Remission induced by renal protective therapy in nephrotic syndrome with thin basement membrane in an older patient: a case report.

BACKGROUND: Adult nephrotic syndrome is a well-known kidney disease that causes heavy proteinuria, hypoalbuminemia, hypercholesterolemia, edema, and hypertension. The treatment varies according to its underlying cause but often faces medication resistance or adverse drug effects. CASE PRESENTATION: A Japanese woman in her 80s presented with nephrotic syndrome after a 3 year latent period of urinary protein and occult blood. She did not have any secondary causes of nephrotic syndrome. Renal biopsy revealed thin glomerular basement membrane, partial foot process fusion on electron microscopy with minor glomerular change on light microscopy, and slight coarse immunoglobulin M deposition in the mesangium on immunofluorescence microscopy, which was inconsistent with any other glomerular diseases. Without steroid treatment, she dramatically remitted from proteinuria after the administration of the renal protective agents enalapril, ezetimibe, rosuvastatin, and dapagliflozin. Recurrence after 8 months of follow-up subsided with the administration of additional doses of the agents. CONCLUSIONS: This case illustrated the novel outcomes of combining medical treatment without steroid use for nephrotic syndrome with thin glomerular basement membrane disease. At the time of writing this report, the patient's renal function was stable and she was free of edema, although moderate proteinuria and occult hematuria persisted. The final diagnosis was uncertain because of the lack of genetic investigation; however, the response to the aforementioned medical treatment suggests the effectiveness of the supportive therapy.

IgD lambda multiple myeloma causing hyperammonaemia with possibly reduced ammonium excretion.

A man in his 70s presented with impaired consciousness due to hyperammonaemia while investigating multiple tumours in his brain, chest, spine and right adrenal gland. He did not have any disorders causing hyperammonaemia, such as liver dysfunction, urea-producing bacterial infection or any medications interfering with ammonium metabolism. Blood and urine tests in addition to tumour biopsy specimens confirmed immunoglobulin D lambda multiple myeloma. His general status responded to chemotherapy using bortezomib, dexamethasone and daratumumab, and he subsequently regained full consciousness and a normalised serum ammonia level. He, unfortunately, died of refractory multiple myeloma with hyperammonaemia. The autopsy specimen revealed lambda light-chain deposits in the distal tubule epithelium with cast precipitation and intact liver cells. Urine osmolality gap analysis suggested possibly reduced urinary ammonium excretion, but further investigation is necessary to elucidate the significance of pathological renal characteristics in multiple myeloma with hyperammonaemia.

Predicting diagnoses from illness experiences with common cold symptoms before physician consultation: a mixed-methods research.

OBJECTIVES: We aimed to explore whether patients' illness experiences with common cold symptoms could help with predicting the final diagnosis before consultation. DESIGN: Exploratory sequential design of mixed methods: Qualitative and quantitative studies used inductive qualitative content analysis and multinomial regression analysis, respectively. SETTING: Consecutive patients at the primary care clinic of a general hospital. PARTICIPANTS: New patients aged 15 years or older were included in the study. Of the 1512 eligible patients who received the questionnaire sheet, 408 selected the common cold as their reason for visiting. All 408 patients responded to the questionnaire. MAIN OUTCOME MEASURES: First, factors representing illness experiences in patients with common cold symptoms were explored. Second, variables with significant relative risk ratio (RRR) were used to diagnose common cold, influenza or other diseases. RESULTS: A total of 171 codes were identified from the responses of 408 patients, which were visually mapped to show their frequencies and occurrence in the same person according to their final diagnoses. Of the 171 codes, 22 found in over nine patients represented the variables for the three independent final diagnoses. The adjusted final model revealed that (1) 'worry about influenza infection', 'want influenza test' and 'transmission from a colleague at school or workplace' predicted the influenza rather than the common cold, when other predicting variables were constant (RRR, 6.20 p<0.001; RRR, 26.1 p<0.01; and RRR, 4.69 p<0.05, respectively); (2) 'want further examination' predicted other diseases (RRR, 2.84 p<0.05); and (3) the combination of 'worry about influenza infection' and 'want influenza test', which predicted the opposite diagnosis: the common cold rather than influenza (RRR, 0.01 p<0.001). CONCLUSION: These findings provide useful information on how illness experiences before consultation can predict final diagnoses for patients with common cold symptoms. TRIAL REGISTRATION NUMBER: UMIN000030697.

Evaluating Outcomes of a Social Media-Based Peer and Clinician-Supported Smoking Cessation Program in Preventing Smoking Relapse: Mixed Methods Case Study.

