Closed Degloving Injury of the Foot Caused by a High Impact Force: A Case Report.

An 18-year-old male subject was referred to our MRI scanning center, by an orthopedic surgeon, for a swelling over the plantar region of the foot. He had been in a motor vehicle accident a few weeks back, with no evidence of fracture at the time of injury. In subsequent weeks, he developed a swelling over his foot. MRI showed the presence of a fluid intensity lesion in the subdermal and dermal layers of his foot. Unguarded motor vehicle accidents often tend to cause severe injuries. Sometimes, they even need operative management since a motor vehicle collision is a high-impact accident. One of the pathologies caused by a high impact force is the Morel-Lavallée lesion or a closed type of degloving injury. A Morel-Lavallee lesion also needs operative intervention if major vascular channels are involved in the degloving. However, if the major vessels supplying the region of degloving are intact, open surgery may not be needed. In such cases, incision and drainage along with serial wound dressing may be attempted. The primary risk in closed degloving is recurrent or subsequent tissue necrosis. Close and watchful monitoring is needed to anticipate and prevent these. Closed degloving injuries or Morel-Lavallée lesions have been commonly described in the thigh and pelvis region. Here, we describe a case that developed in the dermal and fascial layers of the foot and was managed conservatively. The epidermal layer showed regeneration, and the patient did not need subsequent amputation.

Pediatric Glomerular Diseases in North India-Epidemiology and Clinicopathologic Correlation.

Background: Glomerular diseases vary with age, and it is important to investigate the spectrum of glomerular diseases in pediatric patients to help in a more precise clinical diagnosis and optimize the management of patients. We aimed to study the clinicopathologic pattern of pediatric glomerular diseases in North India. Methods: This is a 5-year retrospective, single-center cohort study. The database was searched to identify all pediatric patients with glomerular diseases in their native kidney biopsies. Results: About 2890 native renal biopsies were studied, of which 409 were pediatric glomerular diseases. The median age was 15 years with a male preponderance. Nephrotic syndrome was the most common presentation (60.8%), followed by non-nephrotic proteinuria with hematuria (18.5%), rapidly proliferative glomerulonephritis (7%), isolated hematuria (5.3%), acute nephritic syndrome (3.4%), non-nephrotic proteinuria (1.9%), and advanced renal failure (0.7%). Minimal change disease (MCD) was the most common histological diagnosis, followed by focal segmental glomerulosclerosis (17.4%), IgA nephropathy (IgAN; 10%), membranous nephropathy (6.6%), lupus nephritis (5.9%), crescentic glomerulonephritis (2.9%), and C3 glomerulopathy (2.9%). Diffuse proliferative glomerulonephritis (DPGN) was the most common histological diagnosis in patients with hematuria and non-nephrotic as well as nephrotic range proteinuria. The most common histological diagnoses for isolated hematuria and acute nephritic syndrome were IgAN and postinfectious glomerulonephritis (PIGN), respectively. Conclusions: MCD and lupus nephritis are the most common pediatric primary and secondary histopathologic diagnoses, respectively. The adolescent-onset glomerular diseases have a higher frequency of IgAN, membranous nephropathy, and DPGN. PIGN is still an important differential in our pediatric patients presenting with acute nephritic syndrome.

Clinicopathological characteristics and predictors of poor outcome in anti-glomerular basement membrane disease - a fifteen year single center experience.

INTRODUCTION: Anti-glomerular basement membrane (anti-GBM) disease is a small vessel vasculitis affecting the renal and lung capillary beds. We aim to study the clinicopathological characteristics and predictors of poor outcome of this disease in our population. MATERIALS AND METHODS: This is a 15 year retrospective, single center observational study of Indian cohort. Patients with biopsy proven anti-GBM disease were studied. RESULTS: Anti-GBM disease was found in 0.5% of the total cases. The mean age at presentation was 46.7 years. Compared to renal limited disease those with pulmonary-renal syndrome had a higher frequency of hypertension, oliguria, percentage of crescents, interstitial inflammation and glomerulosclerosis. Double positive (anti-GBM and ANCA antibodies) patients showed more of glomerulosclerosis, tubular atrophy/interstitial fibrosis (IFTA) as well as periglomerular granulomas on biopsy. Patient survival at one year was 40.4% and death censored renal survival was 9.7%. Factors affecting the dialysis dependency at presentation were oligoanuria (p = .04), creatinine levels >5.7 mg/dl (p = .003), and high mean anti-GBM titers (p = .008). Atypical cases accounted for 8.3% of these patients. Oligoanuria (HR = 5.0, p = .05), high serum creatinine (HR = 1.55, p = .05), severe glomerulosclerosis (HR = 1.09, p = .03), and IFTA (HR = 2, p = .04) were associated with poor renal outcome. Advanced age (HR = 1.92, p = .03), high serum creatinine (HR = 1.9, p = .04) and high anti-GBM titers (HR = 1.01, p = .03) were associated with poor patient survival. CONCLUSIONS: Anti-GBM is a rare disease with poor prognosis and varied presentations. Patients with pulmonary-renal syndrome showed severe disease whereas double positive had more of chronic changes. The predictors of poor prognosis include advanced age, oliguria, serum anti-GBM levels, serum creatinine levels, degree of glomerulosclerosis and IFTA. Atypical anti-GBM cases should be kept in mind while evaluating renal biopsies.

