 1.14-49.54). Catheter removal was associated with obesity (i.e., body mass index [BMI] of 31.6 ± 4.1 vs. 25.9 ± 4.9; P = 0.007; 95% CI: -9.8 to -1.6; OR 1.26; P = 0.013; 95% CI: 1.05-1.51) and Modification of Diet in Renal Disease glomerular filtration rate (MDRD-GFR) (i.e., 2.5 ± 0.6 vs. 3.7 ± 2.3; P = 0.003; 95% CI: 0.5-1.9). CONCLUSION: Peritonitis was associated with younger age, higher creatinine levels upon admission, and heart failure; meanwhile, catheter removal was linked to obesity and lower glomerular filtration rate. Compared with previous reports, our study included patients in which PD was initiated shortly after catheter insertion, making the intervention a true urgent-start PD. This study contributes to the existing urgent-start PD literature by providing evidence that urgent-start PD with catheter opening within 72 hours has limited complications, making it a relatively safe option.

Paraneoplastic Cerebellar Degeneration Secondary to BRAF Mutant Melanoma Metastasis from an Occult Primary Cancer.

Melanoma metastasis from an unknown primary cancer has an incidence of 3.2% among melanoma patients. Furthermore, paraneoplastic neurological syndromes (PNS) are rare, occurring in 1-3% of patients with malignancies. Paraneoplastic cerebellar degeneration (PCD) is one of the classic PNS and is characterized by acute or subacute onset of ataxia and/or presence of onconeural antibodies. A 61-year-old male with ataxia, vertigo, and headache later developed dysarthria, multidirectional nystagmus, hyperactive delirium, auditory hallucinations, psychomotor agitation, and myoclonus. Toxicological, metabolic, infectious, and autoimmune etiologies were assessed and reported negative. An osteolytic lesion was observed in the right iliac crest via computed tomography (CT). A positron emission tomography-CT reported increased fluorodeoxyglucose uptake of a right iliac and right inguinal ganglion. After biopsy of the right inguinal ganglion, a BRAF mutation-positive melanoma metastasis from an occult primary cancer was diagnosed. Dermatologic, ophthalmologic, and endoscopic gastrointestinal assessment did not reveal a primary malignant melanoma. The patient's movement disorders and neuropsychiatric symptoms improved with quetiapine, prednisone, azathioprine, and cyclophosphamide. Oncological management was conducted with MAPK pathway inhibitors (i.e., dabrafenib and trametinib). Movement disorders associated with neuropsychiatric symptoms are complex to diagnose. PNS are rare and often associated with antibodies against neural antigens expressed by the tumor. The case presented above describes a patient with a BRAF-positive malignant melanoma metastasis from an occult primary associated with PCD - to the best of our knowledge, the first reported in the literature.

Paraneoplastic opsoclonus-myoclonus syndrome secondary to melanoma metastasis form occult primary cancer.

INTRODUCTION: Opsoclonus-myoclonus syndrome (OMS) is an inflammatory neurological disorder, often requiring a prompt medical evaluation. Among the diverse etiologies associated with OMS are autoimmune, infectious, paraneoplastic, and systemic diseases, and drug intoxication. CLINICAL SUMMARY: The case of a 36-year-old female with a disabling holocranial headache, sudden loss of consciousness, aggressive behavior, vertigo, and a personal history of somatoform disorder and major depression is presented here. After hospital admission, the patient developed sudden stereotyped movements in all four extremities and oculogyric crises compatible with OMS. Cerebrospinal fluid analysis, viral and autoimmune assays, as well as blood, urine, and bronchial secretion cultures, drug metabolite urinalysis, and tumor markers were all negative. Furthermore, brain computed tomography (CT) and brain magnetic resonance imaging, along with thoraco-abdominopelvic CT and electroencephalography, were also all negative. The patient suffered type one respiratory insufficiency after 72 h of hospitalization, requiring an endotracheal tube. After 13 days the patient suffered cardiac arrest. Necropsy was performed reporting lymph nodes with a poorly differentiated malignant neoplastic lesion, HMB-45, melan-A, vimentin, and S-100 positive, compatible with melanoma metastasis from an occult primary cancer. DISCUSSION: While the incidence of melanoma of unknown primary is between 2.6 and 3.2%, with a median overall survival ranging between 24 and 127 months, when melanoma patients develop OMS their survival is markedly decreased. Although only 5 cases of paraneoplastic OMS secondary to melanoma have been reported in the literature, all had a poor prognosis, dying within 8 months of OMS onset.

