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.

Acute renal failure associated with prolonged intake of slimming pills containing anthraquinones.

Chinese herbal medicine preparations are widely available and often regarded by the public as natural and safe remedies for a variety of medical conditions. Nephropathy caused by Chinese herbs has previously been reported, usually involving the use of aristolochic acids. We report a 23-year-old woman who developed acute renal failure following prolonged use of a proprietary Chinese herbal slimming pill that contained anthraquinone derivatives, extracted from Rhizoma Rhei (rhubarb). The renal injury was probably aggravated by the concomitant intake of a non-steroidal anti-inflammatory drug, diclofenac. Renal pathology was that of hypocellular interstitial fibrosis. Spontaneous renal recovery occurred upon cessation of the slimming pills, but mild interstitial fibrosis and tubular atrophy was still evident histologically 4 months later. Although a causal relationship between the use of an anthraquinone-containing herbal agent and renal injury remains to be proven, phytotherapy-associated interstitial nephropathy should be considered in patients who present with unexplained renal failure.

Very long-chain acyl-CoA dehydrogenase deficiency presenting as acute hypercapnic respiratory failure.

Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD) is a key enzyme catalysing the dehydrogenation of long-chain fatty acids in mitochondrial beta-oxidation. VLCAD deficiency is a genetic disorder that commonly presents in infancy or childhood with episodes of hypoketotic hypoglycaemia, cardiomyopathy and liver dysfunction. The present study reports an 18-yr-old Chinese female who presented with acute hypercapnic respiratory failure and rhabdomyolysis after a period of prolonged fasting and exertion. VLCAD deficiency was confirmed with decreased VLCAD activity in cultured fibroblasts. The patient completely recovered with supportive care. Pulmonary function tests after the acute episode showed evidence of chronic subclinical respiratory muscle weakness. In conclusion, this rare metabolic disorder should be considered in patients presenting with unexplained acute respiratory paralysis and failure.

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.