Tacrolimus-Induced Fever in a Patient Undergoing Kidney Transplantation / 대한내과학회지

Tacrolimus is widely used with other immunosuppressive agents to prevent rejection of a kidney transplant (KT). However, tacrolimus-induced fever is very rarely diagnosed. We report a case of tacrolimus-induced fever after KT. A 53-year-old female was diagnosed with cytomegalovirus (CMV) viremia. She had received a KT 2 months previously. Ganciclovir was started immediately at that time. A fever developed on day 12 of admission. Because of dysuria and a residual urine sensation with pyuria, we started intravenous antibiotics to treat urinary tract infection. Although other infectious reasons were ruled out and CMV viremia and the urinary tract infection improved, the fever spike did not improve. Thus, we suspected drug-induced fever. First, the ganciclovir and antibiotics were discontinued. However, the fever continued. To exclude tacrolimus-induced fever, tacrolimus was discontinued and cyclosporine was used with other immunosuppressive agents. Tacrolimus was discontinued after 1 day and the fever was no longer confirmed.

Peripheral Neuropathies in Patients with Rhabdomyolysis: Clinical Characteristics and Electrodiagnostic Findings in the Acute/Subacute Stage

BACKGROUND: Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and characterized by myalgia and swelling of the affected muscles. Peripheral nerve injury rarely occurs in patients with rhabdomyolysis. METHODS: We reviewed the medical records of 8 consecutive patients with peripheral neuropathies associated with rhabdomyolysis. We assessed the clinical characteristics and electrodiagnostic findings of eight patients. RESULTS: In seven patients, rhabdomyolysis occurred after prolonged immobilization. In one patient, blunt trauma was a cause of rhabdomyolysis. All patients presented with weakness and paresthesia in lower extremities and electrodiagnostic tests showed peripheral nerve injury suggesting sciatic neuropathy or lumbosacral plexopathy. Although rhabdomyolysis itself recovered completely in all patients, neurologic deficits from neuropathy recovered partially and slowly. CONCLUSIONS: Sciatic nerve or lumbosacral plexus was injured in all eight patients. Among the various causes of rhabdomyolysis, prolonged immobilization is associated with development of peripheral neuropathy.

Tacrolimus-Induced Fever in a Patient Undergoing Kidney Transplantation / 대한내과학회지

Tacrolimus is widely used with other immunosuppressive agents to prevent rejection of a kidney transplant (KT). However, tacrolimus-induced fever is very rarely diagnosed. We report a case of tacrolimus-induced fever after KT. A 53-year-old female was diagnosed with cytomegalovirus (CMV) viremia. She had received a KT 2 months previously. Ganciclovir was started immediately at that time. A fever developed on day 12 of admission. Because of dysuria and a residual urine sensation with pyuria, we started intravenous antibiotics to treat urinary tract infection. Although other infectious reasons were ruled out and CMV viremia and the urinary tract infection improved, the fever spike did not improve. Thus, we suspected drug-induced fever. First, the ganciclovir and antibiotics were discontinued. However, the fever continued. To exclude tacrolimus-induced fever, tacrolimus was discontinued and cyclosporine was used with other immunosuppressive agents. Tacrolimus was discontinued after 1 day and the fever was no longer confirmed.

The Quality of Life of Hemodialysis Patients Is Affected Not Only by Medical but also Psychosocial Factors: a Canonical Correlation Study

BACKGROUND: The quality of life (QoL) of patients with end-stage renal disease (ESRD) is very poor, plausibly due to both psychosocial and medical factors. This study aimed to determine the relationship among psychosocial factors, medical factors, and QoL in patients with ESRD undergoing hemodialysis (HD). METHODS: In total, 55 male and 47 female patients were evaluated (mean age, 57.1 ± 12.0 years). The QoL was evaluated using the Korean version of World Health Organization Quality of Life Scale-Abbreviated Version. The psychosocial factors were evaluated using the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Montreal Cognitive Assessment, Pittsburgh Sleep Quality Index, and Zarit Burden Interview. The medical factors were assessed using laboratory examinations. Correlation and canonical correlation analyses were performed to investigate the association patterns. RESULTS: The QoL was significantly correlated with the psychosocial factors, and to a lesser extent with the medical factors. The medical and psychosocial factors were also correlated. The canonical correlation analysis indicated a correlation between QoL and psychosocial factors (1st canonical correlation = 0.696, P < 0.001; 2nd canonical correlation = 0.421, P = 0.191), but not medical factors (1st canonical correlation = 0.478, P = 0.475; 2nd canonical correlation = 0.419, P = 0.751). The medical and psychosocial factors were also correlated (1st canonical correlation = 0.689, P < 0.001; 2nd canonical correlation = 0.603, P = 0.009). CONCLUSION: Psychosocial factors influence QoL in patients with ESRD, and should thus be carefully considered when caring for these patients in clinical practice.