Axillobifemoral bypass for total abdominal occlusion secondary to Takayasu's arteritis: A case report.

INTRODUCTION: Takayasu's arteritis (TA) is a rare disease that mainly affects large arteries. Approximately 20% of TA patients will require surgical intervention secondary to arterial complications such as intermittent claudication, persistent hypertension refractory to treatment, and heart failure. PRESENTATION OF CASE: The case of a 22-year-old female with TA of five years of evolution is presented. The patient deteriorated clinically after five years of corticosteroid and immunosuppressant management requiring surgical intervention with an axillobifemoral bypass for a total abdominal occlusion. Onset, pre-surgical and post-surgical Doppler ultrasonography as well as abdominal angiotomographies document and corroborate the patient's clinical and hemodynamic improvement. DISCUSSION: Very limited literature exists regarding surgical interventions for TA patients. While most reported cases present an endovascular surgical management. Open surgical procedures have lower rates of restenosis than endovascular management. Although endovascular management is less invasive than extra-anatomical axillobifemoral bypass, the patient was not a candidate for endovascular stent graft placement due to the increased risk for vascular injury and subsequent perforation. Approximately a fifth of TA patients are candidates for surgical intervention over time. CONCLUSION: Vascular surgery in TA cases becomes an option when the patient does not improve clinically after administration of medical treatment. Although endovascular management has fewer complications, the rate of restenosis is higher. Patients at risk of restenosis and who have increased perioperative vascular risk can benefit from open surgical procedures. Surgical management should be tailored to the patient's needs.

Headache, Delirium or Encephalitis? A Case of Residual Mutism Secondary to Anti-NMDA Receptor Encephalitis.

Encephalitis is a heterogeneous syndrome that is diagnosed through clinical assessment and the assistance of laboratory, neuroimaging and electroencephalographic workup. Over the past 10 years, autoimmune encephalitis has been more frequently recognized; however, most reports come from highly specialized hospital settings. Anti-N-methyl-D-aspartate receptor (NDMAR) encephalitis has been associated with paraneoplastic encephalitis syndromes and was first recognized in 2005. We present the case of a 34-year-old male patient who debuted clinically with a headache associated with neuropsychiatric symptoms (i.e., visual and auditory hallucinations, anxiety, aggressiveness) and memory deficits, progressing to autonomic dysfunction (i.e., tachycardia and hypertension), seizures, and stupor with catatonic features. Initially, infectious, metabolic, and toxicological etiologies were excluded; followed by the assessment of immunological and paraneoplastic etiologies, yielding positive IgG levels for anti-NMDAR antibodies. The patient was treated successfully with systemic steroid therapy and therapeutic plasmapheresis, while mutism was the only sequela. Although large case series reporting on paraneoplastic and autoimmune anti-NMDAR encephalitis have been reported in the literature in recent years, this case is of particular importance due to the stepwise differential diagnosis and treatment management procedure that was used in a regional but not highly specialized hospital setting.

A Case of Acute Pemphigus Vulgaris Relapses Associated with Cocaine Use and Review of the Literature.

Pemphigus is a bullous autoimmune disease that affects the skin and mucous membranes. It is very difficult to establish the etiology and the triggering factors that influence reactivations in pemphigus vulgaris (PV). The case of a 33-year-old male with chronic history of intranasal cocaine consumption is presented in this report. We present the clinical case of the patient, followed for a total of 86 weeks, with ten relapses secondary to probable cocaine use. The patient was admitted to the emergency department after presenting polymorphic dermatosis characterized by blisters, vesicles, and excoriations extending from the oral cavity to the thorax, and to the inguinal and genital regions, affecting approximately 35 % of the body surface area with a score of 56 on the Pemphigus Skin Disorder Index. Skin biopsies were compatible with PV diagnosis. The patient had clinical improvement with a combination of methylprednisolone 500 mg intravenously (IV) and cyclophosphamide 500 mg IV every 15 days, along with prednisone 50 mg orally (PO) q24 h and mycophenolic acid 500 mg PO q6 h. Persistent cocaine use is highly likely to be the factor triggering lesion reactivation and responsible for the torpid evolution. We cannot definitively conclude whether the change from azathioprine to mycophenolic acid after the tenth relapse was the adjuvant medication responsible for the end of the consolidation phase and complete remission on therapy. This case study could potentially serve as a guide for management of patients who continuously persist with cocaine use, leading to a clinical picture refractory to multiple therapeutic schemes.

