Cat Scratch Disease in kidney transplant receptors: is it a rare or underdiagnosed pathology?

Cat Scratch Disease (CSD) is an infectious disorder which appears after cat scratching particularly in children and adolescents. Bartonella henselae is the etiologic agent more frequently involved. There are only a few recent reports demonstrating the disease after transplantation, although the illness is not infrequent in immunologically competent people. Indeed CSD in transplant receptors has only been recently emphasized in the literature and it was concluded that fever and lymphadenopathy in patients who had been exposed to cats should prompt clinicians to maintain a suspicion for the infection. In this report CSD infecting a renal transplanted adolescent complaining of headache, blurred vision and fever, presenting a cat scratching lesion in the right arm, with a bilateral painful cervical lymphadenopathy was related. He also presented indirect immunofluorescency identifying that the two subtype's titles of Bartonella--henselae and quintana--were elevated. Treatment with doxicicline e rifampicin was introduced and the patient became asymptomatic in about 3 weeks.

Cat Scratch Disease in kidney transplant receptors: is it a rare or underdiagnosed pathology? / Doença da Arranhadura do Gato em transplantados de rim: patologia rara ou subdiagnosticada?

Cat Scratch Disease (CSD) is an infectious disorder which appears after cat scratching particularly in children and adolescents. Bartonella henselae is the etiologic agent more frequently involved. There are only a few recent reports demonstrating the disease after transplantation, although the illness is not infrequent in immunologically competent people. Indeed CSD in transplant receptors has only been recently emphasized in the literature and it was concluded that fever and lymphadenopathy in patients who had been exposed to cats should prompt clinicians to maintain a suspicion for the infection. In this report CSD infecting a renal transplanted adolescent complaining of headache, blurred vision and fever, presenting a cat scratching lesion in the right arm, with a bilateral painful cervical lymphadenopathy was related. He also presented indirect immunofluorescency identifying that the two subtype's titles of Bartonella-henselae and quintana- were elevated. Treatment with doxicicline e rifampicin was introduced and the patient became asymptomatic in about 3 weeks.

A Doença da Arranhadura do Gato (DAG) é uma desordem infecciosa que surge após a arranhadela do animal, especialmente em crianças e adolescentes. Bartonella hanselae é o agente etiológico mais frequentemente envolvido. Há somente poucos relatos recentes demonstrando a doença após transplante renal, embora a mesma não seja infrequente em pessoas imunologicamente competentes. Na verdade, DAG em receptores de transplantes tem sido somente recentemente enfatizada na literatura e concluiu-se que a presença de febre e linfadenopatias em pacientes que estiveram expostos a contato com o animal deveriam sinalizar os clínicos a manter suspeita da infecção. Neste relato de DAG, é exposto o caso de um adolescente transplantado de rim queixando-se de cefaleia, visão borrosa e febre, apresentando cicatriz de arranhadura no braço direito, com linfadenopatia cervical bilateral dolorosa. Também apresentava imunoflorescência indireta identificando que os dois subtipos de Bartonella- a henselae e a quintana- estavam elevadas. Tratamento com doxiciclina e rifampicina foi iniciado e o paciente tornou-se assintomático em cerca de três semanas.

Ramsay Hunt syndrome with facial vesicular rash: a unique clinical presentation in a kidney transplant patient.

Ramsay Hunt Syndrome (RHS) is the result of herpes zoster virus reactivation producing hearing loss, pain and vesicles in the ear or mouth, along with ipsilateral facial palsy due to the 7th cranial nerve geniculate ganglion infectious involvement. This condition has not been previously described, particularly in transplant patients. A 38-year old man underwent kidney transplantation and two years later experienced an ache on the left side of the face and hearing loss in the ear, also exhibiting vesicular lesions and concomitant facial peripheral palsy. Acyclovir IV was initiated, and the prednisone dose was increased. The patient was discharged 15 days later, feeling better but still exhibiting dark spots on his face. At three months follow-up he was asymptomatic, showing notable palsy improvement. Until this case, herpes zoster facial lesions causing typical RHS have never been reported in literature, particularly in kidney transplant patients.

Low response to intradermal hepatitis B vaccination in incident hemodialysis patients.

