A Rare Case of Renal Sarcoidosis.

Sarcoidosis is a multisystem granulomatous disorder characterized by non-caseating granulomas in multiple organs. It most commonly involves lungs and it is very rare to find isolated cases affecting other organ systems with no associated pulmonary findings. We hereby present a case of a young 30-year-old male who was referred to the hospital by his primary medical doctor due to right eye pain secondary to iritis and acute kidney injury (AKI). His initial laboratory studies revealed anemia, AKI, mild hypercalcemia, and the urinary analysis revealed proteinuria. Imaging studies were negative and a kidney biopsy was performed and showed results from the biopsy that revealed diffuse tubulointerstitial disease with early fibrosis, widespread moderate inflammation, multifocal tubulitis, and focal aggregate of epithelioid cells suggestive of granuloma consistent with sarcoidosis. The patient was treated with prednisone. Renal involvement of sarcoidosis is extremely rare (around 0.7%). It has a wide spectrum of presentation including abnormal calcium metabolism, nephrolithiasis, nephrocalcinosis, and acute tubulointerstitial nephritis with or without granulomas. This is a unique case as it shows renal sarcoidosis without coexisting pulmonary finding of hilar lymphadenopathy on chest X-ray. There are very few reported cases of renal sarcoidosis in the literature and this case can add to the pool of those cases. It also emphasizes the need for urgent renal biopsy in the settings of AKI associated with mild to moderate proteinuria. Lack of availability of comprehensive research on the disease may lead to misdiagnosis and delay in treatment.

Aggressive versus conservative fluid resuscitation in septic hemodialysis patients.

PURPOSE: Sepsis and bacterial infections are common in patients with end-stage renal disease (ESRD). We aimed to compare patients with ESRD on hemodialysis presenting to hospital with severe sepsis or septic shock who received <20 ml/kg of intravenous fluid to those who received ≥20 ml/kg during initial resuscitation. MATERIALS AND METHODS: We conducted a retrospective chart review of adult patients with ICD codes for discharge diagnosis of sepsis, severe sepsis, septic shock, ESRD, and hemodialysis admitted to our institution between 2015 and 2018. RESULTS: We present outcomes for a total of 104 patients - 51 patients in conservative group and 53 in aggressive group. The mean age was 69.5 ± 11.2 years and 71 ± 11.5 years in the conservative group and aggressive group, respectively. There was no significant difference in the rate of ICU admission, and ICU or hospital length of stay between the two groups. Complications such as volume overload, rate of intubation, and urgent dialysis were not found to be significantly different. CONCLUSION: We found that aggressive fluid resuscitation with ≥20 ml/kg may not be detrimental in the initial resuscitation of ESRD patients with SeS or SS. However, a clinical decision of volume responsiveness should be made on a case-by-case basis rather than a universal approach for fluid resuscitation in ESRD patients.

Bevacizumab-Induced Pneumonitis in a Patient With Metastatic Colon Cancer: A Case Report.

Bevacizumab is a vascular endothelial growth factor-directed humanized monoclonal antibody used to treat many types of cancer and some eye diseases. Due to inhibition of angiogenesis, many adverse reactions such as bowel necrosis, nasal septal perforation, and renal thrombotic microangiopathy have been described. However, its association with interstitial pneumonitis is scarcely reported in the literature. We report a case of a 79-year-old woman with metastatic colon cancer who presented with cough and dyspnea on exertion the day after initiation of bevacizumab. She was found to have bilateral airspace opacities on imaging. Infectious and cardiogenic etiologies of dyspnea were ruled out. Due to the temporal relationship with the initiation of chemotherapy, she was suspected to have developed bevacizumab-induced interstitial pneumonitis. She improved rapidly with high-dose steroids. Follow-up imaging showed resolution of infiltrates. This is the first reported case in the literature that directly links bevacizumab to interstitial pneumonitis.

Cement pulmonary embolism after balloon kyphoplasty.

Osteoporotic vertebral fractures are common among the geriatric population and are managed by vertebral augmentation procedures. Pulmonary cement embolism is a relatively rare complication of these procedures and can range from mild, transient respiratory sequelae to a more severe pulmonary infarction. We discuss the case of a 75-year-old woman, identified with osteoporotic thoracolumbar vertebral fractures, found to have pulmonary cement embolism four days following multi-level balloon kyphoplasty. We attempt to highlight, pulmonary cement embolism as a potential complication following a vertebral augmentation procedure and that systematic pulmonary imaging after surgery may be helpful to facilitate its detection and further management.