Role of tumor necrosis factor inhibitor in granulomatous interstitial nephritis secondary to Crohn's disease.

A 17-year-old male with attention deficit hyperactivity disorder was admitted to the hospital with generalized weakness. Vital signs and physical examination were normal. Laboratory data were notable for a creatinine of 4.5 mg/dL (baseline 0.6 mg/dL), estimated glomerular filtration rate of 18 ml/min/1.73 m² and hemoglobin 10 g/dL. Urinalysis revealed only 30 mg/dL protein. Serology for autoimmune workup was negative. Renal ultrasound was normal. Kidney biopsy showed noncaseating granulomas and acute on chronic tubulointerstitial nephritis (TIN) with lymphocytes, macrophages, plasma cells and no eosinophils. Acid fast bacilli and Grocott's methenamine silver stains were negative. Granulomatous interstitial nephritis (GIN) was diagnosed. Prednisone at 60 mg/day was started and tapered. He was then noted to have diarrhea. Colonoscopy showed active enteritis with granulomatous inflammation consistent with Crohn's disease (CD). Azathioprine was started but due to worsening renal function and diarrhea, it was discontinued. He did not tolerate continued higher doses of prednisone because of mood swings and cushingoid features. Infliximab was initiated with improvement in renal function. There was rapid worsening of renal function when infliximab therapy was interrupted but improved when both prednisone and inflixamb were reinitiated.

Antibiotic resistance in pathogens causing community-acquired urinary tract infections in India: a multicenter study.

BACKGROUND: Empiric treatment of community-acquired urinary tract infections (CA-UTI) is determined by the antibiotic sensitivity patterns of uropathogens in a population. This study was conducted to determine patterns of resistance amongst CA-uropathogens in India, to help establish local guidelines on treatment of CA-UTI. METHODOLOGY: 531 consecutive positive urine cultures taken from adult non-pregnant females attending outpatient clinics of five hospitals in Delhi, India, were analysed. Sensitivity testing was done for ciprofloxacin, trimethoprim-sulphamethoxazole (SXT), amoxicillin, amoxicillin-clavulanate, amikacin, nitrofurantoin, piperacillin-tazobactam and meropenem in each isolate. RESULTS: E. coli comprised 68%; Klebsiella 16.9%; Proteus 5.5%; Enterobacter 5.3%; Staphylococcus saprophyticus 2.8%; and others 1.5% of the isolates. Furthermore, 26.9% of the gram negative isolates were ESBL producers. Antibiotic sensitivity of all the gram negative organisms showed that 35.8% were sensitive to ciprofloxacin; 30% to SXT; 17.7% to amoxicillin; 41.6% to amoxicillin/clavulanate; 75.6% to amikacin; 65.7% to nitrofurantoin; 90.2% to piperacillin-tazobactam; and 100% to meropenem. CONCLUSION: High levels of ESBL producers among gram negative CA-uropathogens was seen in our country. This, along with the alarming rate of resistance to ciprofloxacin, SXT and amoxicillin, precludes the use of these commonly used antibiotics for empiric treatment of CA-UTI in India.

Pulmonary embolism due to catheter fracture from a tunneled dialysis catheter.

The patient presented to the emergency room with hemoptysis and pleuritic chest pain. A chest x-ray revealed a broken dialysis catheter tip lodged in the pulmonary artery. The fractured catheter tip was removed via the femoral vein using a loop snare. As has been described for central lines and venous ports, a fractured catheter tip from a hemodialysis catheter may also lead to pulmonary embolism.