Acute glomerulonephritis with bacteriuria: a probable etiologic relationship

Twenty-one cases of acute glomerulonephritis in children with no previous history of renal disease were studied. Urinary infection with a rising titre of serum agglutinins against the organisms isolated from urine was found in 5 cases. No evidence of previous streptococcal infection was found in these cases. In the meantime all 8 cases with post-streptococcal glomerulonephritis remained without bacteriuria. In one case acute glomerulonephritis followed virus hepatitis, and in the remaining 7 cases the cause of glomerulonephritis was unknown. It is suggested that in predisposed patients the bacteria present in urinary infections might act as antigens starting immunologic reactions in the glomeruli, leading to glomerulonephritis. The final proof of this theory awaits immunofluorescence identification of these antigens in the glomeruli.     

A case of renal paradoxical embolism

Acute renal failure due to paradoxical embolism is exceptionally reported. A new case gives the opportunity to review mechanisms, diagnosis and therapeutic issues. A 49-year-old woman without medical history is admitted for crural venous thrombosis and acute pulmonary embolism. At day 2, a left flank acute pain with fever, doubling of plasma creatinine, and controlateral recurrence at day 12, leads to diagnosis of acute bilateral renal infarction only at day 20. Paradoxical embolism is then suspected and confirmed by transoesophageal contrast echocardiography, disclosing patent foramen ovale with right-to-left shunt. Nine months later, successful percutaneous closure of patent foramen ovale with Amplatzer PFO occluder 25 mm allows subsequent discontinuation of oral anticoagulation. Diagnostic criteria for paradoxical embolism are present in our case. If this mechanism is often discussed in cryptogenic cerebrovascular stroke of young patients, it is exceptionally reported as responsible for clinical renal disease, particularly acute renal failure (whereas anatomical renal involvement is not unfrequent). The clue is the difficulty to suspect and confirm renal infarction, especially when classical causes of cardiac embolism are lacking. The relevance is the opportunity to save renal tissue in the acute phase, and to close patent foramen ovale (currently most often percutaneously) weeks or months after the acute bout.     

A paradoxical air embolism in a closed foramen ovale

This case report deals with a patient who was being operated on for a tumor of the colon and who died from a paradoxical venous air embolism. Accompanying massive blood loss impedes differentiation of hemodynamic disturbances either due to venous air embolism or to hemorrhage, respectively. Air was aspirated from the radial artery catheter that was used for blood-pressure monitoring and for taking blood samples for laboratory analysis. At autopsy, no probe-patent foramen ovale could be demonstrated. The mechanism of air passing from the venous to the systemic circulation in our patient remains speculative; however, mechanical cardiopulmonary reanimation itself with its underlying thoracic pump mechanism has to be considered as contributing to the transport of air from the venous to the arterial side of the circulation.     

Parameters affecting occurrence of paradoxical air embolism

The effects of different patterns of ventilation and intravascular volume infusion on the occurrence of paradoxical air embolism (PAE) were evaluated in 15 pigs with a surgically created atrial septal defect (ASD). A balloon atrial septostomy was created transvenously in anesthetized pigs (mean diameter 8.6 mm +/- 1 mm). Monitoring included transesophageal echocardiography (TEE) of the right and left heart, ECG, EEG, direct arterial pressure, right and left atrial pressures (RAP and LAP), pulmonary artery pressure, and pulmonary capillary wedge pressure (PCWP). With the animal in a head up tilt, air was infused into the superior vena cava at a rate of 0.27 ml.kg-1.min-1 for 6 min or until PAE was identified on the TEE. Four situations were studied--intermittent positive pressure ventilation (IPPV), intermittent positive pressure ventilation with 10 cm H2O positive end-expiratory pressure (PEEP), spontaneous ventilation, and IPPV following infusion of 500 ml hetastarch. The incidence of PAE was not different in any of the four situations. Release of PEEP resulted in an increase in the amount of PAE or new PAE in nine of 14 animals. PAE occurred both with and without mean RAP exceeding mean LAP and the incidence of PAE was not significantly different based on the atrial pressure gradient. In situations during which the mean LAP remained greater than mean RAP throughout the venous air infusion and PAE occurred, transient reversal of the right to left atrial pressure gradient during a portion of each cardiac cycle was demonstrated.     

