Candidal renal papillary necrosis conquered.

Renal papillary necrosis due to Candida albicans is a rare but treatable cause of acute renal failure. We report this case of a middle aged male with history of type 2 diabetes mellitus who presented with infected right lower extremity and right lower lobe pneumonitis with hypotension. Though, he improved initially, during his stay in the hospital, he developed acute renal failure. Blood culture grew Candida albicans and the renal biopsy revealed candidal renal papillary necrosis. He also had candidal retinitis on ophthalmoscopy examination. He was treated with parenteral fluconazole for two weeks followed by oral fluconazole for a total of 4 weeks. Following treatment, the patient improved symptomatically and his renal parameters returned to normal. This case illustrates the need to consider candidal papillary necrosis as a differential in an immunocompromised patient with acute renal failure. It is potentially reversible, nonetheless a diagnostic and therapeutic challenge.

Low dose, oral epsilon aminocaproic acid for renal papillary necrosis and massive hemorrhage in hemoglobin SC disease.

Renal papillary necrosis in sickling hemoglobinopathies can lead to significant complications, including hemorrhage, obstruction, and infection. Despite its frequency, there are limited therapies for protracted hemorrhage. In the past, massive hemorrhage was managed with nephrectomy. Here, we report a patient with hemoglobin SC disease and prolonged, life-threatening hemorrhage from papillary necrosis successfully treated with oral, low-dose epsilon aminocaproic acid (EACA). Although further study is warranted, this case illustrates the need to consider EACA in the conservative management of renal papillary necrosis and significant hemorrhage in sickle cell hemoglobinopathies.

[Emphysematous pyelonephritis with favourable outcome after conservative treatment]. / Une pyélonéphrite emphysémateuse d'évolution favorable après traitement conservateur.

Emphysematous pyelonephritis is a necrotizing renal infection characterized by bacterial gas production in the renal and perirenal area. It is a rare infection diagnosed in diabetic patients in most cases. Emphysematous pyelonephritis is responsible for a high mortality rate. We report the case of a woman, unknown diabetic, who presented with emphysematous pyelonephritis. Early diagnosis performed by CT-scan allowed effective and conservative surgical treatment and final positive outcome.

[Wegener's granulomatosis in the head and neck region]. / Morbus Wegener im Kopf-Hals-Bereich.

Wegener's granulomatosis (WG) is defined as a granulomatous inflammation of the upper and lower respiratory tract and systemic vasculitis of small and medium sized vessels which is often accompanied by a necrotizing glomerulonephritis. The etiology of the disease is still unknown. In former times untreated WG usually ended deadly. Immunosuppressive therapy made WG a treatable disease with a chronically relapsing course. Therefore an early diagnosis of WG is of utmost importance. WG usually starts as a limited and localized organ manifestation in the upper respiratory tract and it generalizes, if untreated, with pulmonary and renal involvement. Symptoms in the head and neck region are observed in up to 95% of the patients with WG. Sinusitis, crusting of the nose, development of a saddle nose, middle and inner ear symptoms and subglottic stenosis are common manifestations. Due to the early and common manifestation of WG in the head and neck region the otorhinolaryngologist plays an important role for the early diagnosis and the fast initiation of immunosuppressive therapy but also during follow-up for activity assessment.

Use of administrative healthcare claims to examine the effectiveness of trimethoprim-sulfamethoxazole versus fluoroquinolones in the treatment of community-acquired acute pyelonephritis in women.

