Landouzy-Sepsis bei einer Patientin mit Miliartuberkulose

This article reports the fulminant course of a pneumogenic sepsis with severe ARDS (acute respiratory failure) in a 36-year-old female Indian patient, who died within 14?h after admission to the intensive care unit due to a multiorgan failure. During treatment the diagnosis of a miliary tuberculosis was suspected but was only confirmed by the autopsy. Due to high hygiene standards, miliary tuberculosis as the cause of septic shock is rare in Europe. Only 1–2% of the patients with pulmonary miliary tuberculosis develop an ARDS with a mortality of 60–90%. Based on this case the diagnostics as well as treatment of the patient are described. Furthermore, the management of an open tuberculosis on an intensive care unit is explained.     

Update Mallampati

In 1985 Mallampati et al. published a non-invasive score for the evaluation of airways (Mallampati grading scale, MGS), which originally consisted of only three different classes and has been modified several times. At present it is mostly used in the version of Samsoon and Young consisting of four different classes. Class I: soft palate, fauces, uvula, palatopharyngeal arch visible, class II: soft palate, fauces, uvula visible, class III: soft palate, base of the uvula visible and class IV: soft palate not visible. Nevertheless, other versions of MGS still exist, each having different values for sensitivity and specification. The current opinion is therefore that MGS is no longer useful as a stand-alone predictor but in combination with others it is still part of today’s most relevant guidelines, such as those of the American Society of Anesthesiologists (ASA), the UK’s Difficult Airway Society (DAS), the European Society of Anaesthesiology (ESA) and the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and must therefore be known by anesthetists. Even in times of sophisticated tools for airway management, the procedure remains a high risk, so every anesthetist has to be prepared for and well trained in management of known and unexpected difficult airways. Evaluation of the patient’s airway is a part of modern airway management to prevent problems and reduce risk of hypoxia during the procedure. The theoretical knowledge and practical skills of European anesthetists were evaluated at two international congresses, the German Anesthesia Congress (DAC) and Euroanaesthesia 2014. The DAC is an annual meeting of German speaking anesthetists, hosted by the DGAI. The Euroanaesthesia is the annual European pendant hosted by the ESA. Participation was voluntary and only physicians were allowed to take part. Theory was evaluated by a questionnaire containing open and closed questions for MGS that had to be answered by every participant alone. Apart from theory, a practical evaluation was performed. Every participant had to classify the MGS of a human airway model. The model was identical on both congresses. According to the original publication a checklist containing the factors essential for the correct performance was filled out by a supervising experienced anesthetist. During DAC 2014 n?=?267 physicians participated in the study, 22 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part. A total of 245 data sets were evaluated. During Euroanaesthesia 2014 n?=?298 physicians participated in the study, 68 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part and 230 data sets were evaluated. At the DAC the mean age (±?SD) was 44.5?±?9.5 years, 157 (64.1%) were male and 88 (35.9%) were female. Working experience was trainee anesthetist in 16.7% and other participants were experienced anesthetists. At the ESA the mean age (±?SD) was 42.4?±?9.5 years, 133 (57.8%) were male and 97 (42.2%) female. Trainee anesthetists were 15.2%, the rest were experienced anesthetists. The DAC participants knew Mallampati classes 1 (65%) and 4 (45%) better than 2 and 3 and there was no relevant differences to the ESA (close to 30% knew the classes 1–4 here). Classification of the airway model was correct in 62% and 67% at DAC and ESA, respectively. Most participants performed the practical evaluation correctly except the sitting position of the model. In agreement with earlier studies, these results show the lack of knowledge in evaluation of airways according to current guidelines of all relevant societies. This is likely to increase preventable risks for patients as unexpected difficult airway management increases the risk for hypoxia and intubation damage.     

Extrakorporale CO<Subscript>2</Subscript>-Elimination als Alternative zur Tracheotomie bei Weaningversagen

We report a patient with chest trauma who was admitted to the ICU after surgery. As he fulfilled protocol-based criteria, he was extubated 7 days after admission. However, despite intermittent non-invasive ventilation, the patient had to be re-intubated on day 10 owing to progressive hypercapnia. We decided to support the patient with a mid-flow veno-venous extracorporeal carbon dioxide removal (ECCO₂?R) system instead of a tracheotomy. Sufficient CO₂ removal was established with a blood flow of 1.5?l/min and the patient was successfully extubated within a few hours. After 5 days of ECCO₂?R the patient could be weaned and transferred to a general ward in a stable condition.     