INTRODUCTION: Hepatitis B (HB) may progress to cirrhosis and liver carcinoma. Its prevalence is estimated at 3.2 % in hemodialysis (HD) patients. HB vaccine when applied intramuscularly (IM) in end-stage renal disease patients often does not induce appropriate antibody titers. However, there has been suggestion for intradermal (ID) to be a more effective inoculation method. OBJECTIVE: To compare the immune response to IM or ID vaccine administration on HD patients. PATIENTS AND METHODS: Thirty one incident HD patients were randomly assigned alternately to IM or ID vaccine inoculation. Vaccine doses were applied at three monthly intervals, with patients being followed-up for six months. Sixteen patients were assigned to IM (40 mg/dose) and 15 to ID (4 mg/dose) vaccine administration. HB-virus surface antibody titer, hematimetric parameters, serum urea level and Kt/V were monthly evaluated. C-reactive protein, parathormone, ferritin, aminotransferases and albumin serum levels were evaluated before and at the sixth month of the initial inoculation. RESULTS: Urea levels were significantly higher in the ID group (P(1) = 0.031); ferritin levels were higher in the IM (P(2) = 0.037) and C-reactive protein levels tended to be higher in the ID group. An interim evaluation by the Safety Monitoring Committee recommended discontinuing the study as IM vaccination had converted 62.5% of the exposed subjects, while ID inoculation converted only 13.3%. CONCLUSION: As performed, ID applied vaccine was inferior to the IM inoculation. Such result may depend on the inoculated doses or some other factor, such as inflammation.

Baixa resposta da vacinação intradérmica contra hepatite B em pacientes incidentes em hemodiálise / Low response to intradermal hepatitis B vaccination in incident hemodialysis patients

INTRODUÇÃO: A hepatite B pode evoluir para cirrose e hepatocarcinoma. Sua prevalência estimada é de 3,2 por cento em pacientes em hemodiálise (HD). A vacina para hepatite B (HB), quando aplicada por via intramuscular (IM) em pacientes com insuficiência renal crônica fase V, frequentemente não induz produção adequada de anticorpos. A injeção intradérmica (ID) foi sugerida como sendo o método de inoculação mais eficiente. OBJETIVO: Comparar a resposta imune à injeção IM ou ID da vacina em indivíduos em HD. PACIENTES E MÉTODOS: Trinta e um pacientes incidentes em HD foram randomizados alternativamente para vacinação contra HB via IM ou ID. Dezesseis foram designados aleatoriamente para receber vacina IM (40 mg/dose) e 15 ID (4mg /dose). Os níveis de anticorpos de superfície do vírus da hepatite B, parâmetros hematimétricos, ureia sérica, e Kt/V foram avaliados mensalmente. Proteína-C reativa, paratormônio, ferritina, aminotransferases e albumina foram avaliados antes da inoculação inicial e seis meses após a mesma. RESULTADOS: Os níveis de uréia foram maiores no grupo ID (P(1) = 0,031); os níveis de ferritina foram mais elevados no IM (P(2) = 0,037). Houve tendência a aumento nos níveis de proteína C reativa no grupo ID. A avaliação do Comitê de Monitoramento de Segurança dos indivíduos expostos recomendou a suspensão do estudo já que a inoculação por via IM converteu 62,5 por cento e a ID converteu apenas 13,3 por cento dos pacientes expostos. CONCLUSÃO: Com a metodologia utilizada, os resultados da vacina contra HB aplicada por via ID foi inferior à inoculação IM. Tais resultados podem ser decorrentes das doses inoculadas ou de outros fatores, como inflamação.

INTRODUCTION: Hepatitis B (HB) may progress to cirrhosis and liver carcinoma. Its prevalence is estimated at 3.2 percent in hemodialysis (HD) patients. HB vaccine when applied intramuscularly (IM) in end-stage renal disease patients often does not induce appropriate antibody titers. However, there has been suggestion for intradermal (ID) to be a more effective inoculation method. OBJECTIVE: To compare the immune response to IM or ID vaccine administration on HD patients. PATIENTS AND METHODS: Thirty one incident HD patients were randomly assigned alternately to IM or ID vaccine inoculation. Vaccine doses were applied at three monthly intervals, with patients being followed-up for six months. Sixteen patients were assigned to IM (40 mg/dose) and 15 to ID (4 mg/dose) vaccine administration. HB-virus surface antibody titer, hematimetric parameters, serum urea level and Kt/V were monthly evaluated. C-reactive protein, parathormone, ferritin, aminotransferases and albumin serum levels were evaluated before and at the sixth month of the initial inoculation. RESULTS: Urea levels were significantly higher in the ID group (P(1) = 0.031); ferritin levels were higher in the IM (P(2) = 0.037) and C-reactive protein levels tended to be higher in the ID group. An interim evaluation by the Safety Monitoring Committee recommended discontinuing the study as IM vaccination had converted 62.5 percent of the exposed subjects, while ID inoculation converted only 13.3 percent. CONCLUSION: As performed, ID applied vaccine was inferior to the IM inoculation. Such result may depend on the inoculated doses or some other factor, such as inflammation.

Streptococcus agalactiae: a rare peritoneal infection in a continuous ambulatory peritoneal dialysis patient.