OBJECTIVE: To evaluate the effectiveness of trimethoprim-sulfamethoxazole and fluoroquinolones in the treatment of community-acquired acute pyelonephritis. PATIENTS AND METHODS: We identified a population-based cohort of non-pregnant women aged 18-65 years, initially treated with trimethoprim-sulfamethoxazole or a fluoroquinolone for community-acquired pyelonephritis in an ambulatory care setting. Subjects were identified from a healthcare claims database in Manitoba, Canada for the period 15 February 1996 to 31 March 1999. Subsequent treatment failure, as evidenced by the provision of additional treatment up to 42 days post-diagnosis, was compared between the two treatments. RESULTS: A total of 1084 women met inclusion criteria: 653 (60.2%) treated with trimethoprim-sulfamethoxazole and 431 (39.8%) treated with a fluoroquinolone. Treatment outcomes were affected by subject age. At age 20, treatment with a fluoroquinolone resulted in a reduced probability of treatment failure compared with trimethoprim-sulfamethoxazole (odds ratio, 0.56; 95% CI, 0.33-0.97). At age 60, there was no difference in the probability of treatment failure (odds ratio, 1.61; 95% CI, 0.82-3.16). No other subject characteristics impacted comparative effectiveness; however, several characteristics increased the odds of treatment failure irrespective of the initial antibiotic. These included: recent urinary tract infection (odds ratio, 2.07; 95% CI, 1.14-3.57), recent antibiotic use (odds ratio, 1.40; 95% CI, 1.00-1.96;), and a treatment duration of less than 10 days (odds ratio, 2.18; 95% CI, 1.59-2.99). CONCLUSION: Younger subjects ( approximately 20 years) treated with fluoroquinolones were less likely to experience treatment failure than those treated with trimethoprim-sulfamethoxazole. Treatment durations of less than 10 days resulted in a higher probability of treatment failure regardless of the initial antibiotic.

Tratamiento acortado de pielonefritis aguda en mujeres / Shortened treatment in female acute pyelonephritis

Stamey, a fines de los setenta, demostró que la esterilización de la orina es un hecho muy precoz en el tratamiento de toda Infección Urinaria (IU), y mi experiencia personal de más de 20 años con tratamiento de tres días en IU en pacientes con cualquier condición clínica (febril o no), con buenos resultados, nos permite proponer tratamiento acortado en PNA. No hay acuerdo sobre la duración del tratamiento de PNA, pero en general, se propone más de 7 días. Se efectúo un protocolo prospectivo de tratamiento acortado de PNA, en pacientes sin patología obstructiva. Todas las pacientes fueron tratadas con 3 días de antimicrobiano parenteral (Gentamicina i.m., 160 mg aldía) por 3 días, y 20 a 30 días de profilaxis posterior con Nitrofurantoína oral 50 mg/noche. Se efectuó examen de orina de diagnóstico, de control al tercer día, y antes de suspender la Nitrofurantoína. Ingresaron al protocolo 40 pacientes consecutivas, con diagnóstico clínico de PNA, recibidos por el Serviciode Urgencia, con temperatura sobre 38 °C, vómitos, dolor lumbar, y examen de orina previo a tratamientocon leucocituria y bacteriuria (con cultivo positivo, confirmado posteriormente), y ecotomografía renal sin dilatación.

Urticaria: signo guía para el diagnóstico de una mononucleosis infecciosa / Urticaria: key sign for the diagnosis of infectious mononucleosis

La mayoría de los casos de urticaria aguda son de causa desconocida. La infección aguda por el virus de Epstein-Barr se puede manifestar, infrecuentemente, en forma de urticaria a frigore. Reconocer esta sintomatología puede permitir un diagnóstico precoz de la mononucleosis infecciosa y descartar otras causas de urticaria aguda como ocurrió en la paciente de 17 años que aquí se describe (AU)

Differential effects of enalapril and irbesartan in experimental papillary necrosis.

This study was undertaken to determine whether angiotensin receptor blockers are as renoprotective as angiotensin-converting enzyme inhibitors in an experimental model of chronic interstitial renal disease. Groups of rats received one of the following treatments for 1 week: (1) enalapril, (2) diltiazem, (3) a cocktail of hydralazine, reserpine, and hydrochlorothiazide, or (4) irbesartan (an AT1 antagonist). The animals were injected with bromoethylamine (200 mg/kg), and antihypertensive treatment continued for 1 month. All drugs were effective in lowering the mean arterial pressure. The bromoethylamine-treated rats developed albuminuria and sustained a 40-50% decrease in creatinine clearance. Enalapril and irbesartan reduced albuminuria, but only enalapril partially prevented the decline in creatinine clearance and lowered the number of ED-1-positive cells. Diltiazem and cocktail had no effect on proteinuria, creatinine clearance, or ED-1 cells. In this experimental model, the effects of enalapril and irbesartan were not identical. Both drugs reduced proteinuria, but enalapril was more effective in protecting the renal function. The fact that the AT1 antagonist protected against albuminuria but did not affect the clearance of creatinine implies that the results seen with angiotensin-converting enzyme inhibition may be in part due to an effect on angiotensin II via AT2 receptor blockade or through an effect on bradykinin.