Pharmacokinetics of rituximab in a pediatric patient with therapy-resistant nephrotic syndrome

Background

Rituximab (RTX) has recently been introduced as a second-line therapy for nephrotic syndrome in children. Studies show that RTX given during the nephrotic state may be less effective than treatment during a non-nephrotic state, possibly due to loss of RTX in the urine.

Case-Diagnosis/Treatment

We describe a 10-year-old boy with steroid-resistant nephrotic syndrome (SRNS) treated with RTX during a phase of active non-selective proteinuria. The serum half-life of RTX in this patient was less than 1 day compared to 20 days in patients without protein losses. Urinary clearance was at least 25 %, compared to approximately 0 % in control patients. However, RTX loss in the urine, as well as in pleural effusion and ascites, only partly explains the rapid drop in the serum RTX concentration of this patient.

Conclusions

Serum half-life of RTX can be extremely short, partly due to excessive urinary losses in therapy-resistant nephrotic syndrome with non-selective proteinuria, as seen in our patient. These findings may help to explain the poor results of RTX treatment in patients with active proteinuria.

     

Mycobacterium tuberculosis infection in renal transplant recipients

Mycobacterium tuberculosis (TB) infection is more common among renal allograft recipients compared with the general population due to immunosuppression. The epidemiological risk in a country is an important determinant of transplant TB after transplantation. We retrospectively analyzed 283 renal transplant recipients who underwent renal transplantation between 1990 and 2004. We evaluated the incidence, patient and disease characteristics, prognosis, and outcome of TB infection. Tuberculosis developed in 10 (seven men and three women of mean age of 41+/-9 years) among 283 patients (3.1%). All patients were culture-positive for M tuberculosis. Although pulmonary TB was the most common presentation in the general population, 50% of patients in the study group developed extrapulmonary TB. The mean elapsed time from renal transplantation was 38 months. Three patients (1%) developed TB in the first year after transplantation. All patients were treated with a quartet of anti-TB therapy. One patient developed isoniazid-related reversible hepatotoxicity. No acute allograft rejection occurred during the anti-TB therapy. Two patients (20%) with pulmonary TB died due to dissemination of the disease. In conclusion, extrapulmonary presentations of TB are more common among renal transplant recipients with the increased risk of mortality.     

Single infusion of rituximab for persistent steroid-dependent minimal-change nephrotic syndrome after long-term cyclosporine

Rituximab (RTX) has been successfully used as a rescue therapy in children with steroid-dependent nephrotic syndrome (SDNS). However, little is known regarding maintenance therapy after a successful response to RTX in such patients. The efficacy and safety of a single RTX infusion (375 mg/m²) were assessed in ten patients who had persistent SDNS associated with minimal-change disease (MCD) despite the long-term use of cyclosporine (CsA). The mean follow-up after RTX infusion was 17 months. Applying RTX resulted in a significant reduction in the mean prednisolone (PSL) dose from 0.39 ±0.18 to 0.15 ± 0.14 mg/kg per day. The mean 12-month relapse rates significantly decreased from 4.1 ± 1.7 to 0.6 ± 0.6. All but one patient who had continued CsA as maintenance therapy after a single RTX infusion were able to withdraw from PSL without any relapses during the study period, whereas the remaining five patients who discontinued CsA experienced relapses after CD19 cells re-emerged, leading to the reintroduction of CsA or an additional RTX infusion. Infusion reactions occurred in five of ten patients. These data indicate that a single RTX infusion may improve response to CsA in patients with persistent SDNS due to the phenomenon of secondary resistance to CsA.     