Streptococcus agalactiae causes a rare and often fatal peritonitis in continuous ambulatory peritoneal dialysis (CAPD). A 52-year-old white female with Alport and chronic kidney disease was initiated on CAPD treatment. Nineteen months later she had a S. agalactiae peritonitis identified and received initially gentamicin-cephalothin, which was changed to ceftazidime, tobramycin, and vancomycin. Recovery started after peritoneal catheter removal. After 3 weeks, severe leucopenia occurred. Granulokine and steroids were given. Six weeks later, she felt well and an abdominal video laparoscopic procedure disclosed a diffuse peritoneal fibrosis, precluding CAPD resumption. She is now doing well on hemodialysis (HD).

Cardiovascular risk factors and carotid intima-media thickness in asymptomatic children.

Atherosclerosis, beginning in childhood, is dependent on several risk factors and may be predictive of coronary artery disease in adulthood. The risk factors for subclinical atherosclerosis are similar to those for clinical disease. Carotid intima-media thickness is a measure of subclinical atherosclerosis and a predictor of subsequent vascular events. This study aimed to examine the relationships of carotid intima-media thickness with known risk factors in asymptomatic children. Family history of cardiovascular disease was collected, together with anthropometric, demographic, and clinical data. Body mass index z-scores were calculated. Serum glucose, lipid fractions, fibrinogen, and C-reactive protein were determined. High-resolution ultrasonography was used to assess intima-media thickness. Associations and relationships of risk factors with composite intima-media thickness were explored. The study enrolled 93 children (44 girls) ranging in age from 49 to 169 months. The boys had a thicker intima-media (0.46 +/- 0.06 mm) than the girls (0.43 +/- 0.06 mm; p = 0.028). The unadjusted triglyceride levels were significantly higher in the overweight and obese children (p = 0.010). Body mass index and overweight/obesity were positively related to intima-media thickness (r = 0.259; p = 0.012 and r (s) = 0.230; p = 0.027, respectively), whereas family history of cardiovascular disease was unrelated. Only gender and overweight/obesity were related to intima-media thickness in a multiple linear regression model (R (2) = 0.125; p = 0.002). Male gender and overweight/obesity were associated with increased intima-media thickness, whereas family history of cardiovascular disease was unrelated.

Warning: an anemia outbreak due to chloramine exposure in a clean hemodialysis unit--an issue to be revisited.

In July 2004, an anemia outbreak was identified in our hemodialysis (HD) unit. The dialysate chloramine levels had risen from <0.1 mg/mL in May to 0.27 mg/mL in August 2004. Other parameters of water quality were within accepted standards. Hematocrit (Ht) and hemoglobin (Hb) returned to basal values after one month without changing recombinant human erythropoetin (rHuEpo) doses and with exchange of activated charcoal column. Chloramines (chlorine and ammonia) are used routinely to disinfect and sterilize potable water. High blood levels of chloramines are associated with hemolysis and rarely methemoglobinemia. Uremic patients have a decreased ability to withstand oxidative stress. It is postulated that their antioxidant capacity is reduced, yet the mechanism remains unclear. Patients on maintenance hemodialysis are vulnerable to chloramine toxicity if chloramines are inadequately removed from water.

Thyrotoxic hypokalemic periodic paralysis: a life-threatening syndrome.

Hypokalemic periodic paralysis is a rare life-threatening syndrome, potentially reversible when detected at an early stage. Hypokalemia may also occur in other conditions characterized by muscle weakness. Acute myopathy associated with thyrotoxicosis has been described in Asian populations, although it seldom affects Caucasians or African-Americans. It can be difficult to recognize in western populations. Acute recurrent episodes of flaccid paralysis, symmetrically affecting the proximal muscles of the lower limbs, either following strenuous physical activity or carbohydrate overindulgence, is the usual presentation. Hypokalemia seems to result from transcellular shifts of potassium rather than losses. A case of thyrotoxic hypokalemic periodic paralysis occurring in a young Caucasian male diagnosed with Graves' disease is reported.

Audiometric changes in patients undergoing liver transplantation using distinct immunosuppressive protocols.

The aim of the study was to disclose a possible association of hearing defects with the use of either cyclosporin (CyA) or tacrolimus (FK-506) in patients undergoing liver transplantation (LT). Pure-tone audiometry (PTA) was performed in the same 42 patients before and after LT. Audiometric frequencies recorded ranged from 250 to 8000 Hz. Patients were divided into 2 groups according to the use of CyA (n = 18) or FK-506 (n = 24). We used Kolmogorov-Smirnov and subsequently Student t test, nonparametric Wilcoxon signed-rank test, and Mann-Whitney test for statistical analysis. Significance was achieved when P