Serological diagnosis of Mycobacterium avium complex lung diseases by enzyme immunoassay of IgA antibodies against MAC-specific glycopeptidolipid core antigen.

INTRODUCTION: There is an increasing trend worldwide in the incidence of Mycobacterium avium complex pulmonary diseases (MAC-PD) and the diagnosis is sometimes complicated. Recently, an enzyme immunoassay (EIA) kit that detects serum IgA antibody against MAC-specific glycopeptidolipid (GPL) core antigen had been developed and found to be useful in discriminating MAC-PD from other lung diseases. The antibody was subsequently also found to be elevated in patients suffering Mycobacterium abscessus pulmonary diseases (MAB-PD). This study is to evaluate this EIA kit in the serological diagnosis of MAC-PD in Hong Kong Chinese patients. METHODS: The study was conducted in Grantham Hospital, Hong Kong between July 2017 and July 2018. Assay of the IgA antibody level using the EIA kit was done on blood samples collected from patients suffering from MAC-PD, MAB-PD, pulmonary tuberculosis and other lung diseases. RESULTS: There were 100 subjects recruited into the study, among which 11 were excluded. By using the cut-off value 0.7 U/mL provided by the manufacturer, the sensitivity and specificity for diagnosis were 73.7% and 77.6% for MAC-PD; 50% and 77.6% for MAB-PD. By receiver operating characteristic curves analysis, new cut-off for MAC-PD and MAB-PD were calculated as 1.771 U/mL and 0.172 U/m, respectively. The sensitivity and specificity were 68.4% and 86.2% for MAC-PD, whereas 66.7% and 72.4% for MAB-PD. CONCLUSIONS: Our study showed that the enzyme immunoassay of IgA antibodies against MAC-specific glycopeptidolipid core antigen could help to distinguishing MAC and M. abscessus pulmonary diseases from pulmonary tuberculosis and other lung diseases among Hong Kong Chinese patients. Further larger scale studies in our local population for the usefulness of this antibody test in the diagnosis and monitoring of MAC and M. abscessus lung diseases might be warranted.

Thymic carcinoma presenting with an unusual and delayed metastasis to the neural foramen, mimicking thoracic spinal radiculopathy.

We report a case of metastatic thymic carcinoma which presented as an enhancing mass located in the neural foramen of the thoracic spine. More common tumours which arise in the neural foramen would include a neurogenic tumour or developmental anomalies such as a foregut duplication cyst. This case is singular firstly because the lesion present as radiculopathy which mimics a neurogenic tumour. Secondly, the presentation was unusually delayed as the patient presented to our centre more than a decade after the resection of the primary tumour in another institution.

Primary spinal oligoastrocytoma mimicking longitudinally extensive transverse myelitis.

Longitudinally extensive transverse myelitis (LETM) is most commonly associated with neuromyelitis optica spectrum disorders (NMOSD). However, a wide range of etiologies may produce longitudinally extensive spinal cord lesions (LESCLs) on imaging. We highlight the case of a patient with a spinal cord tumor whose imaging showed LESCL and was diagnosed with LETM. He did not respond to immunosuppression and subsequently developed a progressive and protracted clinical course. Thoracic cord biopsy performed 6 years after symptom onset showed primary spinal oligoastrocytoma. We discuss the features that should raise suspicion of a neoplasm in the context of LESCL and serve a reminder that not all LESCLs are inflammatory.

Cardiorenal syndrome - a new classification and current evidence on its management.

Patients with chronic kidney disease (CKD) are at high risk for major cardiovascular (CV) morbidity and mortality, especially when they range among the elderly. The co-existence of renal dysfunction is common in patients with chronic heart failure (CHF), and renal failure is among the strongest predictors of mortality in patients with heart failure. Approximately one-third of dialysis patients also suffer from heart failure. The term "cardiorenal syndrome" has been increasingly described in recent literature, as there is growing recognition of the frequent association of combined renal and cardiac dysfunction. The pathophysiology of the cardiorenal syndrome involves interrelated hemodynamic and neurohormonal mechanisms, including the sympathetic nervous system, the renin-angiotensin-aldosterone system, and endothelin and arginine vasopressin system activation. Recently, a new classification of cardiorenal syndrome has been proposed with five subtypes that reflect the pathophysiology, the bidirectional nature of heart and kidney interaction and the time-frame. The management of the cardiorenal syndrome remains a challenge in spite of the advances in medical therapy and novel agents. Novel agents such as B-type natriuretic peptide (BNP) derivative, endothelin antagonist, adenosine antagonist or vasopressin antagonist have been evaluated in randomized controlled trials, and their results are discussed in this review. Mechanical support like hemodialysis and ultrafiltration are found to be useful in acute cardiorenal syndrome. There has been renewed interest in b-blockers in chronic cardiorenal syndrome patients to prevent sudden cardiac death from arrhythmia. In this review, we discuss the evidence behind the definition, pathophysiology, new proposed classification and the various therapeutic measures available for acute cardiorenal syndrome as well as chronic cardiorenal syndrome.