Pyothorax-associated lymphoma: complete remission achieved by chemotherapy alone

We present the case of a patient with malignant lymphoma resulting from chronic pyothorax after artificial pneumothorax for pulmonary tuberculosis. The 81-year-old female patient had a medical history of artificial pneumothorax from left pulmonary tuberculosis when she was 23 years old and subsequent chronic pyothorax. She had become aware of pain in the left back from October 2008. Chest computed tomography revealed a tumor measuring 61 mm × 27 mm behind the left sixth and seventh ribs. After biopsy revealed pyothorax-associated lymphoma, 4 courses of R-CHOP therapy were administered, leading to complete remission. No recurrences were noted during follow-up over a 4-year period after the initiation of therapy.     

Native Renal Cysts and Dialysis Duration Are Risk Factors for Renal Cell Carcinoma in Renal Transplant Recipients

Urinary tract cancers are the third most common cancers in renal transplant recipients (RTX). This study examined the impact of dialysis duration and native renal cyst(s) (NRC) on renal cell carcinoma (RCC) occurrence among 1036 RTX followed‐up from 1995 to July 2007. Abdominal ultrasonography was planned within 1‐month of transplant, then every 5 years, or 2 years if renal cysts developed. Based on presence and time of development of NRC, RTX were grouped into those with no (No‐NRC), new (New‐NRC), preexisting (Pre‐NRC) and time‐indeterminate NRC (TI‐NRC). Ten asymptomatic RTX were diagnosed with RCC at a median of 5.8 years posttransplant and had 5‐year graft and patient survivals of 90% and 100%, respectively, following appropriate therapy. RCC occurred only in Pre‐NRC and TI‐NRC who had significantly longer dialysis duration than No‐ or New‐NRC (6.7 ± 3.9 and 3.3 ± 3.2 vs. 2.7 ± 3.1 and 2.6 ± 2.4 years, respectively). These results suggest that NRC and increased dialysis duration are risk factors for RCC posttransplant. Since early treatment of RCC gives excellent outcomes, regular ultrasonography performed within a month of transplantation, then every 5 years for those without cysts and every 2 years for those with cysts for early detection of RCC is recommended.     

Fulminante Sepsis nach<Emphasis Type="Italic"> Capnocytophaga-canimorsus-</Emphasis>Infektion

Capnocytophaga canimorsus is a Gram-negative bacterium present in the oral cavities of cats and dogs. It is known for its capability to cause life-threatening sepsis following a dog bite, especially in immunocompromised patients. We report the case of a 67-year-old man who suffered from septic shock and multiorgan failure presumably following contamination of a pre-existing minor skin lesion by canine saliva. The purpose of this report is to raise awareness of Capnocytophaga canimorsus among physicians when faced with a patient presenting with fulminant septic shock and Gram-negative bacteremia, who has been exposed to dogs.     

Management of postoperative hemorrhage associated with factor VIII inhibitor: report of a case

This report presents a case that was successfully treated for acquired factor VIII inhibitor after extensive visceral surgery. A 71-year-old male who underwent surgery for bile duct cancer had active bleeding in the abdominal drainage tube on postoperative day (POD) 5, and prolonged activated partial thromboplastin time (aPTT) was detected (83.1 s) on POD 7. An extensive coagulation work-up revealed factor VIII deficiency (1 %), and a diagnosis of an acquired factor VIII deficiency was established when a factor VIII inhibitor of 8 Bethesda units was demonstrated. The patient was treated with activated prothrombin complex concentrate (aPCCs) and bloody discharge was stopped within 3 days. Inhibitor elimination was started using prednisolone on POD 20; rituximab, was administered on POD 74 and 81. Factor VIII inhibitor had disappeared by POD 124, and factor VIII (72 %) and aPTT recovered to 45.9 s. This case report demonstrated the efficacy of aPCCs and rituximab in the treatment of acquired hemophilia associated with visceral surgery.     

A case of tuberculous tenosynovitis in a patient with systemic lupus erythematosus.

A 52-year-old woman with systemic lupus erythematosus (SLE) was infected with tuberculosis (TB) on her forearm and hand, after 16 years of steroid therapy. Debridements and anti-TB therapy were performed successfully. Recently, the risk of significant morbidity from TB has been on the rise; this appears to be a complication of steroid therapy used to treat AIDS and some collagen vascular diseases. It is thought that steroid therapy causes an increased risk of TB. In this paper, we report our experience of this SLE patient who developed tuberculous tenosynovitis. We suggest that TB infection must be considered in the differential diagnosis whenever a patient presents with a chronic wrist or hand inflammation that is non-responsive to steroid treatment. Once TB infection is suspected, both histopathological and bacteriological examinations should be performed. Emergent treatment includes surgical debridement and the institution of early anti-TB therapy immediately after completing histopathological examination.     

