Dalip Gupta

Wasp envenomation-induced acute renal failure: A report of three cases (Case Report)

SUMMARY:  Acute renal failure is an unusual complication of wasp stings. We report three cases who developed acute renal failure after multiple wasp stings (Vespa magnifica). Two patients had evidence of intravascular haemolysis and rhabdomyolysis whereas one patient investigation showed no evidence of intravascular haemolysis or rhabdomyolysis. All three cases had impaired liver functions. Oligo‐anuria was seen in all three of the patients and all of them required dialytic support. One patient died of massive gastrointestinal bleeding while the remaining two recovered completely. Although acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of haemolysis or rhabdomyolysis, in some patients, renal failure may result from a direct nephrotoxic effect or acute interstitial nephritis from a hypersensitivity reaction to the wasp venom.

Scrub typhus associated acute kidney injury—a study from a tertiary care hospital from western Himalayan state of India

Abstract Objective: To report the clinical profile of acute kidney injury (AKI) associated with scrub typhus. Methods: Retrospective study of hospitalized patients of acute febrile illness who were diagnosed scrub typhus and had AKI. Results: 174 (35%) patients (75.9% female), mean age (41.4 ± 15.9 years) were studied. The laboratory abnormalities were: anemia (63.2%), leukocytosis (44.3%), thrombocytopenia (61.5%), hyponatremia (35.6%), hypernatremia (2.9%), and hypokalemia (12.1%), hyperkalemia (11.5%), hypoalbuminemia (56.9%), hepatic dysfunction (70%) and metabolic acidosis (28.7%). The complications of hypotension (5.7%), septic shock (3.4%), pneumonia (10.9%), acute respiratory distress syndrome (ARDS) (11.5%), meningoencephalitis (6.9%), encephalopathy (5.2%), gastrointestinal bleed (1.3%), myocarditis (3.4%), disseminated intravascular coagulation (2.9%) and multi organ failure (MOF) (10.3%) developed during course of hospitalization in these patients. Twenty-five (14.4%) patients required intensive care support (ICU) support and seven (4%) patients were dialyzed. 146 (83.9%) patients survived. Twenty-eight (16.1%) patients died. There was a significant difference in the age, various hematological & biochemical abnormalities, complications and need for ICU support in the non-survival group as compared the survival group. Conclusion: This study shows that AKI in scrub typhus is common and a severe disease. Age, a shorter hospital stay, severities of leukocytosis, thrombocytopenia, azotemia, hypoalbuminemia, hepatic dysfunction and the complications of ARDS, encephalopathy, MOF and need for ICU support are the factors associated with mortality.

Hypothyroidism presenting as reversible renal impairment: an interesting case report

Abstract We describe an interesting case of reversible renal impairment secondary to hypothyroidism. A 57-years-old man was referred from peripheral institution for evaluation of elevated serum creatinine. He had vague complaints of weakness, lethargy and muscle ache but no urinary symptoms. He was found to have hypothyroidism, and thyroid hormone replacement therapy (THRT) was started which resulted in reversal of the renal dysfunction. There was marked improvement in estimated glomerular filtration rate. 99mTc DTPA renal scans done before and after THRT suggested hypothyroidism responsible for this reversible renal impairment. Several studies have described the pathophysiology of diminished renal function in hypothyroidism. Few studies or case reports have shown total amelioration of renal impairment as seen in our patient. The etiology is presumed to be multifactorial, in which hemodynamic effects and a direct effect of thyroid hormone on the kidney play an important role. We suggest that patients with renal impairment of unknown cause have thyroid function tests undertaken as part of routine investigation.

Sodium Stibogluconate-associated Acute Interstitial Nephritis in a Patient Treated for Visceral Leishmaniasis

The spectrum of side-effects of sodium stibogluconate is well described. Patients treated with sodium stibogluconate can develop varied manifestations of renal toxicity, ranging from renal cell casts, proteinuria, renal tubular acidosis and acute tubular necrosis, resulting in acute kidney injury (AKI). We describe a 32-year-old male patient who was treated for visceral leishmaniasis with sodium stibogluconate. The patient was readmitted two weeks after completion of the treatment for evaluation of AKI. Kidney biopsy revealed marked acute interstitial nephritis. The renal dysfunction reversed totally after a course of corticosteroids. Antimonials should be recognized as a new class of agents as a possible cause of drug-induced acute interstitial nephritis.

Epidemiology and outcome of acute kidney injury from a tertiary care hospital in India.

We aimed to study the epidemiology and outcome of acute kidney injury (AKI). This is a prospective study of adults aged 18 years or above diagnosed with AKI over a period of 16 months at a tertiary care hospital. Three hundred and nine patients had AKI. The observed incidence of AKI was eight per 1000 admissions. About 92.2% had community-acquired AKI (CA-AKI), and in 7.8% it was hospital-acquired AKI (HA-AKI). Etiological factors for AKI were medical in 87.4% of the cases, surgical in 9.4%, and obstetric 3.2%. Sepsis was the most common (53.1%) etiology of AKI among the medical cases. Among sepsis, scrub typhus, urosepsis, and pneumonia were the most common causes of AKI. Hypovolemia (9.4%), biological toxins (8.4%), nephrotoxic drugs and chemicals (7.4%), cardiac causes (7.4%), and acute glomerulonephritis (1.9%) were other medical causes of AKI. Nearly 38.2% had multiorgan failure, 20.1% required vasopressors, 6.1 % required Intensive Care Unit support, and 23.3% required dialysis. Mortality was 8.7%. Anemia, use of vasopressor drugs, and need for intensive care support were independent predictive factors for mortality. AKI is common in hospitalized adults in India and leads to significant in-hospital mortality. AKI is largely a CA-AKI and the lesser percentage is due to HA-AKI. Many causes are potentially preventable. Early fluid resuscitation, effective anti-infective treatment, appropriate antidotes, and timely referral of established AKI patients to centers with dialysis facilities can improve AKI outcomes.

