COVID-19 Associated Acute Viral Myocarditis and Thyroid Gland Follicular Neoplasm in a Hemodialysis Patient.

Since the first cases were reported in Wuhan, China, COVID-19 has spread swiftly worldwide and is caused by SARS-CoV-2. The development of myocardial injury is associated with significantly worse clinical course and increased mortality. However, currently, it is unclear whether cardiac injury occurred in COVID-19 patients. Histological results obtained directly from the viral infection of the myocardium (i.e., SARS-CoV-2 viral myocarditis) or indirectly from the complications of COVID-19, showed that only a portion of patients infected with the virus developed viral myocarditis. Therefore, it is possible that with more autopsy evidence of SARS-CoV-2 and more correlation with the severity of the viral infection, viral myocarditis will emerge. Although COVID-19 manifests primarily as respiratory disease, few cases of cardiac injury without respiratory involvement or febrile illness have been reported. The pathogenesis of cancer and viral infections is due to the inability of the immune system to distinguish between self and non-self. Several oncogenic (hepatitis B virus, hepatitis C virus, human papilloma virus, Epstein-Barr virus, and HIV) and oncolytic viruses (coxsackievirus, reovirus, vaccinia virus, and adenovirus) are known to cause and regress various cancer types. We report a case of atypical manifestation of COVID-19-induced acute myocarditis and thyroid gland follicular neoplasm in a hemodialysis patient with no respiratory symptoms. This case illustrates that COVID-19 can present atypically and affect non-respiratory organ systems.

Epidemiology of Cancer Among Chronic Kidney Disease Patients Compared to The General Population.

BACKGROUND: Kidney disease has a major effect on global health, both as direct cause of morbidity and mortality and as an important factor for other comorbid diseases including malignancy. Different studies report a higher risk of cancer development in patients with chronic kidney disease (CKD), but the impact of less sever CKD on risk of cancer is uncertain. However, data concerning the cancer risk in Oman CKD including dialysis patients is scarce. More importantly, there is lack of information about the cancer-specific mortality in CKD and dialysis patients. METHODS: During January 2006 to December 2019, all patients with CKD and those on regular dialysis who are admitted or follow up in Royal Hospital were included for evaluation of malignancy. RESULTS: During the study, a total of 2500 patients with CKD were included, of which 25 patients were found to have different types of cancers, of which 13 were male (52%) and 12 were female (48%).Most of patients 13 (52%) were senior adult (>65 years), then 11 (44%) were adult (19:64- ys) and only one case (4%) was child (<18years.). Cancer was detected in the ovaries (16%), stomach, multiple myeloma and renal (12%) each, while breast and colorectal (1 male/1 female) (8%), parathyroid, thyroid, uterus, cervix, prostate, skin, liver, lymphoma, pituitary gland, and myelofibrosis were present in 4% each. In general population, the breast cancer is the most common cancer among females, followed by thyroid cancer, and colorectal cancer while the most common cancer types among males are colorectal cancer followed by the prostate and then the Non-Hodgkin lymphoma disease. CONCLUSION: These epidemiologic findings should prompt clinicians and health authorities to assess strategies for cancer screening in high-risk population of CKD patients. Additional studies are needed to explain the reasons for this association and represent the potential use of cancer screening in patients with CKD in Oman. KEY WORDS: cancer, chronic kidney disease, epidemiology, hemodialysis.

Late Presentation for Kidney Biopsy: Clinical Presentations and Laboratory Findings.

