RESUMO
A 42-year-old continuous ambulatory peritoneal dialysis patient had presented to us with symptoms and signs of peritonitis, complicated by intestinal obstruction. On fourth day after admission, the Tenckhoff catheter was removed, as there was no response to intraperitoneal antibiotic. He developed hypotension during one of the hemodialysis sessions and was found to have low hemoglobin of 4 g/dL. Computed tomography revealed high-density fluid suggestive of fresh blood and clots in the peritoneal cavity. Conventional visceral angiogram with selective inferior mesenteric arterial cannulation revealed pseudoaneurysm arising from the descending branch of the left colic artery. An effort to embolize the pseudoaneurysm failed on 2 occasions. At laparotomy the pseudoaneurysm of the left colic artery was identified after evacuation of blood clots. The pseudoaneurysm was then excised and a lateral rent in the descending branch of left colic artery was repaired. The pus showed septate hyphae on potassium hydroxide mount. He was treated with injections of amphotericin B and oral voriconazole as the culture showed growth of Aspergillus flavus. The early fibrinous, ''easy'' flimsy adhesions formed during the initial intestinal obstruction phase might have resulted in formation of the pseudoaneurysm when the Tenckhoff catheter was removed with traction. The removal of the Tenckhoff catheter, drop in hemoglobin and distension of the abdomen were temporally so closely related that the pseudoaneurysm as a result of the traction removal of the catheter was undeniable. A controlled trial would provide firm evidence either in favor or against formal dissection for the removal of Tenckhoff catheters.
Assuntos
Falso Aneurisma/complicações , Aspergilose/complicações , Cateterismo/efeitos adversos , Colo/irrigação sanguínea , Doenças Vasculares Periféricas/etiologia , Peritonite/complicações , Adulto , Falso Aneurisma/diagnóstico , Falso Aneurisma/cirurgia , Angiografia , Antifúngicos/uso terapêutico , Aspergilose/tratamento farmacológico , Aspergilose/microbiologia , Aspergillus flavus/isolamento & purificação , Cateterismo/instrumentação , Diagnóstico Diferencial , Seguimentos , Humanos , Falência Renal Crônica/terapia , Laparotomia , Masculino , Doenças Vasculares Periféricas/diagnóstico , Diálise Peritoneal Ambulatorial Contínua/instrumentação , Peritonite/tratamento farmacológico , Peritonite/microbiologia , Tomografia Computadorizada por Raios X , Procedimentos Cirúrgicos VascularesRESUMO
BACKGROUND: A 27-year-old male renal allograft recipient presented to hospital with isolated skin ulcers on both lower limbs. At presentation, he also had a low-grade continuous fever, malaise and anorexia. INVESTIGATIONS: Physical examination, laboratory studies, histopathological examination of tissue biopsy samples from the ulcer edges and ulcer floor, culture of the biopsy tissue, chest radiograph, bone marrow biopsy, abdominal ultrasound, tuberculin skin test and examination of three early morning samples of gastric juice and urine for acid-fast bacilli. DIAGNOSIS: Isolated cutaneous ulcers caused by Mycobacterium tuberculosis. MANAGEMENT: Four-drug antituberculosis therapy with pyrazinamide, of loxacin, ethambutol and isoniazid.