Pediatric C3 glomerulopathy: a 12-year single-center experience.

BACKGROUND: Complement component 3 glomerulopathy (C3G) is a disease with limited data in children. We aimed to compare childhood C3G cases with adults. We also studied subgroups of pediatric C3G and predictors of poor outcome. METHODS: This is a 12-year retrospective, single-center cohort, observational study. All cases of C3G were defined based on the 2013 consensus guidelines. RESULTS: C3G was diagnosed in 162 patients (119 adults, 43 pediatric) predominantly affecting males. With varied light microscopic patterns, pediatric C3G cases were categorized as follows: 23 C3 glomerulonephritis (C3GN) and 11 dense deposit disease (DDD) on electron microscopy. The pediatric DDD patients were relatively younger with more severe disease at presentation (more crescents in biopsy) but with lesser chronicity in biopsy compared with pediatric C3GN patients; however, both had a similar outcome. On comparing pediatric and adult C3G cases, adults had lower median eGFR and a higher degree of chronicity in the biopsy. The prognosis of C3G was better in pediatric patients. Predictors of kidney failure in pediatric C3G were low eGFR (HR = 0.82, p = 0.05) and severe interstitial fibrosis/tubular atrophy (HR = 1.05, p = 0.02). CONCLUSIONS: Electron microscopy-based subgroups of pediatric C3G differ in clinical presentation and course of the disease but have similar prognosis and long-term outcomes. Pediatric C3G differs from adult C3G with respect to presentation, laboratory results, biopsy features, treatment, and outcome, and as such, it should be considered as a separate entity rather than a smaller version of adult C3G.

Red herrings in crossmatching kidneys for transplant.

Crossmatching of prospective renal transplant donors against recipients is a mandatory component of the transplant workup, being performed for over 40 years now. Allografting patients with human leukocyte antigens which are recognized by preformed antibodies constitutes the main cause of hyperacute or acute rejections. The existence of these donor-specific anti-human leukocyte antigen antibodies (DSAs) is regarded as a contraindication for graft trans-plantation, both cadaveric and live kidney. We present two unusual cases in which both complement-dependent cytotoxicity crossmatch and DSA by Luminex were falsely positive due to autoimmune and infectious causes, but single-antigen bead assay showed these antibodies to be against nondonor antigens. After treating their basic disease, thought to be responsible for false-positive DSA, these patients became DSA negative and underwent transplantation with an uneventful posttransplant period. Our aim through these examples is to highlight the problem of false-positive crossmatch in potential renal allograft transplant recipients. Further, we propose antigenic determination of donor-specific antibodies in such patients where we suspect the immune system to be chronically activated to pick up false-positive cases and therefore increase the donor pool without compromising the transplant outcome.

Clinicopathological Significance and Renal Outcomes of Light Microscopic Patterns in Complement Component 3 Glomerulopathy.

BACKGROUND: Complement component 3 glomerulopathy (C3G) is a disease diagnosed based on the predominance of C3 immunostaining in glomeruli. The popular electron microscopic subtyping of C3G into dense deposit disease and C3 glomerulonephritis (GN) is not without limitations. We aimed to study the light microscopic (LM) patterns of C3G along with their clinicopathological correlation and treatment outcome. METHODS: C3G biopsies were classified into 4 LM patterns (membranoproliferative GN [MPGN], mesangial proliferative GN [MesPGN], diffuse proliferative GN [DPGN], and crescentic GN [CrGN]). These patterns were compared for clinicopathological profile, treatment outcome, and renal survival. Further, predictors of end-stage renal disease (ESRD) were determined using the Cox proportional hazards model. RESULTS: Of 162 biopsies, there were 83 MPGN, 36 DPGN, 22 MesPGN, and 21 CrGN. Majority of the patients were young, with males being more than females. About half (48%) of the patients received immunosuppression, steroids alone (29%) or steroids with other immunosuppressants (19%). The overall remission rate was 32.7% (median follow-up = 14 months). CKD developed in 46 patients and 31 patients progressed to ESRD. Predictors of progression to ESRD were older age (hazard ratio [HR] = 1.04, p < 0.01), advanced renal failure at presentation (HR = 3.73, p < 0.01), glomerulosclerosis (HR = 5.07, p < 0.01), and severity of interstitial fibrosis and tubular atrophy (HR = 8.25, p = 0.01). CONCLUSIONS: The LM patterns differed in their clinicopathological profiles, without any significant difference in their renal outcomes. Glomerulosclerosis and interstitial fibrosis portend a poor prognosis. Besides CrGN, MesPGN pattern of C3G presented as a severe form of disease.

Clinicopathological Pattern of Non-lupus Full House Nephropathy.

