A Mass on the Sole Revealing a Giant-Cell Tumor of the Tendon Sheath.

A 61-year-old woman presented with a 3-year history of painless soft-tissue mass on the right sole. The patient reported gradual growth, with a rapid increase in size over the past few months, leading to difficulty in walking. She had no history of past trauma. Examination revealed a 4-cm ovoid mass located over the ball of the foot. It was firm in consistency, with well-defined margins, a smooth surface, and an overlying normal skin (Figure 1). An ultrasound image revealed an eccentric, hypoechoic, nonvascular subcutaneous lobular mass. A magnetic resonance imaging (MRI) of the foot revealed a well-defined mass arising from the flexor tendon sheath of the right foot. The lesion was heterogeneously hyperin-tense on T1- and T2-weighted images with an avid contrast enhancement. All of the surrounding soft tissues indicated normal signal intensity patterns. There was no associated bony destruction. Histopathologic examination after complete excision of the mass established a well-circumscribed lesion composed of osteoclast-like giant cells and mononuclear cells in a hyalinized stroma, consistent with a giant cell tumor of the tendon sheath (GCT-TS) (Figure 2). There was no recurrence during a 6-month follow-up period (Figure 3).

The Clinical Features and Outcomes of Renal Amyloidosis in Tunisia.

Systemic amyloidosis is a rare disease characterized by clinical polymorphism. Indeed, the kidney is the most common organ involved and represents a real turning point in the disease. We aimed to determine the clinicopathological prognostic factors of renal amyloidosis (RA). We conducted a retrospective study including 40 cases with biopsy-proven RA collected in our department over a period of 10 years. Biochemical, demographic, and clinicopathological findings at diagnosis, as well as the follow-up data, were evaluated for each patient. The prevalence of amyloidosis was 2.7 per 100 nontransplant renal biopsies. The mean age at presentation was 55.5 ± 15.6 years with a male-to-female ratio of 1.85. The diagnosis of RA was confirmed by a renal biopsy in 85% of cases. Amyloid A (AA) amyloidosis was the most common type of amyloidosis (65%), and chronic infections ranked first in the panel of etiologies (41%). Amyloid light chain amyloidosis was mainly associated with multiple myeloma (57%). The median patient survival was 59 months versus 12 months for kidney survival. Age and extrarenal localization were independent predictors of mortality, whereas renal failure at presentation significantly influenced renal survival. The results of our study emphasize the rarity but also the severity of RA. AA amyloidosis was the most common type identified, which was mainly caused by chronic infections. Prevention remains the best solution until we can achieve therapeutic advances in inflammatory diseases.

Peritoneal dialysis in Tunisia: complications, technique and patient's survival (twenty-seven years of experience in a single center).

INTRODUCTION: peritoneal dialysis (PD) is a renal replacement therapy method that offers various advantages to end-stage renal disease patients. The aim of our study was to analyze patient characteristics, peritonitis and clinical outcome over a 27-year period of PD in our center. METHODS: retrospective study of incident patients on PD from January 1990 to December 2017. A total of 304 patients were enrolled in the study group. All patients over 15 years of age entering the dialysis program were included in the study. Patients dropping out from PD within three months were all excluded. Biochemical and demographic variables, peritonitis episodes and patient and technique survival were analyzed. RESULTS: the PD prevalence in our center was 4.5% during the study period; the mean age was 46.47 ± 18.6 years; diabetic nephropathy was the main cause of chronic kidney disease: 35.5% (n=108). Cardiovascular disease was the main cause of death: 39.6% (n=34). The peritonitis rate was 0.68 episode per patient-year. Ultrafiltration failure was the most important cause of PD withdrawal: 43% (n=60). Occurrence of peritonitis was the only independent predictor of technique failure: adjusted relative risk [aRR] 5.07, 95% CI 2.69-9.58; p<0.001. The overall non-adjusted patient survival was around 100%, 95% and less than 20% at 1, 4 and 25 years respectively basing on the Kaplan-Meier analysis. The group undergoing renal transplantation had the best survival rate. CONCLUSION: peritonitis remains the most common complication as well as the most provider of technique failure and patient´s transfer to hemodialysis. The technique survival was better in case of absence of peritonitis. However, our series showed the superiority of hemodialysis over PD in terms of overall patient survival.

Hemophagocytic Syndrome in a Pregnant Renal Transplant Recipient Associated With Cytomegalovirus Infection.