Milk-alkali syndrome secondary to the intake of calcium supplements / 영남의대학술지

Milk-alkali syndrome (MAS), a triad of hypercalcemia, metabolic alkalosis, and renal failure, is associated with ingestion of large amounts of calcium and absorbable alkali. MAS is the third most common cause of hypercalcemia in hospital, after primary hyperparathyroidism and malignant neoplasm. MAS is not often reported in the Korean literature. We describe MAS secondary to intake of calcium citrate for the treatment of osteoporosis with thoracic spine compression fracture. A 70-year-old man presented to our hospital with a 1-week history of general weakness and lethargy. He was found with acute kidney injury (serum creatinine, 4.6 mg/dL), hypercalcemia (total calcium, 14.8 mg/dL), and alkalosis. Laboratory evaluation excluded both hyperparathyroidism and malignancy. Mental status and serum calcium level was normalized within a week after proper hydration and intravenous administration of furosemide. However, he developed aspiration pneumonia, pseudomembranous colitis, and sepsis with multi-organ failure. Despite intensive treatment including inotropics, mechanical ventilation, and renal replacement therapy, he expired with no signs of renal recovery on the 28th hospital day.

Acute Kidney Injury due to Rbadomyolysis Complicated with Zolpidem Overdose / 대한내과학회지

Zolpidem (Stilnox®, Handok, Seoul, Korea) is a hypnotic imidazopyridine that is often used to treat insomnia because it has less abuse and addiction potential than benzodiazepines. Its side effects include headache, dizziness, and nausea, but these are mild. Zolpidem intoxication rarely has severe complications. Here, we report a case of acute kidney injury due to rhabdomyolysis related to zolpidem. A 51-year-old man was admitted with drowsy mentality after taking an overdose of zolpidem in a suicide attempt. Laboratory findings showed a blood urea nitrogen of 59.9 mg/dL, serum creatinine of 5.8 mg/dL, and creatine phosphokinase of 16,210 IU/L. Acute kidney injury associated with rhabdomyolysis complicating zolpidem intoxication was diagnosed. The patient was managed with hemodialysis and recovered completely in terms of renal function and muscle enzyme levels.

Amlodipine intoxication complicated by acute kidney injury and rhabdomyolysis / 영남의대학술지

Amlodipine, a calcium channel blocker of the dihydropyridine group, is commonly used in management of hypertension, angina, and myocardial infarction. Amlodipine overdose, characterized by severe hypotension, arrythmias, and pulmonary edema, has seldom been reported in Korean literature. We report on a fatal case of amlodipine intoxication with complications including rhabdomyolysis and oliguric acute kidney injury. A 70-year-old woman with a medical history of hypertension was presented at the author's hospital 6 hours after ingestion of 50 amlodipine (norvasc) tablets (total dosage 250 mg) in an attempted suicide. Her laboratory tests showed a serum creatinine level of 2.5 mg/dL, with elevated serum creatine phosphokinase and myoglobin. The patient was initially treated with fluids, alkali, calcium gluconate, glucagon, and vasopressors without a hemodynamic effect. High-dose insulin therapy was also started with a bolus injection of regular insulin (RI), followed by continuous infusion of RI and 50% dextrose with water. Despite intensive treatment including insulin therapy, inotropics, mechanical ventilation, and continuous venovenous hemodiafiltration, the patient died of refractory shock and cardiac arrest with no signs of renal recovery 116 hours after her hospital admission.