BACKGROUND AND AIMS: Full-house immunofluorescence in a kidney biopsy is a common observation in lupus nephritis (LN) and was previously used synonymously with the diagnosis of LN. Though a minority of the patients will develop features suggestive of SLE during follow-up, a majority of the patients will continue without any clinical or serological evidence of systemic lupus erythematosus (SLE) over time. Our aim to conduct this study was to work up the clinicopathological spectrum of these "full-house" nephropathies (FHN) which were not due to lupus nephritis. METHODS: A total of 6244 renal biopsies were evaluated at SGPGIMS Lucknow from January 2007 to December 2017 for full-house immunofluorescence. All those patients who had no clinical or serological evidence of SLE at the time of renal biopsy or at any time during follow up were included. RESULTS: Among 498 patients with full house immunofluorescence, 81 patients had no clinical or serological evidence of SLE at the time of renal biopsy or at any time during follow up. The prevalence of non-lupus FHN in this study was 19.4%, and the major diagnoses were membranous nephropathy (25.9%), IgAN (22.2%), MPGN (14.8%), DPGN (12.3%), Crescentic GN (12.3%), Amyloidosis (8.6%), C1q nephropathy (3.7%). CONCLUSIONS: Full-house nephropathy (FHN), not otherwise suggestive of lupus nephritis, can also be found in a number of other conditions. Non-lupus full house nephropathy is an umbrella term for such cases which do not satisfy the standard criteria of SLE. This will prevent misclassifying these patients into SLE and further prevent them from unnecessary immunosuppression protocols.

Simultaneous tubular and glomerular involvement with cryoglobulinemia vasculitis in multiple myeloma.

Renal manifestations in myeloma are varied. Tubulopathic light chains cause cast nephropathy or proximal tubulopathy, usually associated with tubulointerstitial nephritis. Glomerular involvement includes amyloidosis and monoclonal immunoglobulin deposition diseases. We report a case of multiple myeloma with systemic manifestation of Type-1 cryoglobulinemic vasculitis (skin rash and polyarthritis) and unusual renal manifestation with both tubular and glomerular involvement on renal biopsy along with features of cryoglobulinemic renal vasculitis. Renal biopsy showed light chain cast nephropathy and glomerular involvement. Glomeruli displayed membranoproliferative pattern with monoclonal immunoglobulin deposition disease and features of cryoglobuminemia. Immunoflourescence showed Kappa restriction in the tubular casts and glomerular deposits. Serum light chain assay and immunoelectrophoresis revealed IgG Kappa light chain restriction. The exact mechanism of the varied renal manifestations of multiple myeloma in different patients is not known.

A rare case of foreign body bronchus: a case report.

Foreign body inhalation is commonly seen in children who need to be treated promptly and immediately otherwise it leads to complications. We here report a rare case of foreign body detached part of metallic tracheostomy tube in left main bronchus.

Clinicopathological profile of cervicofacial masses in pediatric patients.

Four hundred pediatric patients (0-12 years of age) who presented with cervicofacial masses were evaluated clinically and pathologically. Infl ammatory lesions were the commonest (48%) followed by congenital and developmental malformations (26%). In infl ammatory lesions, reactive lymphadenopathy was the commonest (16%) followed by tubercular lymphadenitis (11.5%). In congenital and developmental malformations hemangiomas were the commonest (12%) followed by TG cyst (6.5%). Cystic lesions (non-developmental) constituted 19%, benign neoplastic lesions 7% and malignant neoplastic lesions 2% of the cases. Males predominated the series (53.5%) and commonest age group involved was 10-12 years (20.5%). FNAB was performed in 93% of cases and HPE was available in 51.5% of cases. Sensitivity of FNAB in our series was 87.4%.

CT scan evaluation of the anatomical variations of the ostiomeatal complex.

INTRODUCTION: Functional endoscopic sinus surgery (FESS) has revolutionized the approach and treatment of chronic rhinosinusitis. Certain anatomical variations are thought to be predisposing factors for the development of sinus disease and it is necessary, for the surgeon to be aware of these variations, especially if the patient is a candidate for FESS. OBJECTIVE: The aim of the present study was to identify the various anatomical variations of the ostiomeatal complex in patients of chronic rhinosinusitis who underwent FESS. MATERIALS AND METHODS: A total of 150 patients of chronic rhinosinusitis (medical treatment failures) who were subjected to FESS were CT scanned preoperatively to find any bony anatomic variation and the extent of mucosal disease. RESULTS: Concha bullosa was the commonest anatomic variation and was seen in 45 (30%) patients. The other anatomic variations noted included: paradoxical middle turbinate in 9.33% patients, uncinate process variations in 25% patients, agger nasi cells in 9.33%, Haller cells in 8.66% and posterior septal deviations in 25.33% patients. The mucosal disease was most commonly seen in anterior ethmoids (87.33% ), followed by maxillary sinus ostial area (70%), maxillary sinus disease (65.33%), posterior ethmoidal disease (38%), frontal sinus disease (15%) and sphenoid sinus mucosal disease (8.66%) patients. CONCLUSION: A thorough preoperative CT evaluation of the patients undergoing FESS is necessary to detect various anatomical variations in the ostiomeatal complex.