Profound metabolic acidosis in association with sodium thiosulfate therapy in a patient with calcific uremic arteriolopathy: a case report and literature review.

Calciphylaxis, also known as Calcific uremic arteriolopathy (CUA), is a serious disorder that presents with skin necrosis due to calcification of dermal and subcutaneous adipose tissue capillaries and arterioles. The condition occurs primarily in patients with end-stage renal disease (ESRD) on dialysis, and it carries high morbidity and mortality, primarily due to sepsis, with an estimated six-month survival of approximately 50%. Although there are no high-quality studies to guide the optimal treatment approach for patients with calciphylaxis, many retrospective studies and case series support treatment with sodium thiosulfate (STS). Despite the frequent use of STS as an off-label treatment, data regarding its safety and efficacy are limited. STS has generally been considered a safe drug with mild side effects. However, severe metabolic acidosis associated with STS is a rare and life-threatening complication of STS treatment and is often unpredictable. Herein, we report a 64-year-old female with ESRD on peritoneal dialysis (PD) who presented with a profound high anion gap metabolic acidosis and severe hyperkalemia while on STS treatment for CUA. No other etiology for her severe metabolic acidosis other than STS was identified. ESRD patients receiving STS should be monitored closely for this side effect. Dose reduction, increasing the duration of infusion, or even discontinuing STS treatment should be considered if severe metabolic acidosis develops.

Persistent Norovirus infection in a young patient with renal transplant: The challenging cost of immunosuppression and the negative impact on patient's quality of life.

Norovirus (NoV) is one of the most common causes of acute infectious gastroenteritis in the United States (US). The infection is typically short-lasting and self-limiting in immunocompetent hosts. Renal transplant recipients on immunosuppressive therapy are more prone to infectious gastroenteritis that can be caused by various common and opportunistic organisms. NoV infection in renal transplant patients presents as an acute diarrheal illness that may progress to a chronic infection with frequent relapses leading to adverse short-term complications (acute renal injury (AKI) and acute graft rejection from the reduction of the dose of immunosuppressive medications) and possibly long-term morbidities (malabsorption syndrome, and a decline in graft survival). The management of chronic NoV infections in renal transplant patients may be quite challenging, as no specific antiviral treatment is presently approved, and frequent adjustments of immunosuppressive therapy may be required in the setting of reduced renal clearance and the attempts to decrease immunosuppressive effects to enhance the viral clearance.Herein, the authors present a case of persistent NoV in a young female patient with a renal transplant that was associated with recurrent admissions with AKI, gross electrolyte disturbances, and significant weight loss. The relapsing NoV infection has negatively impacted the patient's quality of life and socioeconomic performance.

A Rare Pathogen of Bones and Joints: A Systematic Review of Osteoarticular Infections Caused by Gemella morbillorum.

Osteoarticular infections (OAIs) caused by Gemella morbillorum (G. morbillorum) are a rare clinical entity. This study aimed to review all published cases of OAI due to G. morbillorum. A systematic review of PubMed, Scopus, and Cochrane Library was conducted to report the demographic and clinical characteristics, microbiological data, management, and outcome of OAIs caused by G. morbillorum in the adult population. A total of 16 studies reporting on 16 patients were included in this review. Eight patients had arthritis and eight patients had osteomyelitis/discitis. The most reported risk factors were immunosuppression, poor dental hygiene/dental infections, and recent gastrointestinal (GI) endoscopy. Five cases of arthritis occurred in a native joint while three patients had prostheses. The potential source of G. morbillorum infection was documented in more than half of the cases (56%) (most commonly odontogenic and GI sources (25% and 18%, respectively). The knee and hip joints were the most frequently affected joints in patients with arthritis, while the thoracic vertebrae were the most common sites for osteomyelitis/discitis. The blood cultures were positive in three patients with arthritis (37.5%) and five patients with osteomyelitis/discitis (62.5%). Associated endovascular infection was found in five patients with bacteremia. Contiguous spread (adjacent mediastinitis) was documented in two patients with sternal osteomyelitis and thoracic vertebral osteomyelitis. Surgical interventions were performed for 12 patients (75%). Most strains of G. morbillorum were susceptible to penicillin and cephalosporins. All patients with reported outcomes had achieved complete recovery. G. morbillorum is an emerging pathogen for OAIs in certain susceptible populations with specific risk factors. This review reported the demographic, clinical, and microbiological features of OAIs caused by G. morbillorum. A careful evaluation of an underlying infectious focus is warranted to control the source. When G. morbillorum bacteremia is present, it is also necessary to have a high index of suspicion to rule out an associated endovascular infection.

A Case Series of Non-Tuberculous Mycobacterial Pulmonary Disease Masquerading as Malignancy From a Community-Based Hospital.

Non-tuberculous mycobacteria (NTM) are ubiquitous organisms in the environment that can potentially cause a range of pulmonary and extrapulmonary infections in humans. Epidemiological risk factors and the host's immune status determine the susceptibility to various clinical syndromes caused by different NTM species. Non-tuberculous mycobacteria pulmonary disease (NTM-PD) is primarily reported in patients with underlying lung disease. These infections often pose a significant disease burden on affected patients as they are often chronic, difficult to treat, and necessitate long-term multi-drug therapy. Mycobacterium avium complex (MAC) is the most common causative pathogen of NTM-PD in the USA, followed by Mycobacterium kansasii (M. kansasii). Less common species in the USA include Mycobacterium xenopi (M. xenopi), Mycobacterium abscessus, and others, largely depending upon the geographic location and exposure to species-specific predisposing risks. In this case series, the authors report on three elderly patients with chronic lung diseases who had pulmonary NTM disease caused by M. xenopi and MAC. The patients were encountered in both inpatient and outpatient settings from a community-based hospital in the midwestern USA. The clinical and radiological features of NTM-PD masqueraded as malignancy and posed a diagnostic dilemma. The epidemiology, clinical and radiological features, diagnosis, and management of NTM-PD are reviewed in this report.

Metastatic Squamous Cell Carcinoma From Primary Hypopharynx Source to Gastric Mucosa Presenting as Massive Gastrointestinal Bleeding.

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure that represents an important supportive adjunctive component for patients with primary head and neck squamous cell carcinoma (HNSCC). The HNSCC population is considered a high-risk group for developing critical nutritional deficiency due to a multitude of factors. Nevertheless, as the use of PEG in modern practice is gaining more popularity due to various indications, unusual complications have been increasingly reported. PEG site metastasis from primary HNSCC has emerged as a rare, yet serious oncological phenomenon that warrants careful consideration. The authors report an unusual case of squamous cell carcinoma (SCC) of the hypopharynx that metastasized to the gastric body mucosa through a PEG site. The metastatic SCC presented as massive gastrointestinal bleeding, and esophagogastroscopy revealed an ulcerated mass in the gastric body masquerading as a primary gastric adenocarcinoma. Histopathology and immunohistochemistry examination confirmed metastatic SCC which concurred with the patient's primary hypopharyngeal SCC. The review of the updated literature revealed that a total of 121 cases of this rare oncological entity have been reported to date. Physicians need to be vigilant of the symptoms of PEG site metastasis to accurately diagnose and manage the care of this rare occurrence as it is associated with poor prognosis.