A Case of Salmonella Infection Complicated by Rhabdomyolysis and Acute Kidney Injury / 계명의대학술지

Rhabdomyolysis a clinical syndrome characterized by injury to skeletal muscle and release of intracellular contents into the systemic circulation, can develop from infections, although trauma is a more common cause. Myoglobinuric acute kidney injury (AKI) is a potentially life-threatening complication of rhabdomyolysis. Reports of rhabdomyolysis and AKI induced by salmonella infection are rare in the Korean literature. This paper describes a case of salmonella enteritis complicated by rhabdomyolysis and AKI. A 58-year-old man presented to the hospital with a two day history of watery diarrhea, abdominal pain and high fever. Initial blood chemistry revealed a serum creatinine (Cr) level of 3.4 mg/dL, with elevations of serum creatine phosphokinase (CK, 5,635 IU/L) and serum myoglobin (>3,000 ng/mL). Intravenous hydration and empirical antibiotic treatment with ciprofloxacin were initiated. Blood and stool cultures grew salmonella group B, which was sensitive to ciprofloxacin, ampicillin, and ceftazidime. Parenteral ciprofloxacin was continued for 14 days. During the first week of hospitalization, peak levels of serum Cr and CK were 9.5 mg/dL and 89,155 IU/L, respectively. Thereafter clinical and biochemical parameters gradually improved without dialysis. The patient was discharged on the 20th hospital day with normal CK levels except for serum Cr. His renal function normalized (serum Cr 1.0 mg/dL) two months after discharge. Based on the results of this case, prompt fluid therapy and early administration of antibiotics should be performed in patients with salmonella infection complicated by rhabdomyolysis and AKI.

A Case of Rhabdomyolysis Presenting with Acute Kidney Injury Complicating Carbon Monoxide Poisoning / 대한내과학회지

Carbon monoxide (CO) poisoning has increased rapidly in South Korea and may cause a variety of clinical effects. The most common complications are neurologic and neuropsychological disturbances. However, in rare cases, CO poisoning may also be associated with acute kidney injury and non-traumatic rhabdomyolysis. Here, we report a case of acute kidney injury and rhabdomyolysis complicating CO poisoning. A 32-year-old woman was admitted to our emergency department with dyspnea and confused consciousness after exposure to CO during a suicide attempt involving charcoal briquettes. Laboratory findings revealed a carboxyhemoglobin (COHb) level of 44.8%, a blood urea nitrogen level of 20.5 mg/dL, a serum creatinine level of 1.4 mg/dL, and a creatine phosphokinase level of 8,688.3 IU/L. Acute kidney injury and rhabdomyolysis complicating CO poisoning were diagnosed. This case was managed with normobaric oxygen therapy and hydration. The patient recovered completely with respect to renal function and muscle enzyme level, and COHb level returned to 0%.

Hyperglycemic Hyperosmolar Syndrome Caused by Corticosteroid Therapy in a Patient with IgA Nephropathy / 계명의대학술지

Glucocorticoids are the most common cause of drug-induced diabetes mellitus or hyperglycemia. Hyperglycemic hyperosmolar syndrome (HHS) secondary to glucocorticoid treatment in patients with glomerular disease has rarely been reported in Korea. This paper describes a case of HHS after corticosteroid administration for the treatment of immunoglobulin A (IgA) nephropathy. A 56-year-old nondiabetic male with biopsy-proven IgA nephropathy was started on a combination therapy of an angiotensin converting enzyme inhibitor and oral prednisolone (60 mg, 0.8 mg/kg/day). Eight weeks after the initiation of steroid therapy, he was admitted with a one-week history of polydipsia, polyuria and general weakness. His laboratory tests revealed a serum creatinine level of 2.7 mg/dL, elevated blood glucose (1,221 mg/dL) and an increase in serum osmolarity (347 mOsm/kg H2O). Urinalysis showed 4+ sugars, 2+ proteins, and negative ketones. Prednisolone was tapered and he was administered with intravenous fluids, insulin and electrolytes. The patient was discharged with normoglycemia without the use of antidiabetic medications on the 18th hospital day. Patients who are taking corticosteroids for the treatment of primary glomerulopathy should be investigated for HHS promptly if they present with dehydration, general weakness and weight loss.