BACKGROUND: Smoking relapse prevention after completion of a smoking cessation program is highly germane to reducing smoking rates. OBJECTIVE: The purpose of this study was to evaluate the 1-year outcomes of a social media-based and peer and clinician-supported smoking cessation program on Facebook and examine communication patterns that could support smoking cessation and identify risk of relapse. METHODS: We used a mixed methods case study evaluation approach featuring a single-case holistic design. We recruited volunteers who signed up after successful completion of a 12-week clinical smoking cessation program in a general medicine department in Japan. Participants contemporaneously accessed a closed Facebook page, and we analyzed their posts including text and emoticons. We used joint display analysis, which involved iterative structuring and restructuring construct-specific tables with both types of data to find the most effective approach for integrating the quantitative results with the qualitative results of content analysis. RESULTS: One successful participant and 2 relapsed participants were analyzed to explore the specific patterns of postings prior to relapse. Decisive comments about quitting smoking were common among participants, but encouraging messages for peers were more common from the successful participant. Comments seeking social support and reassurance were warning signs of relapse. Conflicted comments also may be a warning sign of relapse risk. CONCLUSIONS: These findings based on a mixed methods case study of a social media platform supporting smoking cessation could be used to guide messaging in other online social networking service communities after a smoking cessation program to help reduce smoking relapse. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000031172; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000035595.

Omeprazole-induced hypomagnesaemia, causing renal tubular acidosis with hypokalaemia, hypocalcaemia, hyperlactacidaemia and hyperammonaemia.

A 72-year-old Japanese man treated with omeprazole for 11 years was admitted due to loss of consciousness and muscle weakness. Wolff-Parkinson-White syndrome-induced tachycardia was considered as the cause of syncope. His blood examination revealed rhabdomyolysis, hypokalaemia, hypomagnesaemia, hypocalcaemia, hyperlactacidaemia, hyperammonaemia and high-anion-gap metabolic acidosis. Hypomagnesaemia could be caused by magnesium malabsorption due to omeprazole use. Hypocalcaemia might be caused by the inhibitory effect of hypomagnesemia on the parathyroid gland hormone secretion. Hyperammonaemia might be caused by two reasons: (1) renal ammonium production induced by hypokalaemia; (2) inhibition of ammonium secretion by omeprazole. Both hypocalcaemia and hypokalaemia might cause chronic elevation of serum creatinine phosphokinase which ended up with rhabdomyolysis. Correction of serum electrolytes rapidly improved his muscle weakness. Discontinuation of omeprazole no longer caused these abnormalities. A physician should be aware of unexplained signs and symptoms of patients using proton-pump inhibitors to avoid life-threatening electrolyte and physiologic disturbances.

Granulomatosis with polyangiitis presenting as an orbital inflammatory pseudotumor: a case report.

INTRODUCTION: Granulomatosis with polyangiitis is a systemic inflammatory disease that often presents with necrosis, granuloma formation and vasculitis of small- to medium-sized vessels. Affected patients usually present with disease of the upper respiratory tract, lungs and kidneys, but this disease has been reported to involve almost any organ. We report the case of a patient with ocular manifestations of granulomatosis with polyangiitis after the remission of renal and auditory manifestations. CASE PRESENTATION: An 81-year-old Japanese woman had a four-year history of biopsy-proven antineutrophil cytoplasmic antibody-related glomerulonephritis that had been treated with oral prednisolone and was in serological remission. She had also recovered from a one-year history of complete hearing loss immediately following the steroid treatment for glomerulonephritis. She gradually experienced right eye visual disturbance and exophthalmos over a two-month period. Radiographic and histopathological findings revealed an orbital inflammatory pseudotumor. The administration of prednisolone completely restored her right eye visual acuity and eye movement after two weeks. Considering this case retrospectively, our patient had an orbital inflammatory pseudotumor caused by granulomatosis with polyangiitis including a medical history of reversible hearing loss, although her glomerulonephritis had remitted with an undetectable level of specific antineutrophil cytoplasmic antibody. CONCLUSIONS: In this patient, hearing loss and visual loss occurred at different times during the course of treatment of granulomatosis with polyangiitis. Clinicians should consider a differential diagnosis of granulomatosis with polyangiitis in patients with treatable hearing and visual loss.

Carnitine deficiency presenting with a decreased mental state in a patient with amyotrophic lateral sclerosis receiving long-term tube feeding: a case report.

INTRODUCTION: L-carnitine is an important metabolic mediator involved in fatty acid transport. It is obtained from the diet, particularly from animal products, such as red meat. Previous reports have revealed that long-term tube feeding with a commercial product containing no or low levels of carnitine can lead to an altered mental state caused by hyperammonemia. CASE PRESENTATION: A 72-year-old Japanese man had a 12-year history of amyotrophic lateral sclerosis. He was bedridden and had required mechanical ventilation and enteral tube feeding for 10 years at home. His main enteral solution was a commercial product that contained low carnitine levels, and he sometimes received coffee and homemade products such as miso soup. Our patient's ability to communicate gradually deteriorated over a period of one year. His serum total carnitine level was abnormally low, at 26.7µmol/L (normal range, 45 to 91µmol/L), but his ammonium level was normal. His mental state improved dramatically after starting L-carnitine supplementation (600mg twice daily). CONCLUSION: This case highlights the importance of avoiding carnitine deficiency in patients with amyotrophic lateral sclerosis undergoing long-term tube feeding. These patients experience progressive muscle atrophy that might cause impaired carnitine storage and might manifest as communication difficulties. Carnitine deficiency can be misdiagnosed as a progression of systemic muscle atrophy. Clinicians should be aware of this disorder and should consider periodically measuring carnitine levels, regardless of the patient's serum ammonium levels.