An unusual case of both upper and lower gastrointestinal bleeding in a kidney transplant recipient.

BACKGROUND: Tuberculosis (TB) is an uncommon opportunistic infection in immunocompromised patients. Extrapulmonary infection involving the intestine is rare and poses diagnostic difficulties. CASE REPORT: A 49-year-old man with IgA nephropathy underwent a kidney transplantation in 1996 and was put on cyclosporine, azathioprine, and steroid. He suffered from a recurrence of his primary kidney disease and had a gradual deterioration of renal function since 1998. By 2005, he presented with an unusual gastrointestinal (GI) symptom with alternating signs of upper GI bleeding - melena - as well as lower GI bleeding with fresh rectal bleeding, resulting in severe anemia with hemoglobin level down to 5.0 g/dL. At the same time, his renal function further deteriorated and necessitated the initiation of dialysis while he was maintained on low-dose immunosuppressive drugs. Repeated upper and lower GI endoscopies were either unremarkable or revealed non-specific lesions. Symptoms persisted and exploratory laparotomy finally showed a 1 cm submucosal mass at the proximal jejunum and multiple inflammatory lesions at the terminal ileum. Segmental resection of the lesions was performed and confirmed TB infection. However, despite the initiation of anti-tuberculous treatment, the patient eventually died of complications. CONCLUSION: Diagnosing TB intestinal infection is a clinical challenge. A high index of suspicion in susceptible subjects is necessary, and early surgical intervention should always be considered when facing diagnostic uncertainties.

Risedronate for prevention of bone mineral density loss in patients receiving high-dose glucocorticoids: a randomized double-blind placebo-controlled trial.

UNLABELLED: This 6-month randomized double-blind placebo-controlled trial shows that risedronate is well tolerated and effective in improving lumbar spine BMD and reducing loss of BMD at the hips in patients receiving high-dose prednisolone. INTRODUCTION: Bisphosphonates have proven benefits in patients receiving chronic low-dose glucocorticoids. However, whether they are effective in preventing bone mineral density (BMD) loss during periods of high-dose glucocorticoid treatment is unclear. The objective of this paper is to study the efficacy of risedronate in preventing bone mineral density (BMD) loss in users of high-dose glucocorticoids. METHODS: Adult patients with medical diseases treated with high-dose prednisolone (>0.5 mg/kg/day) were randomized to receive risedronate (5 mg/day) or placebo for 6 months in a double-blind manner, along with elemental calcium (1,000 mg/day). Changes in BMD were studied. RESULTS: One hundred and twenty patients were recruited (82 women, age 42.8 +/- 14.3 years, 63% corticosteroid-naive, 30% women postmenopausal) and 103 completed the study. Baseline clinical characteristics and BMD were similar in the risedronate and placebo groups. At 6 months, a significant gain in spinal BMD was observed in the risedronate group (+0.7 +/- 0.3%; p = 0.03) but a drop was detected in the placebo group (-0.7 +/- 0.4%; p = 0.12). After adjustment for baseline BMD, age, gender, body mass index and cumulative prednisolone dosages, the inter-group difference in spinal BMD remained significant (1.4%; p = 0.006). Both groups had a significant drop in hip BMD, but the magnitude was greater in the placebo arm (-0.8 +/- 0.4% in risedronate versus -1.3 +/- 0.5% the in placebo). No new fractures developed. Subgroup analysis of corticosteroid-naive patients yielded similar results. Upper gastrointestinal adverse events were numerically more frequent in the risedronate group. CONCLUSIONS: Risedronate improves spinal BMD in users of high-dose glucocorticoids.

Disseminated strongyloidiasis: a retrospective study of clinical course and outcome.

A retrospective study was carried out to evaluate the clinical course and outcome of disseminated strongyloidiasis treated in a regional hospital in Hong Kong over a 10-year period. Seven cases were identified, and the case history of each patient was analysed. The most common presenting symptom was fever (100%). Five (71%) patients had gastrointestinal symptoms, the most common being abdominal pain and diarrhoea. Three (42%) patients had a significant drop in haemoglobin. Six (85%) patients had bronchoalveolar infiltrates on chest radiographs. Most patients were immunosuppressed by means of steroid treatment for their underlying primary disease. One patient was diabetic, and another had lymphoma and was receiving chemotherapy. Strongyloides larvae were identified in stool specimens in two patients, in sputum smears in two patients, and in gastric biopsies in three patients. Five (71%) of the patients with lung involvement progressed to respiratory failure and died. Two (29%) cases were complicated by gram-negative bacterial infection. No patient had eosinophilia on presentation. All patients received antihelminthic treatment of variable duration. The case fatality rate in the cohort was 71% despite aggressive supportive therapy. Pulmonary and bowel symptoms were prominent in our series. In conclusion, the diagnosis of disseminated strongyloidiasis is often delayed because of nonspecific presenting symptoms. Early diagnosis relies on a high index of clinical suspicion, especially in immunocompromised hosts. Screening for Strongyloides infection before the initiation of immunosuppressive therapy should be considered, especially in endemic areas.

Mycobacterium chelonae exit site infection in a patient on peritoneal dialysis.