A Case of Acute Kidney Injury in a Patient with Pulmonary Tuberculosis Receiving Ethambutol Therapy / 대한내과학회지

Ethambutol is commonly used as a first-line drug for the treatment of tuberculosis. The most serious adverse effect of ethambutol therapy is optic neuropathy. However, ethambutol-induced acute kidney injury is extremely rare. We report herein a case of acute kidney injury secondary to ethambutol-associated acute interstitial nephritis. A 65-year-old man with pulmonary tuberculosis presented with a > 7-day history of nausea and vomiting. He had begun antituberculosis medications including ethambutol 3 weeks previously. His laboratory findings showed elevated blood urea nitrogen and serum creatinine levels (32.6 and 3.6 mg/dL, respectively). Examination of percutaneous renal biopsy specimens showed diffuse interstitial mononuclear cell infiltration with mild interstitial edema. The patient was treated by cessation of ethambutol and supportive care. His renal function completely recovered (creatinine, 1.1 mg/dL) and his clinical symptoms improved.

Erratum: A Case of Acute Kidney Injury in a Patient with Pulmonary Tuberculosis Receiving Ethambutol Therapy / 대한내과학회지

We correct the revised date of this article.

A Case of Acute Colonic Pseudo-Obstruction Combined with Rhabdomyolysis induced by Severe Hypokalemia / 대한내과학회지

Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome is a rare disorder of intestinal motility characterized by massive colonic dilatation without mechanical obstruction. We report a case of ACPO combined with rhabdomyolysis induced by severe hypokalemia. A 78-year-old male with a 10-year history of hypertension presented with abdominal pain and distension for 2 days. The laboratory findings showed hypokalemia with markedly elevated serum creatine phosphokinase and myoglobin levels. A plain abdominal x-ray revealed a markedly distended ascending and transverse colon with a cut-off sign at the descending colon. Mechanical obstruction of the intestine was excluded by computed tomography and colonoscopy. He was initially treated with supportive therapy, including insertion of a rectal tube and intravenous fluids with potassium replacement. However, the ACPO persisted, and neostigmine was administered in two separate 2.0-mg intravenous injections, 24 hours apart. Subsequently, the abdominal pain and colonic distension were relieved.

A Case of Primary Aldosteronism Accompanied by Hypokalemic Rhabdomyolysis / 영남의대학술지

Primary aldosteronism is characterized by hypertension, hypokalemia, and metabolic alkalosis, associated with excessive aldosterone production and suppressed plasma renin activity. Hypokalemia-induced rhabdomyolysis has been rarely reported in primary aldosteronism patients. This paper reports a case of primary aldosteronism presented with rhabdomyolysis due to severe hypokalemia. A 48-year-old male with a three-year history of hypertension presented himself at the authors' hospital with generalized weakness and myalgia in both legs over a period of several days. His laboratory findings showed hypokalemia (1.8 mEq/L) with elevations of his serum creatine phosphokinase and serum myoglobin. His plasma aldosterone level was also elevated, and his plasma renin activity was reduced. An abdominal computed tomography revealed a 2.0 cm hypodense mass in the left adrenal gland, which suggested adrenal adenoma. The accordingly underwent laparoscopic adrenalectomy. Three months later, his plasma potassium level and blood pressure became normal without the use of medications.

Two Cases of Anti-Glomerular Basement Membrane Antibody Disease Associated with Perinuclear-Anti-Neutrophil Cytoplasmic Antibody / 대한내과학회지

Anti-glomerular basement membrane antibody (anti-GBM Ab) disease is characterized by circulating antibodies to the glomerular basement membrane and the deposition of IgG or, rarely, IgA along the glomerular basement membrane. This disease accounts for 10-20% of crescentic glomerulonephritis. We report two patients with anti-GBM Ab disease who were positive for perinuclear-anti-neutrophil cytoplasmic antibody (p-ANCA). Percutaneous renal biopsies showed many crescent formations and linear deposits of IgG along the glomerular basement membrane. Serologic tests for p-ANCA were positive. They were treated with steroid pulse and cyclophosphamide and one patient also underwent plasma exchange therapy. Despite immunosuppressive therapy, their renal functions did not improve and both required regular hemodialysis.

