Giant insulinoma in a 15-year-old man: A case report.

INTRODUCTION: Giant insulinomas are extremely rare pancreatic neuroendocrine tumor. PRESENTATION OF CASE: A 15-year-old man presenting with acute onset of lightheadedness was found to have serum glucose of 1.5mmol/L. The blood collected from the hypoglycemic episode showed an inappropriately high insulin and C-peptide level. Abdominal computerized tomography showed a 12.5cm well-defined, lobulated hypervascular mass at pancreatic tail, without any evidence of metastasis. En bloc resection with distal pancreatectomy, and splenectomy was successfully performed. The pathological examination confirmed insulinoma, with benign characteristics. Follow-up after the procedure revealed neither hypoglycemic, nor hyperglycemia. CONCLUSION: We report the youngest case of a giant insulinoma. Despite the size of the tumor, the pathological report confirmed the benign characteristics. However, long-term follow-up is still essential to detect recurrence in the future.

BIOPSY-PROVEN BK VIRUS NEPHROPATHY WITHOUT DETECTABLE BK VIREMIA IN A ONE-YEAR POST-KIDNEY TRANSPLANT RECIPIENT.

BK virus nephropathy (BKVN) is an important clinical problem in kidney transplant (KT) recipients. The sequence of disease is usually viruria, viremia and then nephropathy. Diagnosis of BK virus (BKV) infection includes checking BKV DNA in the urine, in the plasma and histology on renal biopsy. This last method is used to diagnose BKVN. We describe a KT patient with BKVN without detectable BK viremia. A 62-year-old female with hypertensive nephropathy underwent renal transplant from a living relative donor in December 2011. Fourteen months after transplantation, her serum creatinine(SCr) rose up from 1.2 to 1.6 mg/dl with biopsy-proven acute antibody-mediated and cellular rejection. After pulse methylprednisolone, plasmapheresis and intravenous immunoglobulin, her SCr decreased to baseline but she subsequently developed cytomegalovirus infection with pancytopenia and transaminitis. The SCr rose to 1.9 mg/dl despite ganciclovir treatment. Renal ultrasound and antegrade pyelogram showed partial obstruction of the proximal ureter with moderate hydronephrosis. A quantitative polymerase chain reaction (PCR) assay for BKV DNA was negative (less than 10 copies/ml). A renal biopsy was performed and the pathology revealed viral cytopathic changes in the tubular epithelium with interstitial inflammation. The renal biopsy also showed BKV nucleic acid sequences by in-situ hybridization confirming BKVN. Immunosuppression regimen was changed to cyclosporine, low-dose prednisolone and leflunomide. A temporary percutaneous nephrostomy was performed. Her renal function improved within one week. The diagnosis of BKVN should be considered in a KT recipient with a rising SCr with or without BK viremia and should be made by renal biopsy.

Intensive plasmapheresis and intravenous immunoglobulin for treatment of antibody-mediated rejection after kidney transplant.

OBJECTIVES: Acute antibody-mediated rejection is an important cause of acute and chronic kidney allograft dysfunction and graft loss. The purpose of the present study was to evaluate our experience using plasmapheresis and intravenous immunoglobulin in treating patients who had acute antibody-mediated rejection after kidney transplant. MATERIALS AND METHODS: A retrospective review of 13 patients who had biopsy proven antibody-mediated rejection was performed to determine the efficacy of plasmapheresis and intravenous immuno-globulin with or without bortezomib. RESULTS: All 13 patients were treated with plasmapheresis (5-18 sessions) with intravenous immunoglobulin (2 ± 1 g/kg) during and/or after plasmapheresis; 6 patients also received bortezomib. Mean age was 43 ± 10 years and median time from transplant to rejection was 4.5 months (interquartile range, 1.25-20 mo). Most patients (11 patients [85%]) had serum creatinine level return to within 20% baseline serum creatinine level before rejection. In all 13 patients, mean hospital length of stay was 27 ± 14 days. Frequency of recurrence of antibody-mediated rejection was 31%, and 1 patient resumed dialysis 7 months after treatment. Mean serum creatinine level was greater before (217 ± 111 µmol/L) than after treatment (141 ± 59 µ mol/L; P ≤ .03). CONCLUSIONS: The combination of intensive plasmapheresis and intravenous immunoglobulin is effective treatment for antibody-mediated rejection after kidney transplant. Long-term, prospective studies are justified to determine the effect of this regimen on graft survival.

The usefulness of short-term in vitro cultivation for the detection and molecular study of Blastocystis hominis in stool specimens.

When in vitro cultivation was used as the 'gold standard' for the detection of Blastocystis hominis in stool specimens, simple smear and trichrome staining showed sensitivities of 16.7% and 40.2% and specificities of 94% and 80.4%, respectively. In vitro cultivation also enhanced PCR amplification for the detection of B. hominis in stool specimens. Our data show the usefulness of in vitro cultivation for the detection and molecular study of B. hominis in stool specimens.