Retraction: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Mimicking as Pulmonary Tuberculosis in an Inmate.

[This retracts the article DOI: 10.7759/cureus.8464.].

Pulmonary Functions and Factors Affecting Them in Patients with Chronic Kidney Disease.

OBJECTIVE: To determine the pulmonary functions in patients with chronic kidney diseases (CKD) and factors affecting them. STUDY DESIGN:  Observational study. PLACE AND DURATION OF STUDY: Nephrology Department, Mayo Hospital, Lahore, from October 2018 to April 2019. METHODOLOGY: All patients of CKD, coming in Nephrology OPD, were included. Patients on maintenance hemodialysis (HD), chronic obstructive pulmonary disease (COPD), smokers, chronic heart disease, and neuromuscular diseases were excluded from the study. Demographic data, physical examination findings and laboratory parameters were taken. Patients underwent spirometry at Pulmonology Department for measurement of forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and FEV1/FVC. RESULTS: One hundred and forty patients were included in the study. Mean GFR was 27.75 ± 17.49 ml/min/1.73m2 and 7(5%) patients belonged to stage 2 CKD, 48 (34.3%) belonged to stage 3 CKD, 45 (32.1%) belonged to stage 4 CKD and rest 40 (28.6%) were from stage 5 CKD. Pulmonary functions were FEV1 (90.81±25.84), FVC (88.91±28.54), and FEV1/FVC (108.57±13.0). According to laid down criteria, 62 (44.3%) cases had restrictive lung disease (RLD), 5 (3.6%) cases had mixed and 78 (55.7%) cases normal lung function status. Important factors affecting pulmonary functions were GFR (p=0.038), monthly income (p=0.017) and education (p=0.041). Drop in GFR and anemia have negative correlation and age has positive correlation with pulmonary dysfunctions. CONCLUSION: Pulmonary functions were abnormal in almost half of the patients and restrictive lung disease was the most common pattern in these patients. Factors affecting the pulmonary functions were progression of CKD, falling hemoglobin level, monthly income and education. Drop in GFR and anemia had negative correlation and age had positive correlation with pulmonary functions. Key Words: CKD, Pulmonary functions, Restrictive lung disease, GFR, Anemia.

An Extremely Rare Case of Anomalous Left Main Coronary Artery Originating From Single Right Coronary Ostium Managed Using Heart Team Approach.

Anomalies of coronary artery origin are rare, difficult to diagnose using conventional testing methods and extremely challenging to eventually manage once diagnosed. The risk of adverse outcomes increases as such patients age and develop atherosclerosis in such vessels. A comprehensive and multidisciplinary approach may be required to best manage such difficult cases.  We present a case of a 65-year-old female with symptoms of chest pain concerning for unstable angina. She also complained of occasional diaphoresis and dizziness. Physical examination revealed a regular heart rhythm with no vascular bruits. An electrocardiogram (EKG) only showed normal sinus rhythm and left axis deviation. Non-invasive testing included an echocardiogram, which showed multiple wall motion abnormalities. A diagnostic cardiac catheterization via right radial artery approach was performed to delineate her coronary anatomy and rule out ischemic etiology. This led to diagnosis of anomalous coronary anatomy with an anomalous left main coronary artery from single right coronary ostium. Furthermore, it showed significant obstructive multi-vessel coronary artery disease involving distal left main artery, proximal left anterior descending artery, left circumflex and right coronary arteries. The patient had a right dominant system with absent left coronary cusp. Percutaneous vs surgical revascularization options were considered. Given high Syntax score and acceptable Society of Thoracic Surgeons (STS) risk, Heart Team approach was pursued and the patient was referred for multi-vessel surgical revascularization.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Mimicking as Pulmonary Tuberculosis in an Inmate.

Coronavirus disease 2019 (COVID-19) is an emerging global infectious disease with emerging medical knowledge. Clinical presentation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is very variable amongst patients, and the literature about unusual presentations is growing rapidly. This lack of knowledge leads to diagnostic, therapeutic, and management challenges in such patients. Here, we describe a case of SARS-CoV-2 infection in a low prevalence area which was initially diagnosed and managed as pulmonary tuberculosis (TB) in a high-risk inmate population. These ambiguous presentations can lead to mismanagement of such patients resulting in potentially fatal outcomes and public health crises in confined facilities. This also highlights the significance of a high index of clinical suspicion for SARS-CoV-2 especially in high risk and vulnerable populations.

Diagnostic Challenge in a Symptomatic Patient of Arteria Lusoria with Retro-esophageal Right Subclavian Artery and Absent Brachiocephalic Trunk.