A Case of Norwegian Scabies in a Patient with Chronic Kidney Disease and Down Syndrome / 대한신장학회지

Norwegian or crusted scabies is a rare, highly contagious atypical form of scabies caused by the mite Sarcoptes scabiei var. homonis. It is usually associated with advanced age, immunosuppression, physical debility, and developmental disabilities. We report here a case of Norwegian scabies in an institutionalized patient with chronic kidney disease (CKD) and Down syndrome. A 56-year-old male presented at our department with pruritic rash and general weakness of 2 months' duration. Examination showed hyperkeratotic, scaly, crusted erythematous plaques on the hands, trunk, and back of the patient. The microscopic examination of the skin scales with potassium hydroxide demonstrated numerous scabies mites. The patient was treated with hemodialysis and repeated applications of 1% lindane lotion for 2 weeks. He reported significant relief of pruritus and resolution of the skin lesions after the treatment. In addition to uremic pruritus, infectious skin diseases such as Norwegian scabies should be considered in the institutionalized patients with advanced CKD and resistant pruritus.

Complete remission of philadelphia chromosome-positive acute myeloid leukemia with imatinib mesylate / 대한내과학회지

Philadelphia chromosome-positive acute myeloid leukemia (Ph+AML) is a rare disease characterized by a poor prognosis with resistance to standard chemotherapy. We report a patient with Ph+AML with a minor BCR-ABL-positive mRNA transcript who achieved a hematologic, cytogenetic, and major molecular complete response after cytarabine-based chemotherapy followed by imatinib. After more than 6 months of continuous imatinib therapy, the patient is in continuous complete remission. Our results show that imatinib mesylate is effective in treating Ph+AML.

A Case of Acute Bilateral Renal Infarction Associated with Protein S Deficiency / 대한신장학회지

Acute renal infarction usually occurs in patients with trauma, atrial fibrillation, atherosclerosis, vasculitis, and valvular heart disease. However, it may occur, though rarely, in patients with hypercoagulable states such as protein C and protein S deficiency. We report here a case of acute bilateral renal infarction associated with type II protein S deficiency without a demonstrable underlying cause. A 48-year-old male was presented to the emergency room with an abrupt, persistent pain at the left flank area. Three-dimensional abdominal computed tomography revealed wedge-shaped, well demarcated, low density lesions in both the kidneys, which were consistent with occlusions of segmental branches of both the renal arteries. Protein S activity by clot-based assay was 43% (73.7-146.3%). The patient was treated with intravenous heparin and later warfarin. He has remained symptom-free on warfarin therapy with preserved renal function during the follow-up of 5 weeks.

A Case of Endogenous Klebsiella Endophthalmitis Associated with Acute Pyelonephritis in a Patient with Chronic Renal Failure / 대한신장학회지

Endogenous endophthalmitis is any inflammation of the internal ocular space that usually has a poor prognosis for visual recovery, and is a rare complication of Klebsiella pneumoniae septicemia. We report here a case of endogenous endophthalmitis due to K. pneumoniae in a patient with acute pyelonephritis and chronic renal failure who did not have any history of diabetes mellitus. A 75-year-old woman was admitted to our hospital, complaining of severe pain and decreased vision in the right eye, accompanied by fever and nausea, of 48 hours' duration. Ophthalmologic evaluation and intervention were performed. Blood, urine and vitreous cultures were all positive for K. pneumoniae. She was treated with intravenous antibiotics, intravitreal antibiotics injection and pars plana vitrectomy. However, her right eye showed progressive worsening to enucleation, and she has been on maintenance hemodialysis ever since.

Two Cases of Bilateral Emphysematous Pyelitis in Patients with Diabetic Chronic Kidney Disease / 대한신장학회지

Emphysematous pyelitis (EP) is an acute bacterial renal infection characterized by the presence of gas localized to the renal collecting system, sparing the renal parenchyma. It is seen more commonly in women, often associated with underlying diabetes mellitus or obstructing stone disease. To our knowledge, EP has not been frequently reported in the Korean literature. We report here two cases of bilateral EP due to Escherichia coli in 55-year-old female and 44-year-old female patients with diabetic chronic kidney disease, were successfully treated with medical management including intravenous administration of antibiotics. Early diagnosis by means of abdominal computed tomography along with prompt antibiotic therapy may be effective in patients with bilateral EP.