Giant cell (temporal) arteritis in Singapore: an occult case and the rationale of treatment.

Further observations in respect of giant cell arteritis (GCA) as encountered in a local neuro-ophthalmology service established in Singapore ten years earlier are reported. The rarely seen occult form of the disease is described along with an illustrative case report concerning an 80-year-old woman. The overall management of GCA is discussed in respect of four clinical scenarios and their treatment.

Technetium myocardial perfusion scanning in prerenal transplant evaluation in the United kingdom.

Because death with a functioning graft remains one of the most important causes of long-term renal transplant failure, cardiac risk stratification and screening for coronary artery disease are essential components of pretransplant assessment. Pretransplant screening for occult coronary artery disease in a subset of these patients may improve outcome. The UK follows the European Best practice guideline 1.5.5 E. Although echocardiography, thallium myocardial perfusion scanning (MPS), dobutamine stress echocardiography, and coronary angiography have been suggested as means of cardiovascular assessment, the best means of assessment remains undetermined. Therefore, we investigated the role of 99m technetium sestamibi myocardial perfusion scanning as an assessment tool for identifying those patients with end-stage renal failure at high risk of cardiovascular death after renal transplantation. Retrospectively, we studied 126 patients that had a MPS as part of their pretransplant assessment. Overall unadjusted survival was 65% at 3 years. Twelve deaths resulted from cardiovascular causes. A reversible defect on MPS was associated with a fatal cardiac event and all-cause mortality. The unadjusted hazard ratio of cardiac event with reversible defect on MPS was 3.1 (95% confidence interval, 1.1 to 18.2) and hazard ratio of death with reversible defect on MPS was 1.92 (95% confidence interval, 1.1 to 4.4). Thus, MPS may be a useful tool in cardiac risk stratification and in selecting patients with a favorable outcome after renal transplantation. Our patients with a reversible defect in particular have increased cardiac mortality. This group may benefit from coronary angiography.

Rapidly deteriorating renal function with membranoproliferative glomerulonephritis Type 1 associated with hepatitis C treated successfully with steroids and antiviral therapy: a case report and review of literature.

INTRODUCTION: The hepatitis C virus (HCV) infection is associated with several renal diseases including mixed essential cryoglobulinemia, membranoproliferative glomerulonephritis (MPGN) and less frequently membranous nephropathy and crescentic glomerulonephritis. We present a case of HCV-associated cryoglobulin-negative, MPGN Type 1 with features of early crescents and rapidly deteriorating renal function requiring urgent treatment. CASE: A 35-year-old male was admitted with history of arthralgia and erythematous rash. His past medical history included being an intravenous drug abuser. Biochemistry test showed raised serum creatinine of 150 micromol/l. He had nephrotic range proteinuria of 6 g/day and a serum albumin of 23 g/l. Viral serology for hepatitis B and HIV was negative but confirmed evidence of HCV infection with genotype 3A and viral load of 151,014 copies. He had a renal biopsy and histology demonstrated features of crescentic MPGN Type 1. His renal function deteriorated rapidly with his serum creatinine rising to 300 micromol/l over 2 days. We commenced treatment with intravenous methylprednisolone, 500 mg once daily (o.d.) for 3 days, followed by oral prednisolone 40 mg o.d. Concurrently, pegylated Interferon- (IFN) I+/- was commenced. After a 2-week treatment, his renal function showed remarkable recovery with creatinine reduced to 140 micromol/l. After 3 months, ribavirin was added when his renal function remained stable. He had tolerated his treatment without any major side effects. At 6 months follow-up clinic, his renal function was normal with serum creatinine of 69 micromol/l, 24-h urinary protein had dropped to 0.35 g/day, serum albumin increased to 38 g/l and HCV PCR was negative. DISCUSSION: The current treatment strategy of HCV-associated renal diseases includes targeting viral trigger HCV with interferon and ribavirin. Both IFN-I+/- and ribavirin have their limitation and adverse effects. In a clinical scenario where there is evidence of rapidly deteriorating renal function with crescentic glomerulonephritis, cautious use of immunosuppressive therapy may well be essential in the acute stage to halt the progression of kidney damage. Literature review of the treatment strategy for MPGN Type 1, cryoglobulin-negative with early features of crescents associated with HCV showed that there was no report or guideline available. CONCLUSIONS: To our knowledge, this is the first case in the literature of rapidly progressing MPGN Type 1 associated with HCV and nephrotic syndrome treated successfully with antiviral drugs and steroids concurrently. Our case highlights an important treatment strategy and may be beneficial to nephrologists facing this clinical scenario in the future. However, a randomized controlled trial is required to evaluate the efficacy of this treatment combination before it can be a standard treatment.