A combination of absent brachiocepahlic trunk and anomalous left circumflex artery with a retro-esophageal right subclavian artery is an extremely rare finding. This can clinically manifest as episodic dysphagia and chest pain. Routine coronary angiography via femoral access could be misleading and right radial access in such cases can be particularly challenging and has never been reported in literature before. We present a case of a 42-year-old female with symptoms of chest, back, and left neck pain. She also complained of occasional dysphagia, dizziness, and palpitations. Physical examination revealed a regular heart rhythm with no vascular bruits. An electrocardiogram (EKG) only showed normal sinus rhythm and incomplete right bundle branch block. Noninvasive testing included an echocardiogram and previously done exercise stress test, and myocardial perfusion scans were noted to be normal. A diagnostic cardiac catheterization via right radial approach was performed to delineate her coronary anatomy and rule out ischemic etiology. This led to diagnosis of anomalous coronary anatomy (retro-esophageal right subclavian artery arising from descending aorta in association with an anomalous right circumflex artery with absent innominate artery) through a technically difficult and risky procedure. Significant vessel tortuosity and abnormal catheter angulations were encountered and were overcome by using specific catheters. Meticulous use of 6 French MP, WR, JL, and JR4 catheters along with an exchange length wire was required to negotiate the anatomical variations and complete the coronary angiogram via right radial artery. From a procedural stand-point, coronary angiography via right radial access in presence of such rare anatomical variations can be particularly challenging. Routine femoral catheterization may fail to depict this important anatomical variation. Coronary angiogram via right radial access in the presence of a combination of anatomical variations of great vessels and anomalous coronary arteries is particularly challenging from a procedural stand point due to vessel tortuosity and shape of catheters. Choice of anatomically appropriate diagnostic catheters and specific maneuvers are imperative in these coronary angiographic procedures.

Granulomatous Interstitial Nephritis: A Rare Cause of Acute Kidney Injury.

Acute granulomatous interstitial nephritis (GIN) is a rare cause of acute kidney injury (AKI) but treatable. It is present in 0.5 to 0.9% of native renal biopsies. Treatment with moderate dosage of steroids is associated with good prognosis. We herein review a case of a 48-year lady having AKI following drug-induced damage [non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics]. Her renal functions did not improve after one month of drug withdrawal, so renal biopsy was done that showed acute GIN. She was treated with intravenous then oral steroids that completely resolved AKI.

Klebsiella Pneumoniae Liver Abscess: a Case Report and Review of Literature.

Klebsiella pneumoniae (K.pneumoniae) is a known cause of pyogenic liver abscess (PLA) in the absence of hepatobiliary disease. In settings of hepatic infection, it has also been known to cause disseminated infections including meningitis and endopthalmitis. Several groups of patients are particularly susceptible to infection, including patients with diabetes mellitus, those from Southeast Asia and those with the preexisting hepatobiliary disease. We present a case of K.pneumoniae PLA with bacteremia. A 39-year-old Vietnamese male with no previous medical history who presented with complaints of abdominal pain, nausea, vomiting, diarrhea and fever. A computed tomography (CT) of the abdomen showed a large complex mass in the right lobe of the liver with multiple septations. Over course of hospitalization, the patient developed acute respiratory failure and was monitored in medical intensive care unit (MICU). Blood cultures grew K. pneumonia. The patient was treated with intravenous ceftriaxone and the abscess was drained by interventional radiology. After appropriate management, he progressed well during his hospital course and was eventually discharged from the hospital. K. pneumonia PLA had previously been an endemic disease in Southeast Asia, however, with a highly mobile patient population, it is now seen throughout the world and should be in the differential of patients who present with solitary liver mass in the setting of sepsis.

Effects of Renin-Angiotensin-Aldosterone System Blockade in Patients with End-Stage Renal Disease.

Blockers of the renin-angiotensin-aldosterone system (RAAS), such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are routinely used in patients with chronic kidney disease because of their cardiovascular (CV) and renoprotective effects. However, there are no uniform recommendations about RAAS blockers for CV protection in the end-stage renal disease (ESRD) population other than the preferred drug class for blood pressure control. This uncertainty stems from the fact that patients with ESRD were generally excluded from randomized controlled trials evaluating the cardioprotective benefits of RAAS blockers. It is important to weigh the potential harms associated with the use of RAAS blockers, such as electrolyte disturbances and worsening anemia, with their role in protection of residual kidney function, alleviation of thirst and potential CV benefits. The objective of this review is to summarize the current knowledge about the use of RAAS blockers in patients with ESRD.