Etiology of ascites in adults living in the Hills of Himachal Pradesh, India: A hospital-based study

Aim: Ascites is one of the major complications of liver cirrhosis. In addition, ascites can develop because of peritoneal tuberculosis, malignancy, cardiac, and renal disorders. The purpose of this study was to evaluate epidemiological data on the etiological profile of ascites in adults in a tertiary care hospital in the Northern hilly state of the Western Himalayas. Materials and Methods: A 1-year hospital-based cross section observational study was conducted in the Department of Medicine and Gastroenterology in a tertiary care center of Himachal Pradesh, located in the Northern India. In all 168 patients who were diagnosed as ascites on the basis of history, physical examination, ultrasonography, and of age >18 years were included in the study. Detail history examination and investigation were carried in each case as per protocol. Results: Cirrhosis of liver was the leading cause of ascites in our study (60.7%), tuberculosis was the second most common cause of ascites (13%), malignancy and cardiac disorders were the third (7.7%) most common causes for ascites. Alcohol was the leading cause of cirrhosis in 75 patients (73.5%). Conclusion: The study identified cirrhosis of liver as the leading cause of ascites and alcoholism as the most common cause of cirrhosis. The measures on taking care of preventable risk factors are desired.

Epidemiology and outcome of acute kidney injury due to venomous animals from a subtropical region of India

Abstract Aim: To study the epidemiology and outcome of acute kidney injury (AKI) caused by venomous animals. Methods: A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla, with AKI due to venomous animals over a period of 15 years (January 2003–December 2017). Medical records were evaluated for patient information on demographic factors, clinical characteristics, complications, and outcome. Outcomes of requirement for intensive care unit (ICU) support, treatment with dialysis, survival, and mortality were analyzed. The survival and non-survival groups were compared to see the difference in the demographic factors, laboratory results, clinical characteristics, and complications. Results: One hundred and eighty-one patients were diagnosed with AKI caused by venomous creatures. Mean age was 44 ± 15.4 years, and the majority (54.1%) was women. Snakebite (77.9%) and wasp stings (19.9%) were the leading causes of AKI. Clinical details were available in 148 patients. The median duration of arrival at hospital was two days. 81.8% had oliguria, and 54.7% had a history of hematuria or having passed red or brown colored urine. The hematological and biochemical laboratory abnormalities were as follows: anemia (75%), leukocytosis (75.7%), hyperkalemia (35.8%), severe metabolic acidosis (46.6%), hepatic dysfunction (54.7%), hemolysis (85.8%), and rhabdomyolysis (65.5%). Main complications were as follows: gastrointestinal bleed (9.5%), seizure/encephalopathy (10.8%), and pneumonia/acute respiratory distress syndrome (ARDS) (11.5%). 82.3% of the patients required dialysis. 154 (85.1%) patient survived, and 27 (14.9%) patients died. As compared to the survival group, the white blood cell count, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, creatine kinase, and lactate dehydrogenase were significantly higher, and serum albumin levels were significantly lower in patients who died. The proportion of patients with leukocytosis, hyperkalemia, metabolic acidosis, pneumonia/ARDS, seizure/encephalopathy, need for ICU support, and dialysis was significantly higher in patients who died. Conclusions: Snakebite and multiple Hymenoptera stings (bees and wasps) were the leading causes of AKI due to venomous animals. AKI was severe, a high proportion required dialysis, and the mortality was high.

Safety and efficacy of therapeutic membrane plasmapheresis in the treatment of Guillain-Barré syndrome: A study from a tertiary care hospital from India.

Background: Reports on therapeutic plasma exchange (TPE) with the standard hemodialysis equipment are scarce, particularly from developing countries. Materials and Methods: A retrospective analysis of safety and efficacy of membrane-based TPE with a standard hemodialysis equipment for the treatment of severe Guillain–Barré syndrome (GBS) was conducted. Results: A total of 120 TPE sessions were performed in 31 GBS patients over a period of 5½ years. Each patient underwent a mean of 3.8 ± 1.5 TPE sessions. One (3.2%) patient died. Thirty (96.8%) patients survived and recovered. At 2 weeks, there was a significant improvement in the grade of power in both the upper and lower extremities (P = 0.001) and a significant decrease in the GBS disability grade (P = 0.001). Twenty four (77.4%) patients were able to walk unaided. Complications observed were: hypotension in 12 (10%), accelerated hypertension in 3 (2.5%), chills and rigors in 5 (4.2%), bleeding in 5 (4.2%), and filter clotting in 6 (5%) sessions. One patient experienced an anaphylactoid reaction and 1 patient survived a cardiorespiratory arrest. Two patients developed aspiration pneumonia and 1 patient developed catheter site infection. Conclusions: Membrane-based TPE can be conveniently delivered with the standard hemodialysis equipment. It is a safe, effective, and comparatively less expensive treatment option for GBS.

Intestinal amebiasis presenting as life threatening lower GI bleed-A rare presentation

Amoebiasis is a common intestinal protozoan infection due to Entamoeba histolytica. In India, the prevalence of the disease varies from 2% to 67%.[1] Acute Fulminant Colitis is a rare complication of intestinal amebiasis. Life threatening lower Gastrointestinal bleed is very rare presentation of amebiasis. Here, we are presenting a case of severe lower GI bleed proved to be caused by amebiasis along with extra intestinal complications.