Mycobacterium tuberculosis infection and laboratory diagnosis in solid-organ transplant recipients

Tuberculosis (TB) is an unusual infection in transplant recipients. We evaluated (i) the frequency of TB, (ii) the duration to develop the TB infection, and (iii) clinical consequences, in 380 solid-organ recipients from January 1995 to December 2000. A total of 10 (2.63%) patients (eight renal, two liver transplant recipients) were found to have post-transplantation TB. The frequency of TB in this patient population is 8.5-fold higher than the prevalance in the general Turkish population. Tuberculosis developed within 2-33 months after transplantation, with a median of 15 months. In all of these 10 patients, Mycobacterium tuberculosis (MTB) was isolated from the culture. All the patients continued to have low dose immunosuppressive treatment, and also quadriple antituberculosis treatment [isoniazid (INH), rifampin (RIF), pyrazinamide (PRZ) and ethambutol (ETB)] has been given. The two recipients had died of disseminated form of TB. Relapse was detected in one patient 6 months after the completion of the treatment. As post-transplant TB infection develops mostly within the first year after transplantation, clinicians should be more careful for early and fast diagnosis and treatment should be started immediately.     

A case of peritoneal TB causing renal failure in a patient with rheumatoid arthritis and initial negative PPD after treatment with infliximab

Opportunistic infection and reactivation of latent infection has been reported with use of monoclonal TNF alpha antibodies used for treatment of severe rheumatoid arthritis. We present a case of peritoneal tuberculosis (TB) causing renal failure secondary to ureteral constriction in a patient who had been treated with infliximab for rheumatoid arthritis. We suggest that physicians should be aware of the increased risk of false negative and false positive TST and IGRA among patients treated with monoclonal TNF alpha antibodies and should regularly look for usual and unusual symptoms of TB in this patient population.     

Die bilaterale renale Onkozytose als diagnostische und therapeutische Herausforderung

Bilateral oncocytosis along with multiple tumours in both kidneys represents a very rare pathology that is accompanied by diagnostic and therapeutic challenges. We report the case of a 60-year old male patient who underwent computer tomography with incidental detection of multiple bilateral and contrast enhancing renal tumours of different size. Subsequently the patient underwent nephron-sparing tumor resection, first on the right side and 4 weeks later on the left side. The histology of all removed tumors showed evidence of pure oncocytoma. There were no postoperative complications and renal function reached a stable state within 6 months follow-up. The major challenge regarding diagnostic process and therapy of this pathology is to distinguish benign oncocytoma from chromophobe renal cell carcinoma and hybrid tumours, which can all be associated with renal oncocytosis. Because of limitations concerning imaging processes and biopsy, all patients should undergo nephron-sparing surgery as far as possible. On the other hand alternative therapies should – regarding to therapy-associated morbidity and the basically benign prognosis of oncocytoma – be well discussed to obtain informed consent. In this case report different therapy options and the international literature concerning renal oncocytosis will be discussed.     

Nierentransplantation: Chancen und Risiken bei medizinischen Flüchtlingen

Background

Families with children and adolescents with end-stage renal disease came to Germany from the former Eastern Bloc countries before the wave of refugees in 2015, in order to enable their children to survive with adequate kidney replacement therapy and in the best case a kidney transplant.

Methods

In a case study, medical records of 4 childen and adolescents were retrospectively analyzed. These patients who fled to Germany for the treatment of terminal renal failure applied for asylum and were successfully transplanted after the usual waiting period.

Results

Four of the eight children and adolescents who came to Erlangen for treatment of terminal renal failure between 2003 and 2013 received a functioning kidney transplant (deceased donor kidney) after dialysis therapy was difficult due to lack of compliance to drug and dietary recommendations such as fluid restriction. Since children and adolescents are treated with chronic dialysis only with the aim of kidney transplantation, a living donation was discussed but was not possible for medical reasons. 3 recipients are symptom-free with a functional graft.