Alveolar hemorrhage associated with cocaine consumption.

Cocaine is an illegal drug; its abuse and toxicity are a public health problem due to its high morbidity and mortality. Cocaine can affect the cardiovascular, central nervous and respiratory systems. The case of a 42-year-old male without history of chronic or degenerative diseases, but previous cocaine consumption is presented in this report. The patient is admitted to the Emergency Department given that the clinical presentation included hemoptysis and dyspnea with mild to minimal activity, which evolved to orthopnea. Advanced airway management was required and supportive care at the Intensive Care Unit was provided. Imaging studies showed evidence compatible with alveolar hemorrhage diagnosis. In search of an autoimmune etiology, an antibody-screening panel was requested, reporting negative results for autoimmune disorders. The patient management was based on corticosteroid therapy and plasmapheresis to counter the persistent hemoptysis and hemoglobin serum level decline. The management strategy was based on the clinical suspicion of vasculitis and a torpid clinical evolution. Pulmonary sepsis ensued, resulting in patient's death. The necropsy report describes the primary cause of death as diffuse alveolar hemorrhage secondary to diffuse alveolar injury. This case report presents the detailed clinical, imagining and histopathological findings of a patient with alveolar hemorrhage secondary to cocaine consumption, as well as a review of the literature.

Invasive Pulmonary Adenocarcinoma with Lepidic Growth Pattern in a Pregnant Patient.

Among the differential diagnoses that should be considered in acute respiratory failure (ARF) are infectious processes, autoimmune diseases, interstitial pulmonary fibrosis, and pulmonary neoplasia. Timely diagnosis of lung neoplasia is complicated in the early stages. An opportune diagnosis, as well as the specific treatment, decrease mortality. ARF occurs 1 in 500 pregnancies and is most common during the postpartum period. Among the specific etiologies that cause ARF during pregnancy that must be considered are: (1) preeclampsia; (2) embolism of amniotic fluid; (3) peripartum cardiomyopathy; and (4) trophoblastic embolism. The case of a 36-year-old patient with a 33-week pregnancy and ARF is presented. The patient presented dyspnea while exerting moderate effort that progressed to orthopnea and type 1 respiratory insufficiency. Imaging studies showed bilateral alveolar infiltrates and predominantly right areas of consolidation. Blood cultures, a galactomannan assay and IgG antibodies against mycoplasma pneumoniae, were reported as negative. Autoimmune etiology was ruled out through an immunoassay. A percutaneous pulmonary biopsy was performed and an invasive pulmonary adenocarcinoma with lepidic growth pattern (i.e. lepidic pulmonary adenocarcinoma, LPA) result was reported. This etiology is rare and very difficult to recognize in acute respiratory failure cases. After infectious, autoimmune and interstitial lung fibrosis have been excluded the clinician must suspect of lung cancer in a patient with acute respiratory failure and chest imaging compatible with the presence of ground-glass nodular opacities, a solitary nodule or mass with bronchogram, and lung consolidation. In the presence of acute respiratory failure, the suspicion of pulmonary neoplasia in an adult of reproductive age must be timely. Failure to recognize this etiology can lead to fatal results.

Diagnosis and Treatment Options of Spinal Metastases.

Cancer patients with spinal metastases are a diagnostic and treatment challenge for the clinician. This challenge must be addressed through a multidisciplinary, multimodal, and individualized management. The presence of tumor cells in bone metastases results in homeostatic disruption between bone formation and remodeling. Bone destruction is a late event in the formation of lytic bone metastasis, starting when tumor cells proliferate; this in turn activates osteoclasts, seen as trabecular destruction in imaging studies. There may be excessive bone destruction and increased bone formation, which produce blastic lesions. Bone scintigraphy is currently the most widely used diagnostic method and is considered as the reference test for the diagnosis of spinal bone metastasis. However, we believe that in the near future positron emission tomography associated to computed tomography with 18F-NaF, or magnetic resonance using diffusion-weighted whole-body imaging with background body signal suppression, will replace bone scintigraphy due to their improved diagnostic accuracy. These new diagnostic tools will help prevent bone metastasis complications such as: intractable pain; spinal cord or cauda equina compression; hypercalcemia; pathological fractures; and spinal instability. With regards to the treatment, it can be uni- or multimodal, depending on the type and number of bone metastases. Among the types of treatment available for bone metastasis are chemotherapy, radiotherapy, and invasive procedures. The prognosis of patient survival depends on the histopathology of the primary tumor, the presence of bone metastasis, and the presence of neurological deficits.