Bruno Eduardo Pedroso Balbo

Hypercalcemia and Suppressed PTH Levels in a Renal Transplant Patient Infected with Pneumocystis Carinii

Pneumocystis carinii pneumonia is a serious and relatively common complication of immunosuppressive therapy. In immunocompromised patients, P. carinii pneumonia can cause significant morbidity and mortality. Another common complication, typically seen in the subpopulation of renal transplant recipients, is hypercalcemia. The prevalence of hypercalcemia varies, reaching as high as 71%. We report the case of a renal transplant recipient who developed P. carinii pneumonia and hypercalcemia, the latter being resolved after the successful treatment of the former. We argue that there is a causal relationship between P. carinii pneumonia and hypercalcemia in renal transplant recipients. In immunocompromised patients, pulmonary infection accompanied by hypercalcemia should raise the suspicion of P. carinii pneumonia.

Secondary Hypertension Caused by Massive Renal Lymphangiomatosis

Renal lymphangiomatosis is a rare disease characterized by lymphatic vessel proliferation. We present a case of an adult patient with chronic flank pain, hypertension, and a right kidney mass. The magnetic resonance imaging findings were consistent with unilateral renal lymphangiomatosis. Technetium-99m dimercaptosuccinic acid renal scintilography revealed decreased ipsilateral renal function. From these findings, the patient underwent right nephrectomy, which resulted in complete remission of his hypertension and pain.

Dialysis as a Treatment Option for a Patient With Normal Kidney Function and Familial Tumoral Calcinosis Due to a Compound Heterozygous FGF23 Mutation

Primary tumoral calcinosis is a rare autosomal recessive disorder characterized by ectopic calcified tumoral masses. Mutations in 3 genes (GALNT3, FGF23, and KL) have been linked to this human disorder. We describe a case of a 28-year-old man with a history of painful firm masses over his right and left gluteal region, right clavicle region, knees, and left elbow. Biochemical analysis disclosed hyperphosphatemia (phosphate, 9.0 mg/dL) and normocalcemia (calcium, 4.8 mg/dL), with normal kidney function and fractional excretion of phosphate of 3%. Parathyroid hormone was suppressed (15 pg/mL), associated with a low-normal 25-hydroxyvitamin D (26 ng/mL) concentration but high 1,25-dihydroxyvitamin D concentration (92 pg/mL). Serum intact FGF-23 (fibroblast growth factor 23) was undetectable. Genetic analysis revealed tumoral calcinosis due to a compound heterozygous mutation in FGF23, c.201G>C (p.Gln67His) and c.466C>T (p.Gln156*). Due to lack of other treatment options and because the patient was facing severe vascular complications, we initiated a daily hemodialysis program even in the setting of normal kidney function. This unusual therapeutic option successful controlled hyperphosphatemia and reduced metastatic tumoral lesions. This is a report of a new mutation in FGF23 in which dialysis was an effective treatment option for tumoral calcinosis with normal kidney function.

Infundibular stenosis in Bardet-Biedl syndrome.

A 22-year-old Caucasian man was referred for nephrolithiasis. Episodes of low back pain started at age 12, when bilateral calculi and cysts were detected by renal ultrasound. His phenotype was complex, including cognitive disability, visual impairment due to rod–cone dystrophy, primary hypogonadism, and post-axial foot polydactyly. In the past 10 years he had several lithotripsy sessions, serum creatinine level increased from 0.6 to 1.2 mg/dl, and hypocitraturia was detected. Previously obese, at age 18 he presented with significant weight loss and abdominal lymphadenomegaly, splenomegaly, and thrombocytopenia. A lymph node biopsy showed non-specific inflammation, requiring surveillance for a lymphoproliferative disorder. Nephrolithiasis recurrence, in turn, required an endourologic procedure that revealed bilateral, diffuse infundibular stenosis and partially removed the calyceal and pelvic calculi and corrected the stenosis (Figures 1 and 2).

Giant Renal Angiomyolipoma Following Ovarian Stimulation Therapy

Renal angiomyolipomas (AMLs) are benign tumors with higher prevalence in women. Female hormones have been shown to induce AML enlargement. This case refers to a 40-year-old woman with 4 left kidney AMLs, the larger ones with 1.0 and 1.3 cm. Ten months after ovarian stimulation for egg harvesting, a computed tomography revealed an 18-cm AML with large-caliber vessels. Given her high risk of AML bleeding, the patient was submitted to selective arterial embolization, which turned out unsuccessful, supporting a plan of nephron-sparing surgery. Our case highlights the pro-growth effects of female hormones on AML, with particular emphasis to ovarian stimulation.

Female Patient with Alport Syndrome and Concomitant Membranous Nephropathy: Susceptibility or Association of Two Diseases

Alport syndrome (AS) is a disorder of collagen IV, a component of glomerular basement membrane (GBM). The association of AS and immunocomplex nephropathies is uncommon. This is a case of a 37-year-old woman with family history of X-linked AS, including 4 affected sons. This patient developed full-blown nephrotic syndrome along a 3-month period, a presentation not consistent with AS progression. This scenario suggested an alternative diagnosis. A kidney biopsy was therefore performed, showing membranous nephropathy (MN) in addition to GBM structural alterations compatible with AS. Whole exome sequencing also confirmed the diagnosis of X-linked AS, revealing a heterozygous pathogenic mutation in COL4A5. While a negative serum anti-phospholipase A2 receptor did not rule out a primary form of MN, it was also uncertain whether positive serologic tests for syphilis could represent a secondary factor. It is currently unknown whether this unusual association represents AS susceptibility to immunocomplex-mediated diseases or simply an association of 2 disorders.

Abdominal pain, arthritis, and nephrotic syndrome in a Syrian patient

Familial Mediterranean fever (FMF) is an autosomal recessive disorder that is characterized by sporadic paroxysmal attacks of fever and serosal inflammation. Although it occurs primarily in ethnic groups originating in the Mediterranean region, FMF is not restricted to these groups and is still underdiagnosed in nephrology settings in non-Mediterranean countries (1). The disease morbidity is largely associated with recurrent attacks of pain and fever, and mortality is mainly associated with amyloidosis and kidney disease (1). The discovery of colchicine in 1972 led to an effective treatment for FMF in the prevention of acute attacks and secondary amyloidosis, significantly increasing the importance of an accurate and early diagnosis (2). The clinical criteria proposed by Livneh et al. (3) in 1997 continue to be the gold standard for diagnosis. However, limitations arise in atypical cases and in patients of non-Mediterranean origin. The gene mutated in FMF, MEFV (Mediterranean fever), was cloned in 1997, shedding light on the disease pathogenesis and improving the tools for diagnosis (4). In this scenario, genotype-phenotype correlation studies revealed specific alleles that were associated with amyloidosis and kidney disease, and mutation-based analysis, particularly directed toward hot spots, emerged as an essential approach for diagnosis in atypical cases (5).