Acute renal failure and nephrotic syndrome due to membranoproliferative nephritis during the second trimester of pregnancy.

We report the case of a patient with acute renal failure and nephrotic syndrome during the second trimester of an otherwise uncomplicated pregnancy. Despite pregnancy, percutaneous renal biopsy was performed to evaluate the etiology, showing Type I membranoproliferative glomerulonephritis. Two therapeutic options were considered: pregnancy termination, suggested by the gynecologists, and our proposal of starting steroid therapy, in order to reduce proteinuria and improve renal function. The patient refused pregnancy termination. She received i.v. methylprednisolone boluses, followed by maintenance oral prednisone and aspirin, with prompt acute renal failure resolution and reduced proteinuria. At Week 34 + 5 days of gestation, cesarean section was performed, without intra- and postoperative complications both for mother and newborn. Clinical maternal and fetal outcomes were excellent. One-year follow-up showed normal renal function and absence of proteinuria. Lacking guidelines concerning treatment of acute renal failure due to primary nephropathy in pregnancy, we consider this case of interest for our decision-making process and for the favorable outcome.

Urine chemokines: biomarkers of human lupus nephritis?

Lupus nephritis is characterized by intrarenal inflammation. Leukocytes trafficking from peripheral blood into affected tissues spaces represent an important factor in the development of many renal diseases. During the past few years has been attributed the crucial role of a family of chemotactic cytokines--the chemokines--in this process. In the course of renal diseases, the infiltration of monocytes/macrophages and T cells into kidneys represent an important role in progressive interstitial fibrosis and the progression of chronic renal failure. In this review, we summarize the in vitro and in vivo data on chemokines and chemokine receptors in kidney diseases, with a special focus on urine chemokine measurement as possible biomarker of human lupus nephritis.

[A 52 year-old woman with fever, cough and dyspnoea]. / Donna di 52 anni con febbre, tosse e dispnea.

A 52 year-old woman with gastric cancer treated with surgery and chemotherapy, is admitted in our Internal Medicine Department because of the presence of fever (max 41.2 degrees C), dyspnoea, non-productive cough and mental confusion. The anamnesis and the physical examination address to the diagnosis of CAP (Community-Acquired Pneumonia); in particular the alteration of consciousness and the onset of symptoms after the insertion of a nose-gastric tube let us to consider the diagnosis of aspiration pneumonia. The clinical presentation and radiological imaging (Rx and CT of thorax) suggest the pattern of bronchiolitis obliterans with organizing pneumonia (BOOP). BOOP is not a disease, but a non specific pattern of answer to a lung injury. It can be either idiopathic or associated with a variety of causes, such as infections, drugs, radiations and connective tissue diseases. Besides the clinical course is complicated by the onset of an ARDS (Adult Respiratory Distress Syndrome). The gold standard for the diagnosis is represented by lung biopsy with hystopathologic confirmation but, if it cannot be done, it's necessary to start immediately steroid therapy because BOOP may be fatal. The patient received antibiotic and steroid therapy with success.

[Multiple cerebral tuberculomas resistant to conventional therapy in an immunocompromised subject]. / Tubercolomi cerebrali multipli resistenti alla terapia convenzionale in un soggetto immunosoppresso.

A 33 years old immunocompromised woman was admitted for a fever of unknown origin during the last five months. She referred a body temperature up to 38.3 degrees C, headache, weakness. The physical examination revealed right homonymous hemianopia, hyperreflexia and Babinski on her right side. A TC scan and a following bioptic specimen showed multiple cerebral tuberculomas. A conventional therapy was started but no significative improvement was observed. She was finally treated with interferon gamma and GM-CSF in addition to the therapy with an important regression of the lesions and significative improvement of the fever and neurological findings.

[A 74-year-old woman with macrocytic anemia]. / Donna di 74 anni con anemia macrocitica.

A seventy-four years old woman is assessed for asthenia, fatigue, non ulcerous dyspepsia with macrocytic anemia. The patient's medical history taking in Binswanger disease--diagnosed 5 aa before-, epilepsy-2 aa before- and a previous episode of TVP of the left leg, suggested the hypothesis that a B12 deficiency, by a chronic gastritis, would involve an increase of homocysteine cause of the clinical manifestations of megaloblastic anemia, Binswanger disease, tardive epilepsy and previous TVP. The fisic and blood and instrumental exams confirmed the clinical diagnosis. The patient is having vitamin B12.

[A 35-year-old woman with fever, dyspnea, and pain in the left thigh]. / Donna di 35 anni con febbre, dispnea e dolore alla coscia sinistra.

A thirty-five years old woman during her twelfth pregnancy presented fever and pain at the left thigh. After cesarean delivery dyspnea added to the first two symptoms and pulmonary embolism was suspected. A clinical history revaluation suggested a diagnosis of infectious endocarditis and femoural osteomielitis due to a septic embolus.

[67 year old man with abdominal pain, anorexia and low-grade fever]. / Uomo di 67 anni con dolore addominale, anoressia, febbricola.

A case of pericardial effusion presenting clinically with pretamponade is shown. TBC is not a rare cause of Pericardial effusion and at present Tuberculosis is a more and more frequent infection also in occidental countries. Guide lines for diagnosis and treatment are revised.

[A 61-year-old woman with abdominal pain and urination disorders]. / Donna di 61 anni con dolore addominale e disturbi della minzione.

The case of a 61 yo diabetic woman presenting with dysuria and lower abdominal pain is described. The incomplete resolution of the clinical picture after short antibiotic treatment and a strong suspect of autonomic neuropathy oriented to an anamnestic reevaluation that evidenced the presence of pneumaturia. The last was the key-symptom that guided to diagnostic imaging showing emphysematous cystitis while a gastroscopy confirmed the presence of autonomic neuropathy manifested by gastroparesis. Emphisematous cystitis is a characteristic infectious complication of diabetic patients induced by a persistent incomplete bladder emptying and bacterial glucose fermentation. The complete eradication of the infectious agent requires a long term antibiotic course and a prompt identification of this pathology.

[A 73-year-old woman with vomiting and metabolic alkalosis]. / Donna di 73 anni con vomito ed alcalosi metabolica.

A severe, life-threatening metabolic alchalosis associated with a stenosing pancreatic carcinoma in a female type II diabetic patients is presented, and a review of the most frequent causes of hyperemesis, orthostatic hypotension and lethargy is shown.

[Prevention of acute tubular necrosis caused by the administration of non-ionic radiologic contrast media]. / Prevenzione della necrosi tubulare acuta da somministrazione di mezzi di contrasto radiologico non ionici.

Radiographic contrast agents can cause acute renal failure that may be due to acute tubular necrosis (ATN). We prospectively studied 45 patients with risk factors for ATN who were undergoing computed tomography with three nonionic contrast agents (ioversolo, iobitridolo and iodixanolo). Patients were randomly assigned either to receive preventive management (0.45% saline intravenously, before and after administration of the contrast agent; mannitol 20% 250 mL i.v. 60 min before and 60 min after the contrast agent; furosemide 80 mg i.v. 30 min before the contrast agent; dopamine 3 g/Kg/min i.v. after administration of the contrast agent for 24 hours) or to receive placebo. Prophylactic management prevents the reduction in renal function induced by ioversolo, iobitridolo and iodixanolo, three noninonic contrast agents in patients with risk factors for ATN.