Hemophagocytic syndrome is a disorder of the mononuclear phagocytic system resulting in uncontrolled hemophagocytosis and cytokine overproduction. We report the first case of hemophagocytic syndrome, which occurred in a pregnantfemale patient 14 years after kidney transplant who displayed an atypical presentation and who had septic shock following cytomegalovirus infection. The patient, a-39-year-old woman at 27 weeks gestation with end-stage renal disease of unknown etiology, was admitted 14 years after living-donor kidney transplant (donor was her father) with high-grade fever, cough, and pancytopenia. Her immunosuppressant regimen included tacrolimus, azathioprine, and prednisone. Initially, she was hospitalized in the intensive care unit for septic shock without an identifiable focus of infection. She received intravenous broad-spectrum antibiotics before being transferred to our department following optimization of her hemodynamic status. Hemophagocytic syndrome was suspected, and bone marrow aspirate was performed, revealing macrophages with hemophagocytic activity. We confirmed the diagnosis of hemophagocytic syndrome given the presence of more than 5 criteria. We extensively investigated the underlying cause of hemophagocytic syndrome, and we diagnosed cytomegalovirus-induced hemophagocytic syndrome in a pregnant patient receiving immunosuppressive therapy after kidney transplantation. She was treated with corticosteroids and intravenous immunoglobulin. At 31 weeks gestation, she underwent a cesarean section; the baby developed newborn respiratory distress syndrome and died despite adequate resuscitation. We administered ganciclovir for 15 days following an increased cytomegalovirus viral load after delivery, leading to complete recovery.To date, optimal therapeutic and diagnostic guidelines for pregnancy-related hemophagocytic syndrome in female kidney transplant recipients are not well defined, and both patient and allograft survival rates remain low.

Urine Leak After Kidney Transplant: A Review of the Literature.

Although they are not common, urologic complications after renal transplant are associated with risk of graft loss. Fluid collection during the postoperative period can be caused by urine leak or lymph leak of seroma. Biochemical analysis of the drained liquid is essential and should be compared with a concomitant serum sample. Surgical exploration is indicated if suspected urine leak is significant. Reimplantation of the ureter to the bladder can be challenging if there is extensive ureteral necrosis due to compromised vascularization.

Cytomegalovirus Ocular Involvement in a Kidney Transplant Recipient.

Cytomegalovirus remains the most common infection after kidney transplant. We report cytomegalovirus retinitis and anterior uveitis, which developed consecutively within 1 year in a kidney transplant recipient. A 25-year-old man presented 5 months after transplant with decreased visual acuity in his left eye. Fundus examination revealed bilateral areas of necrotizing retinitis with intraretinal hemorrhages. The confirmation of cytomegalovirus disease was based on clinical findings and positive polymerase chain reaction for cytomegalovirus in plasma and in aqueous humor. The patient was treated with intravenous ganciclovir for 21 days and then with valacyclovir for 3 months. The patient's symptoms improved, and fundus examination revealed resolution of retinitis with appearance of retinal scarring. One year later, the patient presented with cytomegalovirus anterior uveitis associated with increased intraocular pressure, which was treated with antiviral agents, antiglaucomatous eye drops, and trabeculectomy. Cytomegalovirus ocular involvement for our immunocompromised patient presented in 2 consecutive forms: bilateral retinitis and anterior uveitis. Early diagnosis and treatment of active cytomegalovirus retinitis and uveitis remain crucial to prevent their progression to irreversible visual impairment.

Acute post-infectious glomerulonephritis in adults: a single center report.

Acute post-infectious glomerulonephritis (APIGN) is uncommonly seen in adults; its incidence is progressively declining, particularly in developed countries. The aim of this study was to evaluate the epidemiological, clinical and biologic features of APIGN in a Tunisian center. A retrospective descriptive analytic study was carried out on 50 patients aged more than 15 years who were admitted to the Monastir Hospital between 1991 and 2007, with a diagnosis of APIGN. There were more males than females (66% vs. 34%), and the mean age of the patients was 36.8 ± 10 years. Only 10% had an immunocompromised background, including diabetes. The most common site of infection was upper respiratory tract, followed by skin and pneumonia. The most common causative agent was Streptococcus (66%), followed by Staphylococcus (12%). 73.8% of the patients had low C3 complement levels. The mean peak serum creatinine was 190 µmol, and 4% of patients required acute dialysis. The patients were followed-up for a mean period of 18 months (range, 0.16-97 months). During follow-up, of the 46 patients reviewed in the consultation, the majority showed complete remission, 12 patients had persisting abnormalities such as hypertension in 17%, chronic renal failure in 8% and proteinuria in 6.5%, and one patient had concomitant hypertension and chronic renal failure. Our study suggests that APIGN is still endemic in some parts of the world such as Tunisia, and our data showed a favorable prognosis in adults.

[Post-infectious glomerulonephritis: unusual etiology of postpartum acute renal failure]. / La glomérulonéphrite aiguë postinfectieuse : une cause inhabituelle d'insuffisance rénale aiguë du post-partum.

