Intestinal complications of thrombotic microangiopathy in the adult. 4 cases and review of the literature

We report four cases of adult thrombotic microangiopathy associating diarrhea with severe ischemic colitis. In one case, the intestinal complications was severe and diffuse ischemic colitis, in two cases an inaugural colonic perforation requiring colectomy and in the last case a massive mesenteric infarct. In three cases, histologic examination showed vessel occlusion with microthrombi. Despite treatment with plasma exchange and plasma infusion, death ensued in two cases. Principally described in childhood thrombotic microangiopathy, intestinal complications occur exceptionally in adult thrombotic microangiopathy and are associated with a poor prognosis. Inaugural ischemic colitis revealing an adult thrombotic microangiopathy is also uncommon and thrombotic microangiopathy could be evoked in all patients presenting acute ischemic colitis.     

Extensive emphysematous pyelonephritis in a renal allograft: case report and review of literature

Emphysematous pyelonephritis (EPN) is an acute, severe necrotizing infection of the renal parenchyma and perirenal tissue, which results in the presence of gas within the renal parenchyma, collecting system, or perinephric tissue. EPN of renal allograft is rare, with only 23 cases reported in Western literature. Here, we report a patient treated successfully with surgery. We also review the literature, focusing on old and new suggested classification systems for EPN.     

Temporal arteritis and renal disease. Case report and review of the literature

Renal abnormalities have been described in a small percentage of patients with temporal arteritis. Transient microscopic hematuria is the most common finding. In rare instances, widespread vasculitis involving renal arteries or microscopic polyarteritis nodosa can be seen. This case report describes the association of temporal arteritis with membranous glomerulonephropathy and the nephrotic syndrome in an elderly patient, an occurrence not previously reported. Whether this association is coincidental or pathogenetically linked remains to be determined.     

Recurrent peripheral arterial embolism from pulmonary cancer. Case report and review of the literature.

Peripheral arterial embolism arising from a malignant tumour is an infrequent manifestation of neoplastic disease and also a rare cause of acute arterial occlusion. A case of recurrent arterial embolism of the lower extremities due to a primary lung cancer is reported and the literature on this topic is reviewed.     

Spontaneous renal artery dissection. Case report and review of the literature]

Focal idiopathic renal arterial dissection (RAD) is a rare event. Nevertheless, a RAD should always be considered in the differential diagnosis in patients with flank pain or acute abdomen, since only an immediate diagnosis and correction can guarantee the maintenance of kidney function. Early operation is also necessary because other clinical pictures with a similarly dramatic clinical course and similar symptoms can likewise only be treated surgically. These include a renal arterial aneurysm with endo-aneurysmatic thrombus and poststenotic dilatation in fibromuscular dysplasia. We describe the case of an isolated idiopathic RAD which could only be diagnosed in the context of abdominal pain symptoms. Clinical, pathophysiological and therapeutic aspects of RAD are discussed with reference to the case report and the international specialist literature.     

Extensive emphysematous pyelonephritis in a renal allograft treated conservatively: case report and review of the literature

Emphysematous pyelonephritis (EPN) is a rare occurrence in renal allografts. An aggressive approach resulting in transplant nephrectomy is viewed as the standard of care. Over the recent years, treatment with percutaneous drainage (PCD) of the renal and perinephric collections and appropriate antibiotics has been reported with good success in lesser grades of this infection. Only 4 cases of extensive EPN disease with Escherichia coli, treated with conservative management, are reported in the English‐language literature. We present a case of severe EPN caused by Klebsiella pneumoniae, successfully managed with early PCD, and propose a step‐up strategy aimed toward graft preservation.     

Aspergillus infection limited to renal allograft: case report and review of literature

We report a case of a 28-year-old recipient of a cadaveric renal transplant who developed Aspergillus infection in the allograft without having disseminated disease. We review the previously reported cases of isolated Aspergillus in kidney transplant recipients and discuss the possible route of transmission in our patient. We also discuss the alternate but successful treatment that our patient received.     

Post-appendectomy thrombotic thrombocytopenic purpura: a case report and review of the literature

Thrombotic thrombocytopenic purpura (TTP) is a syndrome characterized by microangiopathic hemolytic anemia and thrombocytopenia with varying degrees of renal dysfunction, neurologic signs and symptoms, and fever. Evidence has supported that a large proportion of cases of acquired TTP are due to the accumulation of ultralarge von Willebrand factor (vWF) multimers due to an acquired deficiency in the vWF cleaving protease, ADAMTS-13. TTP is rare in the post-surgical setting but is best described after cardiothoracic and vascular surgeries. We present a case of postoperative TTP first presenting with microangiopathic hemolytic anemia and thrombocytopenia 9 days after emergent appendectomy for a ruptured appendix. ADAMTS-13 and factor H levels returned normal and an ADAMTS-13 inhibitor was not identified. To our knowledge, this is the first case report of postoperative TTP after an appendectomy and the first report with correlative ADAMTS-13 data. Plasma exchange with fresh frozen plasma followed by cryopoor plasma, along with steroids resulted in eventual remission of TTP in our patient. Early postoperative diagnosis and aggressive management with consideration of initiation of plasma exchange is imperative to decrease the morbidity and morality associated with TTP.     

