[Acute tubulointerstitial nephritis in HIV infection]. / Akute tubulointerstitielle Nephritis bei HIV-Erkrankung.

We report about a patient with human immunodeficiency virus infection who developed acute renal failure after therapy with atazanavir. Renal biopsy showed acute interstitial nephritis. After discontinuing medication with atazanavir serum creatinine level decreased spontaneously without steroids. The different etiologies of acute renal failure in patients with human immunodeficiency infection are discussed.

Treatment of hepatic hydrothorax and reduction of chest tube output with octreotide.

Hepatic hydrothorax is a dreaded complication in patients with liver cirrhosis. Placement of chest tubes can alleviate respiratory distress, but patients often succumb due to excessive fluid and protein loss via the open drain. Our case illustrates that high-dose octreotide can strongly reduce hepatic hydrothorax drainage volume. This allows removal of the chest tube, which would otherwise not have been possible.

Diagnostic approach to hypercalcemia: relevance of parathyroid hormone and parathyroid hormone-related protein measurements.

Background: Parathyroid hormone (PTH) and parathyroid hormone-related protein (PTH-rP) are two potent hypercalcemic hormones that act on the same targets. Autonomous secretion of the former is involved in primary hyperparathyroidism (PHPT), whereas the latter is responsible for humoral hypercalcemia of malignancy (HHM). Methods: From 250 consecutive, hypercalcemic serum samples sent to our laboratory for assessment of intact PTH, we were able to obtain clinical information, as well as an additional plasma sample for PTH-rP measurement, in 134 patients. At the time of sampling, patients could be classified into seven groups: cancer without known bone metastases (CaNoMeta, n=36), cancer with bone metastases (CaMeta, n=9), no evidence of cancer (noEvCa, n=71), sarcoidosis (Sarc, n=3), end-stage renal disease (ESRD, n=12), vitamin D overdose (VIT-D, n=2), and hyperthyroidism (Thyr, n=1). Results: In the CaNoMeta group, 29/36 patients had elevated PTH-rP levels, 9/36 patients had inappropriately elevated PTH levels, and 5/36 had elevated levels of both hormones. In the CaMeta group, three of the nine patients had inappropriately elevated PTH levels, two of them with concomitantly elevated PTH-rP levels. In the NoEvCa group, 63/71 patients had an inappropriate elevation of PTH levels and were diagnosed as having PHPT. Four of the 71 patients had elevated levels of both PTH and PTH-rP; three of them were in poor health and died within a short period of time. All of the ESRD patients had very high PTH and normal PTH-rP levels, except for one woman with high PTH-rP and undetectable PTH levels; she died from what later turned out to be a recurrent bladder carcinoma. In the Sarc, Vit-D, and Thyr groups, both PTH and PTH-rP levels were normal. Conclusions: (1) Elevated PTH-rP levels are a common finding in cancer patients without bone metastases. Intact PTH, however, should always be measured in hypercalcemic patients with malignancy because concurrent primary hyperparathyroidism is not rare. (2) Primary hyperparathyroidism accounts for hypercalcemia in 90% of patients without evidence of cancer whose PTH-rP levels may also be found to be elevated in a few cases, even some with surgically demonstrated parathyroid adenoma.

Emphysematous cystitis in a patient presenting with paradoxical arterial embolism and intestinal mycobacteriosis without evidence of diabetes.

We describe the case of a 72-year-old woman who displayed massive multiple intramural gas collections of the bladder wall as an incidental finding on CT. The patient presented with critical ischemia of the left leg caused by paradoxical arterial embolism, raised corpuscular sedimentation rate, anemia by gastrointestinal blood loss, hypoproteinemia, diarrhea, malabsorption, and exudative enteropathia caused by mycobacterial ileocolitis. The patient had no dysuria and there was no evidence of diabetes. The intramural gas collections of the bladder wall, as shown by CT, were compatible with emphysematous cystitis. Urine samples proved infection by a multi-resistant strain of E. coli. Emphysematous cystitis is a rare form of bladder infection that can be diagnosed by plain-film radiograms or CT.