Although the number of patients reaching end-stage kidney disease without a biopsy- proven diagnosis is increasing, kidney biopsies play a key role in diagnosing kidney disease. We analyzed prospective data from patients with kidney disease who underwent percutaneous native kidney biopsies from January 2006 to December 2017. Demographic data, clinical presentations, and the laboratory and radiological findings at the time of biopsy were analyzed. Of 530 patients, 42.8% were male. The mean age was 33.9 (32.8-34.9.2) years; 66.3% were aged 25-64 years. Edema was the main clinical presentation (61.9%), with clinical urine changes seen in 66.7%. Most (89.6%) were nondiabetic; 46.8% had high blood pressure or were on antihypertensive therapy. Most patients (77.5%) were in Stages I, II, and III, and 12.3% underwent hemodialysis at the time of admission. Most (54.4%) were obese. Low hemoglobin (31.8%), high triglycerides (30%), high total cholesterol (58.2%), low serum albumin (73.9%), nephrotic proteinuria (61.8.6%), and microscopic hematuria (79.8%) were the main laboratory findings. The immunological investigations showed that antinuclear antibodies, positive anti-double-stranded DNA (anti-dsDNA), and extractable nuclear antigens were positive in 29.6%, 20.7%, and 19.7%, respectively. Perinuclear antineutrophil cytoplasmic antibodies (ANCA) were positive in 9.6% and cytoplasmic ANCA were positive in 5.4%, whereas immunoglobulin A was detected in 4.6%. More than one- third of the patients had reached advanced chronic kidney disease (CKD) Stages IIIB, IV, and V. This indicates the need to increase awareness about CKD, greater utilization of kidney biopsies, and earlier investigations to enable accurate diagnoses, and proper and timely management.

COVID-19 Infection Associated with Psychosis in Hemodialysis Patient.

Hemodialysis is a medical procedure to correct electrolyte imbalance and remove fluids and waste products from the blood of patients with end-stage renal disease. Dialysis patients are immunosuppressed and hence at risk of complications of coronavirus infection. In addition, dialysis for most patients is performed in-center, with therapy offered three times per week for 3.5 hours per session in sites highly exposed to virus contamination. A weak immune system and low cytokine storm explain why COVID-19 may be less severe in dialysis patients as death due to COVID-19 or effects on comorbidities in COVID-19 patients is due to overresponse against the virus by the immune system and cytokine storm. However, during the frequent trips between the dialysis center and home, the risk of coronavirus infection could be high. Moreover, hemodialysis patients constitute a distinct and high-risk group that is often associated with low immunity, decline or loss of the ability to work, substantial economic burden, the inability to fulfill family responsibilities and participate in an active social life, and suffer from various complications such as muscle weakness, pruritus, fatigue, diabetes, hypertension, and restless legs. These factors are associated with lower quality of life and poor clinical outcomes, leading to a higher risk of psychological problems than in the general population. We report a rare case of new-onset psychosis (mostly delirium) following COVID-19 infection in a middle-aged hemodialysis patient with rapid recovery.

Clinical and laboratory findings of patients with diabetes undergoing kidney biopsy.

Diabetic kidney disease (DKD), one of the most frequent microvascular complications of diabetes mellitus (DM), is the leading cause of end-stage kidney disease worldwide. We reviewed all kidney biopsies performed at the Royal Hospital, Muscat, Oman, between January 2005 and December 2016, and data of 51 DM patients were analyzed. Of the 51 patients, 54.9% were male and 45.1% were female. The mean age was 50.8 (47.1-55.2) years; 86% were between 25 and 64 years old. Edema was the main clinical presentation (70.6%) with clinical urine changes in 84.3%. Diabetic retinopathy was present in 62.2% in ophthalmological examination of 44 patients. Majority (67.5%) of patients were in advanced chronic kidney disease Stages III, IV, and V. About one-quarter underwent hemodialysis at the time of admission. Majority (76.9%) were obese and hypertensive (78.4%). Low hemoglobin (51%), high triglyceride (35.7%), high total cholesterol (56.8%), low serum albumin (78.4%), nephrotic-range proteinuria (75.6%), and microscopic hematuria (77.1%) were the main laboratory findings. In addition, immunological investigations were examined and immunoglobulin A was the most common findings (35.7%) of serological investigations. About 24.4% had positive antinuclear antibody, 20.8% had positive anti-dsDNA, and 23.3% had positive extractable nuclear antigens. Also, p-antineutrophil cytoplasmic antibody (p-ANCA) was positive in 30% and c-ANCA was positive in 9.7%. This study represents the findings of the whole country for more than 10 years. It showed that only a small percentage of patients with DM undergo kidney biopsy. These patients have many clinical and laboratory abnormalities including those of specific immuno-logical investigations. Progression of DM nephropathy seems to be further aggravated by many coexisting risk factors of dyslipidemia and/or obesity. The prevalence of non-DKD is remarkably frequent in diabetics in whom nephrologists should consider kidney biopsy as an appropriate measure to enable better management.