Cardiac hamartoma. Case report and literature review

Primary cardiac tumors are infrequent and usually benign. They can manifest as dyspnea, chest pain, palpitations, sudden death, peripheral embolism, cyanosis, or general symptoms. They are sometimes an incidental finding in an asymptomatic patient. We describe a 33-year-old man who was seen because of dyspnea and palpitations. Transthoracic echocardiography revealed, on the lateral wall of the left ventricle, an intramyocardial mass that was successfully resected surgically. The pathologic diagnosis was hamartoma of mature cardiac myocytes. We discuss the usefulness of imaging techniques for identifying cardiac masses.     

Reactive plasmacytosis. Case report and review of the literature

The case history of a patient presenting with an acute myelogenous leukemia plus marked reactive plasmacytosis is summarized. Kinetic studies demonstrated a very high proliferative activity of the polyclonal plasma cell population in marked contrast to the very low proliferative activity observed in monoclonal gammopathies. These data are discussed and the published literature on reactive plasmacytosis is reviewed.     

Gonococcal osteomyelitis. Case report and review of the literature

We report the 11th case of gonococcal osteomyelitis in the postantibiotic era. This case demonstrates the classic presentation of osteomyelitis associated with gonorrhea, a subacute illness with minimal systemic symptoms. In addition, we present radiologic evidence of the pathogenesis of this unusual osteomyelitis from a contiguous joint infection.     

Pancreaticobronchial fistula. Case report and review of the literature

Fistulas between the pancreas and bronchial tree are uncommon examples of internal pancreatic fistulas. We describe a case of pancreaticobronchial fistula in which the diagnosis was made by bronchoscopy and biochemical analysis of respiratory secretions. Endoscopic retrograde cholangiopancreatography was confirmatory and guided treatment by internal drainage of the pancreatic duct. Ten other cases were found in the Western literature that emphasize the principles of diagnosis and treatment.     

Resolution of renal failure with malignant hypertension in scleroderma. Case report and review of the literature.

The ominous prognosis of rapidly progressive renal failure associated with malignant hypertension in scleroderma has led to aggressive management by dialysis, early bilateral nephrectomy and renal transplantation. We describe a woman with scleroderma who recovered after the development of malignant hypertension and renal failure. Renal biopsy and arteriography demonstrated the classic vascular lesions of scleroderma with secondary cortical ischemia. Of note, plasma renin activity was normal. Review of the literature revealed 40 patients with scleroderma and rapidly progressive renal failure who have been treated by dialysis. Thirteen patients survived, four of whom did not undergo bilateral nephrectomy. In eight patients treated by transplantation, five achieved excellent allograft function although one sustained a late rejection. Analysis of our case and of five recently reported cases of reversible renal failure and malignant hypertension reveals no distinctive features identifying patients with a favorable prognosis, except for the normal plasma renin activity level in our patient. Vigorous control of hypertension and renal failure by drugs and dialysis is recommended. Bilateral nephrectomy should be considered only for patients with refractory hypertension, since recovery of renal function may follow even after months of dialysis. For patients with irreversible renal failure without other major organ system involvement, transplantation is a reasonable alternative to dialysis.     

Amiodarone in pregnancy. Case report and review of the literature

A case of the use of amiodarone in pregnancy is reported and the literature on this subject reviewed. The data available to date show: there is no risk of teratogenic effects, the QT interval is prolonged during infancy (no associated arrhythmias noted), infant bradycardia occurs and should be monitored and thyroid function can be affected and should be monitored at birth.

If fetal electrocardiographic monitoring is performed before and during labour and after birth, and thyroid function is assessed, then, to date, there does not appear to be any significant contraindication to the use of amiodarone during pregnancy. In view of the potential side effects, however, the use of amiodarone should be restricted to arrhythmias which are life-threatening or not controlled by conventional therapy.     

Azathioprine hypersensitivity. Case report and review of the literature

Fever in a transplant recipient is an important sign of graft rejection or infection. Rarely, fever may result from an immunosuppressive agent used to prevent graft rejection. A case of fever, rigors, arthralgias, and myalgias is reported in a cardiac transplant recipient in whom azathioprine therapy was recently begun. These findings resolved on discontinuation of the azathioprine, recurred on rechallenge, and were most consistent with a hypersensitivity reaction. The clinical spectrum of reported azathioprine hypersensitivity reactions is reviewed.