COVAN Leading to ESKD Despite Minimal COVID Symptoms.

We report a case of dialysis dependence in a patient with COVID-19-associated nephropathy (COVAN) who had minimal respiratory manifestations. A 25-year-old man with a history of multiple sclerosis in remission presented with mild dyspnea due to COVID-19 pneumonia and was found to have rapidly worsening kidney function. He only required nasal cannula and was able to be weaned off within a few days. Despite having only mild respiratory disease, his kidney function worsened and urgent hemodialysis was started for hyperkalemia and uremic encephalopathy. Kidney biopsy demonstrated collapsing glomerulopathy due to COVID-19 with moderate interstitial fibrosis and tubular atrophy. His kidney function did not recover, and he unfortunately now has been dependent on hemodialysis for over 3 months. Multiple case reports have described COVAN causing dialysis dependence, but to our knowledge this is the first reported case of COVAN causing dialysis dependence in a patient with such mild respiratory disease. Currently the indications for intensive COVID-19 therapies are based on oxygen requirements. This case demonstrates that the oxygen requirement may not fully reflect the severity of COVID-19 and raises the question of whether these therapies should be considered in patients with COVAN.

Ectoparasitosis, a rare cause of severe iron deficiency anemia: A case report.

Pediculosis is a common condition caused by an infestation of head and body louse (ectoparasites) and remains a public health concern. Generally, infestation presents as pruritus in children and has a benign course, but there have been a handful of cases reported in the literature describing severe iron deficiency anemia (IDA) in high-risk groups such as children, history of psychiatric disorder including depression, and low socioeconomic status. Though an uncommonly encountered etiology of anemia, the aim of this case is to increase awareness of a rare cause of severe anemia from an ectoparasites affecting a high risk population, even in developed countries.

A Case of IgG4-Related Kidney Disease Developing While on Steroid Treatment for Autoimmune IgG4 Pancreatitis.

IgG4 (immunoglobulin G4)-related systemic disease is an autoimmune process affecting multiple organ systems. This inflammatory process can present as but not limited to pancreatitis, cholangitis, or unspecified kidney disease. In this case, our patient developed IgG4-related kidney disease while already on a prolonged steroid course for IgG4-related pancreatitis. The patient ultimately had renal recovery after starting a higher dose of prednisone, but also developed steroid-related complications. This case further highlights the relationship between IgG4 diseases now termed IgG4-related systemic disease. This case brings to light the need for further investigative research into ideal steroid dosing, as well as steroid-sparing agents for IgG4-related systemic disease.

Bedside Ultrasonography for Arteriovenous Fistula Cannulation.

Difficulty in accessing a new arteriovenous fistula (AVF) is a common technical issue in hemodialysis patients, which often leads to interventional radiology and/or vascular surgery referral. As a consequence, the patient who needs dialysis may require a temporary dialysis catheter with its known potential complications. We present a case where bedside ultrasonography facilitated successful cannulation of a difficult AVF. Ultrasonography (US) training in this procedure may allow early cannulation of new AVFs when the venous diameter is large enough (>0.6 cm) but the fistula is too deep (>0.6 cm). Real-time, US-guided AVF cannulation may also decrease the number of failed venous punctures per hemodialysis (HD) session minimizing vessel wall damage and subsequent potential hematoma and aneurysm formation.

Pseudo-Pelger-Huët anomaly and granulocytic dysplasia associated with human granulocytic anaplasmosis.

Pseudo-Pelger-Huët anomaly (PHA) refers to mono- or bi-lobed granulocytes, reportedly observed in patients with severe infections and inflammation or hematological malignancies including myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Dysplastic changes in granulocytes are typical manifestations in MDS and granulocytic leukemias. Here, we report the unique case of a patient found to have human granulocytic anaplasmosis (HGA), a tick-borne disease caused by Anaplasma phagocytophilum, a Gram-negative coccobacillus. This patient showed striking hematological manifestations including a large number of pseudo-PHA, a severe degree of left shift, and dysplastic granulocytes. These hematological presentations on the peripheral smear all resolved with doxycycline treatment, implying that the changes were most likely reactive manifestations secondary to HGA, rather than underlying hematological malignancies such as MDS or AML.