Psoas abscess in hemodialysis patients

Background  

The insidious onset and occult characteristic of psoas abscess can cause diagnostic delays, resulting in high mortality and morbidity rates. Here, we investigated the characteristics of psoas abscess in hemodialysis patients.     

Psoas abscess in a dialysis patient with dialysis-related amyloidosis

Psoas abscess is an infrequent clinical entity which poses diagnostic and therapeutic challenges. Few cases have been reported in chronic hemodialysis patients. We describe a case of psoas abscess in a dialysis patient with dialysis-related amyloidosis, successfully treated with percutaneous drainage and parenteral antibiotics.     

Pheochromocytoma in a long-term hemodialysis patient.

A right adrenal tumor was found incidentally by renal echography in a 25-year-old man, who had been on hemodialysis for 4 years. Inquiry and clinical examination suggested pheochromocytoma, which was confirmed by plasma catecholamine measurements. Subsequent adrenalectomy was uneventful. Although hypertension, headache, and diaphoresis are common symptoms in a dialyzed patient, pheochromocytoma has to be eliminated in the presence of this clinical triad.     

Renal oncocytoma with bilateral synchronous renal cell carcinoma in a patient undergoing long-term hemodialysis

Abstract:   We report a case of bilateral synchronous renal cell carcinoma and renal oncocytoma in a 56-year-old male who had been treated with hemodialysis for 32 years. Because anemia gradually worsened, computed tomography and magnetic resonance imaging were carried out and revealed bilateral renal tumors within acquired cystic disease of the kidney. Bilateral nephrectomy was carried out, and the patient was diagnosed with multiple renal cell carcinomas and a single renal oncocytoma. To our knowledge, this is the first reported case of renal oncocytoma with synchronous renal cell carcinoma in a patient undergoing long-term hemodialysis.     

Tumoral calcinosis in a patient undergoing hemodialysis.

Recently, tumoral calcinosis was found in a patient who had been undergoing haemodialysis in this hospital. The tumor was partially removed and subsequently regressed. The tumoral calcinosis of hemodialysis patients seems to be different from classical tumoral calcinosis.     

Pharmacokinetics of ganciclovir in a patient undergoing hemodialysis.

The pharmacokinetics and effect of hemodialysis on the clearance of ganciclovir were evaluated in a patient with cytomegalovirus (CMV) retinitis and pneumonitis requiring dialytic support. A dose of 300 mg ganciclovir (5 mg/kg) was administered by intravenous infusion over a 60-minute period. Blood samples were obtained over the next 10 hours and used to assess plasma ganciclovir concentrations. The patient underwent hemodialysis the following day during which paired arterial and venous blood samples were obtained to determine dialyzer clearance of this antiviral agent. High-performance liquid chromatography was used to quantify ganciclovir plasma concentrations. Ganciclovir levels declined in a monoexponential manner following infusion and prior to dialysis. The patient's peak ganciclovir concentration was markedly elevated (20 micrograms/mL) compared with previously reported peak concentrations in patients with normal renal function. Similarly, the elimination half-life (t1/2) was increased (6.3 hours) in this patient compared with values reported in patients with normal renal function. The volume of distribution (0.21 L/kg) and total body clearance prior to hemodialysis (35.5 mL/min) were diminished in this patient. Hemodialysis reduced ganciclovir levels by approximately 62% with an extraction coefficient of 0.29 resulting in a dialyzer clearance of 48.3 mL/min. This supports supplementation of ganciclovir in patients receiving this antiviral agent when they are undergoing hemodialysis. Additionally, close monitoring of ganciclovir concentrations in patients with abnormal renal function is necessary in order to make appropriate dosage adjustments.     

Acquired renal cystic disease mimicking adult polycystic kidney disease in a patient undergoing long-term hemodialysis.

Acquired renal cystic disease (ARCD) is defined as the development of multiple cysts in the renal cortex and medulla in patients with chronic renal failure who are free from congenital polycystic kidney disease. ARCD develops generally in contracted kidneys. We report a case of grotesque enlargement of a single kidney in a patient who had been receiving hemodialysis for 18 years. Although the exact causes of ARCD are not known, 3 factors may contribute to the development of nephromegaly; the sex, the duration of hemodialysis and previous unilateral nephrectomy. As in polycystic disease, when the involved kidney reaches considerable size, ARCD may have a favorable effect on anemia caused by chronic renal failure.     

Perinephric abscess in patients with polycystic kidney disease undergoing chronic hemodialysis.

5 patients with polycystic kidney disease undergoing chronic hemodialysis who developed perinephric abscesses are described. Gallium-67 scintigraphy was helpful in making a diagnosis in 2 of these patients. All 5 patients initially presented with urinary tract infections. Perinephric abscess became evident over a variable period of time (2--28 days) following completion of antibiotic therapy for their urinary tract infection. Gallium-67 scintigraphy appears useful in detecting this complication, and nephrectomy should be considered once the diagnosis is confirmed.     