Atypical mycobacterial infe tion of the Tenckhoff catheter exit site is rare. Eradication of the infection is often difficult without the removal of the Tenckhoff cath ter. We report here a case of Mycobacterium chelonae exit site infection in a peritoneal dialysis patient. He was treated with a combination regimen of prolonged antibiotics, local heat therapy, deroofing and shaving of the Tenckhoff catheter outer cuff. This resulted in the successful treatment of the infection without the need for removal of the Tenckhoff catheter. We recommend that this therapeutic approach could be considered in similar cases and that removal of Tenckhoff catheter is not mandatory.

Acute renal failure related to intravenous immunoglobulin infusion in an elderly woman.

Intravenous immunoglobulin infusion induces acute renal failure via a mechanism of osmotic nephrosis. Most reported cases are related to the use of sucrose-based intravenous immunoglobulin. Maltose-based intravenous immunoglobulin is thought to be a safer alternative and have a lower risk of renal toxicity than sucrose-based preparations. Maltase, but not sucrase, is present in the brush border of proximal convoluted renal tubules, where the maltose is metabolised. We report a case of maltose-based intravenous immunoglobulin-induced acute renal failure in an elderly diabetic woman. In this case, the risk factors included advanced age, hypovolaemia, sepsis, diabetes mellitus, and the high infusion rate of the intravenous immunoglobulin. Maltase is readily inhibited by hyperglycaemia; therefore, poor glycaemic control may predispose patients to develop acute renal failure even with the better-tolerated maltose-based intravenous immunoglobulin.

Successful kidney re-transplantation in a patient with previous allograft kidney tuberculosis.

Opportunistic infections, and in particular tuberculosis (TB), carry substantial morbidity and mortality in solid organ transplant recipients. We report a 39-year-old man who underwent a cadaveric renal transplant. Three months postoperatively, he was diagnosed to have tuberculous infection of his graft kidney manifested as fever and renal impairment. The diagnosis was confirmed by renal biopsy, which showed granuloma formation and positive stain for acid-fast bacilli (AFB). His systemic symptoms responded well to a complete course of anti-tuberculous therapy, but his renal function continued to deteriorate. Graft nephrectomy was performed and the patient underwent a second kidney transplant 1 year later. He remained well and asymptomatic thereafter. No signs of recurrence of tuberculous infection were noted up until the present time. This case illustrates that TB remains an important threat to transplant recipients. Although reactivation of dormant TB is the usual mode of infection, acquisition from the donor graft is also possible. The latter may account for the infection in our case, as our patient had a negative tuberculin skin test and normal chest radiograph prior to transplant. The identification of AFB in the kidney graft less than 3 months postoperatively also suggested that causal relationship. While diagnosing TB in post-transplant recipients is difficult and may require renal biopsy, as in our case, treatment on the other hand is no different from the standard protocols. However, no consensus has been reached on the safety of re-transplantation. Also, the need for graft nephrectomy and chemoprophylaxis remains unclear.

Treatment of vancomycin-intermediate Staphylcoccus aureus endocarditis with linezolid.

We report a case of infective endocarditis due to vancomycin-intermediate Staphylococcus aureus that developed after repeated courses of vancomycin. The patient had underlying end stage renal disease and dissecting aortic aneurysm with aortic graft and prosthetic aortic valve replacement. He responded to prolonged combination therapy with linezolid and amikacin without undergoing surgical intervention.

Misplacement of a right internal jugular vein haemodialysis catheter into the mediastinum.

A 69-year-old woman with end-stage renal failure discontinued continuous ambulatory peritoneal dialysis and commenced temporary haemodialysis because of resistant peritonitis. Right internal jugular vein haemodialysis catheter placement was performed. The cuffed, tunnelled haemodialysis catheter was inserted using the modified Seldinger technique. When haemodialysis was initiated the following day, blood could not be aspirated from the catheter and the patient complained of central chest pain during the aspiration. Subsequent venography and computed tomography scan of the thorax showed that the catheter was placed extraluminally into the posterior mediastinum. The importance of a chest radiograph after placement of a central venous catheter is highlighted by this case report. Subtle deviations in catheter position from normal should alert the physician to the possibility of catheter misplacement and lead to further investigation.

Treatment of diffuse proliferative lupus glomerulonephritis: a comparison of two cyclophosphamide-containing regimens.

Cyclophosphamide (CYC) has proven beneficial in preserving renal function in patients with lupus with diffuse proliferative glomerulonephritis (DPGN). However, the optimal route of CYC administration is unknown because direct comparative studies are unavailable. In this open study, we compared the renal outcome of two historical cohorts of patients with diffuse proliferative lupus nephritis (World Health Organization classes IVa and IVb) treated with either intravenous (IV) pulse CYC (group A; n = 22) or sequential oral CYC followed by azathioprine (AZA; group B; n = 21) and followed up prospectively. Both groups of patients had similar clinical, biochemical, and renal parameters at baseline. At 24 months posttreatment, significant improvements in proteinuria, creatinine clearance, serum albumin level, and lupus serological results were evident in both groups. Compared with patients in group A, patients in group B had more complete or partial remission (90% versus 73%) and less risk for treatment failure (5% versus 14%), renal flares (5% versus 14%), and doubling of creatinine levels (5% versus 9%), but the difference was not statistically significant. However, patients treated with oral immunosuppression had an insignificant increase in rates of herpes zoster infection (19% versus 9%) and menstrual disturbance (50% versus 29%). We conclude that sequential oral immunosuppression with CYC and AZA tended to have better efficacy than IV pulse CYC in the treatment of lupus DPGN but was associated with more toxicities. Additional randomized trials involving a larger cohort of patients with a longer period of observation are necessary.