Impending paradoxical embolism across a patent foramen ovale: case report

We describe a case of impending paradoxical embolism in a 43-year-old male patient with pulmonary embolism. Transesophageal echocardiography revealed a thromboembolus straddling a patent foramen ovale. The patient underwent emergency removal of the intracardiac clot with closure of the patent foramen ovale. A postoperative work-up for a hypercoagulable state revealed a protein-S deficiency and bilateral lower extremity deep vein thromboses. A Greenfield inferior vena cava filter was inserted, anticoagulation was performed, and warfarin treatment was continued after the patient was discharged home.     

Renal paradoxical embolism in a hypertensive young adult without acute ischemic symptoms

A 22-year-old woman, who often carried heavy books, was admitted for evaluation of hyperreninemic hypertension. Two months prior to admission, she noted leg edema. Radiological examinations revealed bilateral renal infarction with no other abnormal findings. An echocardiography showed a patent foramen ovale (PFO). Hypertension was considered secondary to renal infarction caused by paradoxical embolism through PFO. Antihypertensive and anticoagulant therapy led to improvement of hypertension. In previously reported cases of renal paradoxical embolism, multiorgan involvement was usually observed. Our case is unique in that embolism was confirmed only in the kidneys, and that clinical characteristics of renal embolism were not observed.     

A rare case of impending paradoxical embolism with a complex patent foramen ovale

A 68-year-old woman, who presented with pulmonary embolism, was diagnosed as having an impending paradoxical thromboembolism by transthoracic and transesophageal echocardiography, which revealed an entrapped thrombus in the atrial septum. The patient underwent surgery for thromboembolectomy. A patent foramen ovale (PFO) appeared as a tunnel with three openings into the left atrium; one opening located close to the antero-superior left atrial wall and two small atrial septal defects of a septum primum. A thrombus was trapped at two small atrial septal defects. This was a rare case of impending paradoxical embolism with complex morphology of PFO.     

Severe paradoxical intracranial embolism and pulmonary emboli during hip hemiarthroplasty

Both paradoxical intracranial embolism, an intracranial arterialembolism caused by venous embolic material that has passed througha right-to-left shunt, and pulmonary arterial embolism are life-threateningcomplications of joint arthroplasty. We report a case of severeparadoxical intracranial embolism and pulmonary embolism thatoccurred during hip hemiarthroplasty. Br J Anaesth 2003; 91: 911--13     

Pulmonary and paradoxical embolism in protein C and S deficient patient

We document the case of a 67-year-old woman who presented with a history of right upper quadrant anopia, dyspnea, hypoxemia, and a systolic murmur. An intracardiac embolus wedged at a patent foramen ovale was successfully removed by resecting the atrial septum along with a pulmonary embolectomy on cardiopulmonary bypass. We review the literature with specific focus on the pathogenesis and acute treatment options of this life-threatening occurrence.     

Intracardiac migration of nitinol TrapEase vena cava filter and paradoxical embolism.

The nitinol TrapEase inferior vena cava filter is a new device for pulmonary embolism prophylaxis. No cases of filter migration or filter-related complications with this type of device have so far been described. We report a case of intracardiac migration of this filter in a patient with a patent foramen ovale, resulting in severe cardiogenic shock, cerebral and right arm paradoxical embolism. Surgical treatment, results, causes of these complications are discussed.     

Amniotic fluid embolism: A report of four probable cases

Canadian Journal of Anesthesia/Journal canadien d'anesthésie - Four probable cases of amniotic fluid embolism (AFE) are reviewed. The outcome appeared to be determined by the severity of...     

The role of thrombolytic therapy in the management of paradoxical embolism

Paradoxical emboli are considered a rare event, representing less than 2% of all arterial emboli. The most common intracardiac defect associated with paradoxical emboli is a patent foramen ovale. Most commonly, a pulmonary embolism is the cause of the acute increase in right atrial pressure leading to a reversal of intracardiac flow and passage of venous embolic material to the left heart. We present a patient with a pulmonary embolism and paradoxical emboli, and discuss therapeutic approach. We suggest that the treatment of choice for the patient with pulmonary embolism and non-limb-threatening acute ischemia due to a paradoxical emboli should be thrombolytic therapy and intracaval filter placement, followed by patent foramen ovale repair.