Prostaglandin E1 for renal papillary necrosis in a patient with diabetes mellitus.

We report a case of renal papillary necrosis with diabetes mellitus which was treated with prostaglandin E1. An intravenous infusion of 40 mg/day prostaglandin E1 was given for 14 days in an attempt to improve renal circulation. Treatment resulted in an improved creatinine clearance, renal plasma flow and renogram, and proteinuria was decreased. The administration of prostaglandin E1 produced an improvement in renal haemodynamics and can be considered as a possible therapy for renal papillary necrosis in diabetic patients.

Natriuresis obtained by intracerebroventricular infusion of hypertonic NaCl in rats with papillary necrosis.

Raising the sodium concentration in the third cerebral ventricle increases renal sodium, potassium and water excretion. The identification and characterization of the factor(s) mediating the centrally evoked natriuresis would be greatly facilitated if the exact intrarenal effector site were known. We have assessed the importance of inner medullary structures for the effects of CNS stimulation by examining its ability to alter renal excretion in rats with papillary necrosis, induced 2 d earlier with 2-bromoethylamine hydrobromide (BEA), 250 mg kg-1 body wt i.v. Male Lewis x DA rats were divided into a BEA-treated group (n = 6) and a control group receiving vehicle alone (n = 6). In contrast to the white papillae normally seen, the papillae of BEA-treated animals were bright red and showed a clear line of demarcation at their base. The rats were anaesthetized i.p. with Inactin (120 mg kg-1 body wt). Artificial cerebrospinal fluid (CSF) was infused (520 nL min-1) via a cannula into the left lateral ventricle. After 45 min CSF containing 1 M NaCl was used. Stimulation of the control rats with hypertonic CSF increased urine flow rate five-fold (5.4 +/- 0.8 to 27.1 +/- 6.1 microL min-1), Na excretion 23-fold (0.4 +/- 0.1 to 7.6 +/- 1.8 mumol min-1) and K excretion fourfold (0.6 +/- 0.18 to 3.8 +/- 0.5 mumol min-1). When the concentration mechanisms were damaged with BEA, the basal excretion rates of water and Na increased. The natriuretic response to ICV stimulation was severely impaired in these rats, but the kaliuretic effect was sustained.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of renal functional changes on the intrarenal distribution and urinary kinetics of amdinocillin.

The maintenance of effective therapeutic concentrations of antibiotics within the renal parenchyma is an important issue in the management of acute and chronic pyelonephritis. Available clinical data indicate that an important clinical-therapeutic correlation exists between the physiologic state of the kidney and the antibiotic concentrations that can be achieved in the medulla and papilla. Using a healthy canine model, we evaluated the influence of hydration and the state of acid-base balance upon the intrarenal distribution and urinary clearance of the semisynthetic penicillin amdinocillin. Renal physiologic activity significantly modulates the intrarenal distribution pattern of this compound. During the production of maximally acid and concentrated urine, the highest renal parenchyma levels of amdinocillin are achieved. During the latter circumstances the antibiotic undergoes distal tubular nonionic diffusion, which appears to be an important contributing factor to the high medullary and papillary concentrations of the drug. Nonetheless, at all levels of tested renal physiologic activity tissue and urine drug concentrations are adequate for the treatment of sensitive urinary pathogens.

Experimental renal papillary necrosis. Effects of beta adrenergic receptor blockade, heparin and hydrocortisone.

Renal papillary necrosis was induced in rats by daily subcutaneous injection of 15 mg 2-bromoethylamine hydrobromide (BEA) per 100 g of body weight for 2 successive days. This dose was 50% higher than that reported previously. Beta adrenergic receptor blockade with oxyprenolol did not influence the kidney damage. The administration of heparin did not show any effect. The doses applied did not induce the incoagulability for a sufficient period of time. On the contrary, treatment with hydrocortisone decreased papillary necrosis without inducing increased diuresis.

Emphysematous pyelonephritis.

A case of emphysematous pyelonephritis with perirenal gas is presented. This patient underwent vigorous medical treatment followed by nephrectomy and survived. This condition has a high mortality and should be distinguished from less severe infections where gas is confined to the collecting system. This case and others previously reported suggest that treatment should initially be medical, followed by early surgical intervention consisting of either drainage or nephrectomy depending upon the degree of renal involvement.