A non-immunocompromised host with nontuberculous mycobacteria-associated tubulointerstitial nephritis.

A 50-year-old man was admitted to our hospital with the complaints of fever and general malaise. He had no history of human immunodeficiency virus (HIV) infection or treatment with immunosuppressive agents. We performed renal biopsy to investigate possible acute kidney injury. Pathological findings showed inflammatory cell infiltration, including granulomatous lesions in the interstitium. We diagnosed the patient with acute granulomatous tubulointerstitial nephritis. We initiated prednisolone (PSL) 40 mg/day (0.6 mg/kg), in combination with isoniazid for a latent tuberculosis infection, because of positive results in interferon-γ release assays. The patient's fever and malaise promptly disappeared, and his renal function improved. After the patient had been discharged, Mycobacterium intracellulare grew in cultures of his renal tissue and urine. We gradually reduced the dose of PSL; we initiated combination therapy with ethambutol, clarithromycin, and rifampin. After 2 years of follow-up, the patient continued treatment for chronic kidney disease; it has since enabled him to avoid renal replacement therapy. This report describes a rare instance of nontuberculous mycobacteria-associated tubulointerstitial nephritis in a patient without a history of HIV infection or organ transplantation. In differential diagnosis of granulomatous tubulointerstitial nephritis, clinicians should consider drugs, sarcoidosis, tubulointerstitial nephritis and uveitis syndrome, vasculitis, and infections (e.g., involving mycobacteria). Prompt microbiological examinations, especially of urine or biopsy cultures, are vital for diagnosis.

Critical peritonitis secondary to gastrointestinal mucormycosis in a peritoneal dialysis patient: a case report.

Immunodeficient patients are susceptible to systemic fungal infections; however, these rarely cause secondary peritonitis. A 66-year-old man with multiple myeloma and diabetes mellitus on continuous ambulatory peritoneal dialysis (CAPD) presented with cloudy ascitic fluid. He had been treated with corticosteroids for 1 month for Tolosa-Hunt syndrome. We diagnosed peritoneal dialysis-related peritonitis caused by Enterococcus avium, removed the CAPD catheter, and initiated intravenous ampicillin. Computed tomography (CT) revealed an intramural gastric mass and a thinning ascending colon wall. Four days later, follow-up contrast-enhanced CT showed penetration of the ascending colon and rupture of the ileocolic artery. Emergency open surgery revealed hemorrhagic infarction with mucormycosis. We initiated intravenous liposomal amphotericin B 20 days after admission; however, he died 55 days later. Anatomical abnormalities, such as gastrointestinal perforation, should be considered for peritonitis in immunodeficient patients. Gastrointestinal mucormycosis is rare but fatal, resulting from a delay in diagnosis and consequent gastrointestinal perforation. For an early diagnosis and a favorable clinical outcome, it is important to consider the risk factors for mucormycosis, including corticosteroid use, diabetes, end-stage kidney diseases.

Comparison of Prognostic Values of Daytime and Night-Time Systolic Blood Pressures on Renal Outcomes in Patients With Chronic Kidney Disease.

BACKGROUND: Differences in the predictive value of daytime systolic blood pressure (SBP) and night-time SBP by ambulatory blood pressure monitoring on renal outcomes have not been fully investigated in chronic kidney disease (CKD) patients. This study compared the prognostic value between daytime and night-time SBP on renal outcomes in CKD.Methods and Results:This prospective observational study included 421 patients. The composite renal endpoint was endstage renal disease (ESRD) or death. Cox models were used to determine associations of daytime and night-time SBP with renal outcomes. There were 150 renal events (ESRD, 130; death, 20). Multivariable Cox analyses demonstrated that hazard ratios (HRs) [95% confidence interval (CI)] for composite renal outcomes of every 10-mmHg increase in daytime and night-time SBP levels were 1.13 (1.02-1.26) (P=0.02) and 1.15 (1.05-1.27) (P<0.01), respectively. In addition, compared with the 1st daytime or night-time SBP quartile, HRs (95% CI) for outcomes in the 2nd, 3rd, and 4th quartiles were: daytime SBP, 1.25 (0.70-2.25), 1.09 (0.61-1.94), and 1.58 (0.88-2.85; P=0.13) (P for trend=0.16); night-time SBP, 1.09 (0.61-1.96), 1.31 (0.76-2.28), and 1.82 (1.00-3.30; P=0.049) (P for trend=0.03), respectively. CONCLUSIONS: Night-time SBP appeared superior to daytime SBP for predicting renal outcomes in this population of patients.