Severe pre-eclampsia and acute tubular necrosis due to hemorrhagic shock are the major causes of postpartum acute renal failure. Cortical necrosis and haemolytic uraemic syndrome are less frequently. Post-infectious glomerulonephritis as a cause of postpartum acute glomerular disease and renal failure has been rarely reported. We report a patient with postpartum acute glomerulonephritis who presented nephritic syndrome, the diagnosis of which was confirmed by renal biopsy.

Mycophenolate mofetil-related pancolitis in a kidney transplant recipient.

Gastrointestinal adverse effects are common with mycophenolate mofetil administration, especially diarrhea. We report a case of mycophenolate mofetil-related colitis in a kidney transplant recipient. Colonoscopy revealed an ulcerative diffuse colitis. The colonoscopic biopsy specimen showed mild crypt distortion, accompanied by cryptitis and focal graft-versus-host disease like changes. The patient's symptoms improved after we discontinued the mycophenolate mofetil. A repeat colonoscopy 2 months after we discontinued the mycophenolate mofetil showed reparative changes. Mycophenolate mofetil is an important drug in organ transplant immune-suppression regimens; however, with its widespread use, additional adverse effects continue to be recognized.

Brown tumors in dialyzed patients with secondary hyperparathyroidism: report of 16 cases.

Brown tumors (BTs) are relatively uncommon but they are serious complications of renal osteodystrophy. The objective of this study was to analyze the clinical, biological, and radiological characteristics of 16 patients with BTs provoked by secondary hyperparathyroidism (sHPT) and its response to the decrease in parathyroid hormone levels after parathyroidectomy (PTX). The management of that uncommon condition was also reviewed. We conducted a retrospective study including 16 end-stage renal disease patients who underwent subtotal PTX between 1997 and 2007 for severe sHPT with BTs. Our study included 10 men and 6 women, whose average age was 34 years. All patients were on dialysis. Ten of them were on dialysis for more than 5 years. The median duration on dialysis was 84 months. Patients included suffered from swellings associated with functional limitations. BTs had multiple locations in 7 patients. Jaw was the most frequent location (62%). Radiography and tomodensitometry demonstrated a mixed radio lucent and radio-opaque lesions with an expansion of the cortical bone. Bone scan demonstrated an increased uptake of lesions. Chirurgical treatment was indicated in all cases because of severe refractory sHPT with functional limitations and/or disfiguring deformities. In all cases, BTs stopped its progression and even decreased in size. However, it was insufficient in four cases, which required a surgical resection. PTX remains an efficacious approach in resistant cases of sHPT with persistent BTs.

[Surgical treatment of secondary hyperparathyroidism in patients with chronic renal failure]. / Traitement chirurgical de l'hyperparathyroïdie secondaire chez l'insuffisant rénal chronique.

OBJECTIVE: To identify the indications for subtotal parathyroidectomy (PTX) in secondary hyperparathyroidism (SHPT) and report postoperative, early and late complications of PTX. PATIENTS AND METHODS: We conducted a retrospective study of subjects with chronic renal failure operated in Tunisian hospitals who received subtotal PTX over 10 years from January 1997 to December 2007. We analyzed the clinical, biological and radiological parameters pre- and postoperatively. RESULTS: We included 70 patients with average age of 39.4 years, 55.7% men and 44.3% in dialysis for 7.75 ± 4.8 years before PTX. The initial nephropathy was interstitial in 50% of cases. No cases of diabetic nephropathy have been reported. The clinical signs were bone pain (88.6%), muscle pain (85.6%), pruritus (81.4%). Radiological signs of osteitis fibrosa were observed in the majority of patients mainly resorption of extremities (92.9%), thinning of cortical (85.7%) and osteosclerosis (87.1%). The most common indication of PTX (85.7% of cases) was the persistence of serum PTH of more than 800 pg/ml associated with hypercalcemia and/or hyperphosphatemia refractory to medical treatment. A subtotal PTX (3/4 or 7/8) was performed after ultrasound and scintigraphy in the majority of cases. The histology of the parathyroid glands showed diffuse hyperplasia (51.4%), nodular hyperplasia (45.7%) and adenoma (2.8%). The postoperative evolution was marked by an improvement of the clinical and radiological criteria in 80% of cases. A PTH level of less than 15 pg/ml was rarely observed (10% of cases), and a PTH level of more than 300 pg/ml concerned 13% of patients. We noted a low morbidity and mortality (no cases laryngeal paralysis or cervical hematoma). CONCLUSION: Surgical treatment of SHPT in Tunisia is very effective in our experience. The biological results are comparable to treatment with calcimimetics, not available in Tunisia and whose price is higher. An early treatment of disorders of bone and mineral metabolism should reduce the incidence of SHPT.