Endobronchial nocardiosis associated with broncholithiasis.

Pulmonary nocardiosis is a rare respiratory infection which commonly affects immunocompromised patients but also in immunocompetent hosts. The clinical manifestation is variable and endobronchial nocardiosis is a very rare condition. We report a case of endobronchial nocardiosis associated with the presence of a broncholith. The pathogenesis and the treatment of this condition are discussed below.

Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis.

INTRODUCTION: Non-dialytic treatment (NDT) has become a recognized and important modality of treatment in end stage renal disease (ESRD) in certain groups of chronic kidney disease (CKD) patients. However, little is known about the prognosis of these NDT patients in terms of hospitalization rates and survival. We analyzed our experience in managing these NDT with a multidisciplinary team (MDT) approach over a three-year period. PATIENTS AND METHODS: The Renal Unit at the Royal Liverpool University Hospital set up a dedicated MDT clinic to manage NDT patients in January 2003. Patients approaching end stage chronic kidney disease who chose not to dialyse were recruited from other nephrologists. The study group was classified according to age band (<70 years, 71-80 years, and >80 years), estimated glomerular filtration rate (eGFR) (<10 ml/min, 11-20 ml/min, and >20 ml/min) according to the Modified Diet In Renal Disease formula and Stoke comorbidity grade (SCG). The SCG is a validated scoring system for the survival of patients on renal replacement therapy. We also used the ERA-EDTA primary renal diagnosis codes. As there are no existing standards for NDT patients, we used the U.K. national set for haemodialysis patients as a reference and target for our NDT patients. Data was collected prospectively. RESULTS: The median age was 79 years and the male: female ratio was approximately 1. The most common primary cause of kidney disease in the NDT study population was chronic renal failure of unknown cause n = 22 (31%), but the most common identifiable cause was diabetic nephropathy, n = 20 (28%). The most common comorbidity was ischaemic heart disease n = 25 (34%). Those achieving the standards for anaemia were 78% at referral. Only 30% of the NDT patients achieved the standard for blood pressure (<130/80 mmHg) at referral. Forty-three patients (60%) had no admissions at all. There were a total of 30 patients admitted on 58 occasions. Thirty-one (53%) of these were due to a non-renal cause. The median length of stay for the other NDT patients was 10 days. The median overall survival (life expectancy) was 1.95 years. The one-year overall survival was 65%. SCG was an independent prognostic factor in predicting survival in NDT patients studied (p = 0.005), the hazard ratio being 2.53, for each incremental increase in the SCG. At one year, the survival for comorbidity grade 0, 1 and 2 were 83%, 70% and 56% respectively. Of the 28 patients who died, 20 did so at home (71%). DISCUSSION: The NDT of ESRD has become an important alternative modality in renal replacement therapy. With the emergence of epidemic proportions of CKD, more elderly patients with progressive renal disease will need to make informed decisions regarding renal replacement therapy. There is likely to be increasing number of elderly patients that will tolerate dialysis badly and who will be very dependent on others. We believe that there should be a multidisciplinary approach to assist the ESRD patients in choosing their modality of renal replacement therapy, and with an agreed care plan to support these patients in managing their chosen modality to achieve the best possible quality of life. There should be integrated services with primary care, community nurses, and palliative care teams to enable the majority of the patient's treatment to be carried out at home and to allow a dignified death. However. there was a statistically significant trend for shorter survival among those with greater comorbidities, as determined by the SCG. This is the first report of the potential importance of SCG as an independent prognostic factor in NDT patients. This will help us to counsel our patients in the future about their prognosis if they choose NDT as their modality of renal replacement therapy. CONCLUSION: Our prospective study is the first and currently the largest observational study of a multidisciplinary approach in the management of NDT patients. SCG was an independent prognostic factor in predicting survival. In those patients who chose not to dialyse, SCG provides a potentially useful indication of expected prognosis.