Discussion

The case study demonstrates that children and adolescents fleeing to Germany due to their end stage renal disease are better integrated after kidney transplantation, have better chances of obtaining a good education and can be expected to live independently with their own income in the future.

     

Tuberculosis in southern Chinese renal‐transplant recipients

Abstract: Objectives: To analyze the characteristics of tuberculosis (TB) in Southern Chinese renal transplant recipients, and summarize the corresponding experiences in diagnosis and management. Method: Retrospectively study 41 documented post‐transplant TB cases out of the 2333 patients who received kidney transplantation in the First Affiliated Hospital of Sun Yat‐sen University between Jan. 1991 and Apr. 2007. Results: TB in the post‐renal‐transplant population in Southern China displayed the following characteristics: (i) high incidence within a short time after transplantation, the median interval between renal transplantation and diagnosis of TB was 8 months (range: 1‐156 months) and 56.1% were diagnosed within the first year post‐transplant; (ii) high prevalence (51.2%) of extra‐pulmonary tuberculosis; (iii) high co‐infection rate (19.5%), pathogens included candida albicans, pseudomonas aeruginosa, staphylococcus aureus, Acinetobacter haemolyticus and cytomegalovirus; (iv) fever (82.9%), cough (56.1%) and sputum (39.0%) are the most common clinical manifestations; (v) purified protein derivative of tuberculin (PPD) skin test had little diagnostic value in this group with a negative result in all 41 cases; (vi) acute rejection (29.3%) and liver function damage (17.1%) were the main adverse effects of anti‐tuberculosis chemotherapy; (vii) mortality of patients with post‐transplant tuberculosis reached up to 22.0%. Conclusions: Chinese renal transplant recipients face a high risk of TB because of their immuno‐compromised state and epidemiological prevalence of the disease. Therefore, attention should be given to this differential diagnosis in clinical practice. Balancing the benefits and disadvantages of anti‐tuberculosis chemotherapy is of importance for this specific population.     

Mycobacterium Tuberculosis Infection Incidence in Hospitalized Renal Transplant Patients in the United States, 1998–2000

The incidence, risk factors, and prognosis for Mycobacterium tuberculosis (MTB) infection have not been reported in a national population of renal transplant recipients. We performed a retrospective cohort study of 15,870 Medicare patients who received renal transplants from January 1, 1998 to July 31, 2000. Cox regression analysis derived adjusted hazard ratios (AHR) for factors associated with a diagnosis of MTB infection (by Medicare Institutional Claims) and the association of MTB infection with survival. There were 66 renal transplant recipients diagnosed with tuberculosis infection after transplant (2.5 cases per 1000 person years at risk, with some falling off of cases over time). The most common diagnosis was pulmonary TB (41 cases). In Cox regression analysis, only systemic lupus erythematosus (SLE) was independently associated with TB. Mortality after TB was diagnosed was 23% at 1 year, which was significantly higher than in renal transplant recipients without TB (AHR, 4.13, 95% CI, 2.21, 7.71, p < 0.001). Although uncommon, MTB infection is associated with a substantially increased risk of mortality after renal transplantation. High-risk groups, particularly those with SLE prior to transplant, might benefit from intensified screening.     

Clinical characteristics of tuberculous infection following renal transplantation

