Syndrome of Inappropriate Antidiuretic Hormone Secretion Complicating Systemic Nocardiosis in a Renal Transplant Recipient: A Case Report.

BACKGROUND: Infection by Nocardia species is an uncommon cause of severe clinical syndromes, particularly in immunocompromised patients, and solid-organ transplantation is the most common underlying condition. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been described thus far in lung and stem cell transplants with systemic nocardiosis. CASE REPORT: We report the first case of SIADH in a female elderly renal transplant recipient diagnosed with systemic nocardiosis 2 years after transplantation. The SIADH was managed appropriately, and her immunosuppressive regimen remained unchanged but was adjusted at a lower level. The systemic Nocardia infection was successfully treated with intravenous administration of trimethoprim-sulfamethoxazole and imipenem for 2 weeks followed by oral trimethoprim-sulfamethoxazole for a total of 12 months. CONCLUSIONS: The SIADH syndrome is a recognizable complication of Nocardia infection in renal transplant recipients. Prompt identification along with proper management and prolonged antimicrobial treatment are essential to improve patients' outcome.

Efficacy of prolonged antimicrobial chemotherapy for brucellar spondylodiscitis.

The standard treatment of brucellar spondylitis with a combination of two antibiotics for 6-12 weeks is associated with high rates of treatment failure and relapse. The present study aimed to assess the safety and efficacy of a treatment strategy based on the prolonged administration of a triple combination of suitable antibiotics. Eighteen patients with brucellar spondylitis were treated with a combination of at least three suitable antibiotics (doxycycline, rifampin, plus intramuscular streptomycin or cotrimoxazole or ciprofloxacin) until the completion of at least 6 months of treatment, when clinical, radiological and serology re-evaluation was performed. If necessary, the treatment was continued with additional 6-month cycles, until resolution or significant improvement of clinical and radiological findings, or for a maximum of 18 months. At presentation, the median age was 66 years (range, 42-85 years) with male predominance. The median duration of therapy was 48 weeks (range 24-72 weeks). Treatment was discontinued early because of side-effects in only one patient. Surgical intervention was required for three patients. At the end of treatment all patients had a complete response. After completion of treatment, all patients were followed up with regular visits. During the follow-up period (duration 1-96 months, median 36.5 months), no relapses were observed. In conclusion, prolonged (at least 6 months) administration of a triple combination of suitable antibiotics appears to be an effective treatment for brucellar spondylitis.

Prevalence and outcome of pulmonary fibrosis in microscopic polyangiitis.

We sought to determine the type of pulmonary involvement in microscopic polyangiitis (MPA), primarily focusing on pulmonary fibrosis (PF), its prevalence, temporal relationship with other disease manifestations and outcome. 33 patients (16 males) with biopsy proven perinuclear anti-neutrophilic cytoplasmic antibody-positive MPA (age 63.5 yrs) participated in the study. Pulmonary involvement was assessed using standard methods, including radiographic imaging (chest radiographs and high-resolution computed tomography), pulmonary function testing, bronchoscopy and bronchoalveolar lavage, and, if indicated, lung biopsy. All-cause mortality was analysed by the Kaplan-Meier method and was compared between MPA patients with and without PF. At the time of diagnosis, renal involvement was detected in all patients, with renal biopsies being consistent with segmental necrotising glomerulonephritis in all patients. The most common respiratory symptom was haemoptysis, which was found in nine (27%) patients. PF was present in 12 (36%) patients at the time of diagnosis, whereas one patient developed PF while on therapy approximately 10 yrs after disease diagnosis. In seven patients with PF, respiratory symptoms related to fibrosis preceded other disease manifestations by a median (range) period of 13 (5-120) months. Patients were followed up for a period of 38+/-30 months. Presence of PF was associated with increased mortality (p = 0.02), with six deaths occurring in the fibrotic group and one in the nonfibrotic group. In the fibrotic group most deaths were related to PF. PF occurs frequently in MPA, may precede other disease manifestations by a variable length of time and has a poor prognosis.

Extranodal non-Hodgkin lymphoma presenting as a soft tissue mass in the proximal femur in a HIV(+) patient.

Primary soft tissue non-Hodgkin lymphomas (NHL) are very rare especially among HIV-1 infected patients. We describe a patient with HIV-1 infection who presented with acute pain of the right proximal femur. The clinical and laboratory investigation revealed a high grade centroblastic B-cell lymphoma of soft tissue. The patient was treated by surgical resection of the tumor, chemotherapy and local radiotherapy with no serious side effects. After 36 mdnths of follow up he is in excellent clinical condition, with his lymphoma in complete remission.

Sternal tuberculosis after coronary artery bypass graft surgery.

We report a case of sternal tuberculosis following sternotomy, which was performed during coronary artery bypass graft surgery. Although pre-operative evaluation revealed signs of asymptomatic tuberculosis of the lung, isoniazid chemoprophylaxis was not instituted, and the patient developed active tuberculosis in both the lung and sternum 5 y later.

An unusual case of brucellar spondylitis involving both the cervical and lumbar spine.

We report an unusual case of brucellar spondylitis, involving both the cervical and lumbar spine. Diagnosis was established using magnetic resonance imaging (MRI). An initial plain radiograph of the lumbar spine, showing mild degenerative lesions, was misleading. Therefore, institution of a proper treatment was delayed.

Excretory phase CT urography for opacification of the urinary collecting system.

OBJECTIVE: The purpose of our study was threefold: to evaluate the ability of excretory phase CT urography to opacify the urinary collecting system by comparing opacification seen on CT with the opacification seen on a series of unmatched IV urography examinations; to determine the optimal CT urography technique for ureteral filling by comparing studies of patients who were imaged supine, prone, and with abdominal compression; and to assess the possible value that reformatted planar images might add to axial excretory phase images. SUBJECTS AND METHODS: Seventy patients with hematuria were imaged in one of four ways. Twenty-five patients underwent contrast-enhanced excretory phase helical CT of the kidneys, ureters, and bladder. All patients were imaged in a supine position. Ten other patients underwent a similar CT protocol in which we used abdominal compression. Ten further patients underwent excretory phase CT while in a prone position. A final 25 patients underwent IV urography. Each patient's collecting system was arbitrarily divided into 10 parts (both right and left sides of calices; pelvis; upper, mid, and lower ureters) for scoring of images on a five-point scale for opacification by contrast material. Opacification scores for the four groups of patients were then compared. For patients who underwent CT, reformatted images of the collecting systems were generated and evaluated for their potential to add value to the conventional axial images. RESULTS: We found no significant difference in the ability of CT urography and IV urography to yield opacification of the calices, pelvis, and upper or mid ureters. Opacification of the distal ureter was less well seen on supine CT urography than on IV urography. Prone and compression CT urography resulted in better opacification of the collecting system than the supine noncompression technique. Opacification of the distal ureter was best seen with compression CT and was as good as that seen with IV urography. Reformatted CT urography was judged to be of probable or definite additional value to the axial images in 44% of cases. In each case, we saw a pathologic finding whose relationship to the kidney and collecting system was not as easy to appreciate on the axial CT scans. CONCLUSION: CT urography with abdominal compression results in reliable opacification of the collecting system that is comparable with opacification seen on IV urography. In patients with abnormalities, reformatted images were a useful adjunct to axial images. CT urography has potential as an imaging tool for the urothelium.