A case of Intravascular Lymphoma Masquerading as Calciphylaxis in a Patient on Haemodialysis.

Intravascular large B-cell lymphoma (IVLBCL) is a rare lymphoma entity with intravascular proliferation of clonal lymphocytes restricted to the lumen of small- and medium-sized blood vessels. In this case report, we describe a 70-year-old lady on maintenance hemodialysis who presented with altered sensorium and painful lesions over her inner thigh. While preliminary investigations were favoring calciphylaxis, it was the skin biopsy that showed vasculopathic lymphoid infiltrate with focal panniculitis, consistent with intravascular lymphoma. Although overall survival is poor, prompt use of intensive therapies have shown to improve the outcome.

Assessment of accuracy of Cockcroft-Gault and MDRD formulae in critically ill Indian patients.

BACKGROUND: Cockroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) formulae have not been validated in critically ill Indian patients. We sought to quantify the discrepancy, if any, in Glomerular Filteration Rate (GFR) estimated by CG and MDRD formulae with 24 hrs urine Creatinine Clearance (Cr Cl). MATERIALS AND METHODS: Prospective cohort study in 50 adult patients in a mixed medical-surgical intensive care unit. INCLUSION CRITERIA: Intensive Therapy Unit (ITU) stay >48 hrs and indwelling urinary catheter. EXCLUSION CRITERIA: Age <18 years, pregnancy, dialysis, urine output <400 ml/day and patients receiving ranitidine, cefoxitin, trimethoprim or diuretics. We estimated Creatinine Clearance by CG and MDRD formula and measured GFR by 24 hrs urine creatinine clearance. Bland Altman plot was used to find the difference between the paired observations. The association between the methods was measured by the product moment correlation coefficient. RESULT: The mean GFR as calculated by Creatinine Clearance was 79.76 ml/min/1.73 m(2) [95% Confidence Interval (CI) 65.79 to 93.72], that by CG formula was 90.05 ml/min/1.73 m(2) [95% CI: 74.50 to 105.60], by MDRD was 85.92 ml/min/1.73 m(2) [95% CI: 71.25 to 100.59]. The Bias and Precision between CG and Cr Cl were -4.5 and 140.24 respectively, between MDRD and Cr Cl was -6.1 and 122.52. The Correlation coefficient of CG formula as a measure of GFR was 0.65 (P < 0.0001), that of MDRD was 0.70 (P < 0.0001). CONCLUSION: We conclude that CG and MDRD formulae have a strong correlation with measured GFR but are not a reliable measure and overestimate GFR in critically ill Indian patients.

Sepsis-induced acute kidney injury.

Acute kidney injury (AKI) is a common sequel of sepsis in the intensive care unit. It is being suggested that sepsis-induced AKI may have a distinct pathophysiology and identity. Availability of biomarkers now enable us to detect AKI as early as four hours after it's inception and may even help us to delineate sepsis-induced AKI. Protective strategies such as preferential use of vasopressin or prevention of intra-abdominal hypertension may help, in addition to the other global management strategies of sepsis. Pharmacologic interventions have had limited success, may be due to their delayed usage. Newer developments in extracorporeal blood purification techniques may proffer effects beyond simple replacement of renal function, such as metabolic functions of the kidney or modulation of the sepsis cascade.

Microalbuminuria: A novel biomarker of sepsis.

CONTEXT: Diffused endothelial dysfunction in sepsis leads to an increase in systemic capillary permeability, the renal component manifesting as microalbuminuria. The degree of microalbuminuria correlates with the severity of the acute insult, the quantification of which may serve to predict sepsis and mortality in critically ill patients. AIMS: To evaluate whether the degree of microalbuminuria could differentiate patients with sepsis from those without and predict mortality in critically ill patients. SETTINGS AND DESIGN: Prospective, non-interventional study in a 20-bed Intensive Care Unit (ICU) of a tertiary care hospital. METHODS AND MATERIALS: After exclusions, between Jan-May 2007, 94 consecutive adult patients were found eligible. Albumin-creatinine ratio (ACR, mg/g) was measured in urine samples collected on ICU admission (ACR1) and at 24 hours (ACR2). RESULTS: PATIENTS WERE CLASSIFIED INTO TWO GROUPS: those with sepsis, severe sepsis and septic shock (n = 30) and those without sepsis [patients without systemic inflammatory response syndrome (SIRS) and with SIRS due to noninfectious causes] (n = 64). In the sepsis group, median ACR1 [206.5 (IQR129.7-506.1)] was significantly higher compared to the non sepsis group [76.4 (IQR29-167.1)] (P = 0.0016, Mann Whitney). The receiver operating characteristics (ROC) curve analysis showed that at a cut off value 124 mg/g, ACR1 may be able to discriminate between patients with and without sepsis with a sensitivity of 80%, specificity of 64.1%, positive predictive value (PPV) of 51.1% and negative predictive value (NPV) of 87.3%. The median ACR2 [154 (IQR114.4-395.3)] was significantly higher (P = 0.004) in nonsurvivors (n = 13) as compared to survivors [50.8 (IQR 21.6-144.7)]. The ROC curve analysis revealed that ACR2 at a cut-off of 99.6 mg/g could predict ICU mortality with sensitivity of 85%, specificity of 68% with a NPV of 97% and PPV of 30%. CONCLUSION: Absence of significant microalbuminuria on ICU admission is unlikely to be associated with sepsis. At 24 hours, absence of elevated levels of microalbuminuria is strongly predictive of ICU survival, equivalent to the time-tested APACHE II scores.

Thrombotic thrombocytopenic purpura associated with Human Immunodeficiency Virus infection.

Thrombotic thrombocytopenic purpura (TTP) belongs to the group of diseases called Thrombotic microangiopathies (TMA). While several triggering conditions are known, often none is apparent in the individual case. We report a patient presenting with TTP that was associated with a Human Immunodeficiency Virus (HIV) infection, with its consequent diagnostic, therapeutic and prognostic implications. Further, our case had individual clinical features that were of interest within the TTP-HIV subgroup.