ObjectiveThis study investigated the clinical characteristics of patients with tuberculosis (TB) following renal transplantation (RT) in order to identify markers or signs that can facilitate early diagnosis.MethodsA retrospective analysis was performed on 12 cases of Mycobacterium tuberculosis infection treated at our hospital between 2005 and 2020.ResultsThe incidence of TB after RT at our hospital was 0.9%, and the median postoperative onset time was 22 months. The average age of patients included in our analysis was 44.2 ± 9.4 years; 11 of the 12 patients were male, and most patients had (low) fever as the first or only manifestation. Five patients had respiratory symptoms; 5 had typical computed tomography (CT) presentation; and 2 had a confirmed history of TB. Two sputum smears from 12 patients were positive by acid fast staining, and M. tuberculosis was detected in peripheral blood samples by metagenomic next-generation sequencing (NGS). One patient had a positive result in the purified protein derivative (PPD) test, 7 were positive with the interferon gamma release assay (IGRA), 8/12 patients were confirmed to have TB infection by NGS and 1 was confirmed positive by lung biopsy.ConclusionBecause of the use of immunosuppressive agents, most patients with TB following RT have atypical clinical symptoms and CT findings, and may have a high probability of a false negative result with the traditional PPD test and a low probability of M. tuberculosis detection, making early diagnosis difficult. Therefore, in RT recipients with prolonged fever of unknown origin and unusual clinical manifestations, especially those who are unresponsive to antibiotic treatment, a diagnosis of TB should be considered. The interferon gamma release assay and NGS are relatively new detection methods with high sensitivity and specificity; these along with regular, repeated testing by various approaches can aid the early diagnosis of TB.     

Does rituximab induce hypogammaglobulinemia in patients with pediatric idiopathic nephrotic syndrome?

Background

Rituximab (RTX) is a promising strategy for treating steroid-dependent idiopathic nephrotic syndrome (SDNS). RTX induces profound B-cell depletion, suggesting hypogammaglobulinemia as a potential side effect after long-term treatment.

Patients and methods

We analyzed immunoglobulin G (IgG) levels in 12 pediatric patients on RTX with a B-cell depletion of a minimum of 3 months and compared the results to 16 patients on orally administered immunosuppressive drugs, such as mycophenolate mofetil (MMF) and/or cyclosporine A (CyA). All patients were in stable remission of SDNS at the time of IgG analysis.

Results

IgG levels in the RTX group before RTX introduction were 6.2?±?1.0 g/L and were not significantly different from the MMF/CyA group (8.2?±?2.5 g/L). In the MMF/CyA group, five patients had at least one episode of hypogammaglobulinemia. In two of them, this episode was prolonged (>3 months), and only one required IgG supplementation. In the RTX group, eight patients had decreased IgG levels before RTX infusion. After RTX, hypogammaglobulinemia persisted in seven among those eight patients. No decreased IgG plasma levels were noted in patients with normal baseline IgG levels before RTX treatment.

Conclusion

RTX does not seem to directly induce decreased IgG levels in patients with SDNS, but it seems to prolong a preexisting low IgG levels.     

Late Complications after Proctectomy in Rectal Cancer Patients who Underwent Radiotherapy

Background

Radiotherapy for advanced rectal cancer is an important treatment to reduce local recurrence.

Objective

The purpose of this study was to identify the late structural changes of pelvis and adverse effects after radiotherapy for rectal cancer.

Methods

Between January 2000 and December 2009, we performed a single-center case–control study with 687 patients who underwent curative treatments for rectal cancer. A radiotherapy group (RTX) and a non-radiotherapy group (NRTX) were compared. Of the 687 patients, 207 cases in the RTX group were identified, and 207 controls for the NRTX group were selected for analysis. Each case had one control matched for age (±5 y), sex, tumor location, and operation type. All instances of radiotherapy were performed as long-course treatment methods (45.0–50.4 Gy) with concurrent 5-fluorouracil (5-FU)-based chemotherapy. Late complications were usually assessed as structural changes of the pelvic organ based on physical examination or radiologic or endoscopic findings 6 months after the rectal resection or pelvic radiation.

Results

In terms of overall complications, the RTX group (N = 45, 21.7 %) experienced more frequent complications than the NRTX group (N = 25, 12.1 %, p = 0.009). In particular, anastomosis-related complications were more common in the RTX group (9.2 %) than in the NRTX group (2.4 %, p = 0.003). Successful treatment after late complications in the RTX group (33.3 %) was less likely than in the NRTX group (70.0 %, p = 0.010). Late complications in the RTX group gradually increased with time (11.6 % at 2 y, 17.9 % at 3 y, 19.8 % at 4 y) at a higher rate than in the NRTX group (6.8 % at 2 y, 10.6 % at 3 y, 10.6 % at 4 y, p = 0.009).

Conclusions

Radiotherapy for rectal cancer patients may induce late pelvic complications as time progresses, and irreversible tissue changes due to radiation could disrupt the successful treatment of radiation-related complications.