Anaerobic clavicular osteomyelitis following colonoscopy in a hemodialysis patient

Patients on dialysis are immunocompromised and are therefore susceptible to both common and unusual infectious complications. These infections are often related to their dialysis access but even routine diagnostic tests unrelated to dialysis can also lead to rare adverse events. We present an unusual case of clavicular osteomyelitis from Bacteroides fragilis in a patient on maintenance hemodialysis following colonoscopy. The risk factors for this unusual site of infection, the incidence and guidelines for prophylactic antibiotic administration are discussed here.     

Psoas abscess in children

In children, psoas abscess does not head the list in the differential diagnosis of the child who presents with a limp or lower abdominal pain. Therefore, the road to this diagnosis can be long and complicated leading to numerous studies and specialty consultations. Over a 7-year period, seven psoas abscesses have been drained surgically. All were Staphylococcal though one was mixed. In each case, the original admitting diagnosis was that of septic arthritis of the hip. In general, this diagnosis was ruled out by negative hip aspirations and bone scans. Often, the severity of symptoms led to persistent evaluation with noninvasive tests such as gallium scan, intravenous pyelogram, or barium enema. Though these tests were often suggestive, a positive ultrasound or CT scan was the key studies diagnostic enough to warrant surgical exploration and drainage. During this time period, there have been no negative explorations for psoas abscess. Upon surgical drainage, all patients improved, with subsequent recovery of hip function. The child who presents with a limp or painful hip should be considered for ultrasonography or computerized tomography once hip pathology is ruled out. We feel that the results of other tests such as gallium scan, IVP, or barium enema are not sufficiently specific to indicate surgery.     

Digoxin-induced abdominal pain in a patient undergoing maintenance hemodialysis.

A patient who had recently been started on digoxin developed acute severe right upper quadrant pain shortly after hemodialysis. He underwent an extensive work-up for abdominal pain but all findings were normal. With reduction of digoxin dosage, a substantial relief of pain was achieved. The pain totally resolved when digoxin was discontinued and recurred when it was restarted. Cardiac glycosides may be a cause of abdominal pain in patients undergoing maintenance hemodialysis and this side effect should be considered before costly work-up is performed.     

Successful treatment of renal abscess with percutaneous needle aspiration in a diabetic patient with end stage renal disease undergoing hemodialysis

Renal abscesses in patients with end stage renal disease are quite rare, and misdiagnosis or delaying in diagnosis is frequent. This report examines a case of renal abscess in a patient with end stage renal disease on maintenance hemodialysis and diabetes mellitus, which presented with a prolonged fever. An infected diabetic foot was impressed initially. Purulent urine, pyuria, bacteriuria, and bacteremia were noted after admission. Renal abscess was diagnosed by percutaneous needle aspiration under computerized tomography guidance. The patient was treated with parenteral antibiotics and percutaneous aspiration of the abscess. Follow-up ultrasonography showed renal abscess resolution. This case demonstrated that nephrectomy was not required in selected uremic patients with renal abscess.     

Emphysematous cystitis complication in a patient undergoing hemodialysis

Emphysematous cystitis is a rare condition characterized by air formation in and around the bladder wall by gas-forming organisms. Although diabetes mellitus and chronic urinary infection, which are frequently encountered in patients with endstage renal disease (ESRD), are predisposing factors for this entity, emphysematous cystitis is actually not common in ESRD patients. Here we provide the first report of a hemodialysis patient who developed typical emphysematous cystitis. Unlike other cases, the emphysematous cystitis recurred after discontinuation of urinary drainage and antibiotic therapy. The possible reason that this case is of a less common type that is more refractory than the other cases, and the method by which patients with ESRD are commonly treated, are discussed. Not anuric but rather oliguric diabetic patients, even after long-term hemodialysis, are the patients at risk for emphysematous cystitis.     

Sarcoidosis and hypercalcemia in a patient undergoing hemodialysis

We report sarcoidosis-related hypercalcemia in a patient undergoing hemodialysis, The patient, a 54-year-old woman, had been undergoing maintenance hemodialysis since 1989. The cause of end-stage renal disease was membranoproliferative glomerulonephritis. The patient was admitted to our hospital in January 2002 for the treatment of hypercalcemia(13.5 mg/dl), which was diagnosed in December 2001. Chest X-ray showed bilateral hilar lymphadenopathy, chest CT scan showed mediastinal lymph node swelling, and Ga-scintigraphy showed abnormal accumulation of gallium in the mediastinum. The patient's intact-PTH was 80-100 pg/ml. ACE(31.4 IU/l) and 1.25(OH)2D3(85 pg/ml) were elevated, and the bronchial lavage fluid CD4/CD8 ratio was slightly elevated. Epitheloid granulomatous tissue was obtained from a subclavian lymph node biopsy. Thus, the patient was diagnosed with sarcoidosis. The hypercalcemia and bilateral hilar lymphadenopathy improved with corticosteroid therapy.