In O Sun

Prediction of Patient Survival in Cases of Acute Paraquat Poisoning

Paraquat concentration-time data have been used to predict the clinical outcome following ingestion. However, these studies have included only small populations, although paraquat poisoning has a very high mortality rate. The purpose of this study was to develop a simple and reliable model to predict survival according to the time interval post-ingestion in patients with acute paraquat poisoning. Data were retrospectively collected for patients who were admitted with paraquat poisoning to Soonchunhyang University Choenan Hospital between January 2005 and December 2012. Plasma paraquat levels were measured using high-performance liquid chromatography. To validate the model we developed, we used external data from 788 subjects admitted to the Presbyterian Medical Center, Jeonju, Korea, between January 2007 and December 2012. Two thousand one hundred thirty six patients were included in this study. The overall survival rate was 44% (939/2136). The probability of survival for any specified time and concentration could be predicted as (exp(logit))/(1+exp(logit)), where logit = 1.3544+[−3.4688×log10(plasma paraquat μg/M)]+[−2.3169×log10(hours since ingestion)]. The external validation study showed that our model was highly accurate for the prediction of survival (C statics 0.964; 95% CI [0.952–0.975]). We have developed a model that is effective for predicting survival after paraquat intoxication.

Predicting the probability of survival in acute paraquat poisoning.

Background Paraquat (PQ) concentration–time data have been used to predict prognosis for 3 decades. The aim of this study was to find a more accurate method to predict the probability of survival. Methods This study included 788 patients with PQ poisoning who were diagnosed using plasma PQ concentration between January 2005 and August 2012. We divided these patients into 2 groups (survivors vs. nonsurvivors), compared their clinical characteristics, and analyzed the predictors of survival. Results The mean age of the included patients was 57 years (range, 14–95 years). When we compared clinical characteristics between survivors (n = 149, 19%) and nonsurvivors (n = 639, 81%), survivors were younger (47 ± 14 years vs. 59 ± 16 years) and had lower plasma PQ concentrations (1.44 ± 8.77 μg/mL vs. 80.33 ± 123.15 μg/mL) than nonsurvivors. On admission, serum creatinine was lower in survivors than in nonsurvivors (0.95 ± 0.91 mg/dL vs. 1.88 ± 1.27 mg/dL). In multivariate logistic regression analysis, age and logarithmically converted serum creatinine [ln(Cr)], [ln(time)], and [ln(PQ)] were assessed as prognostic factors to predict survival in PQ poisoning. The predicted probability of survival using significant prognostic factors was exp (logit)/[1 + exp(logit)], where logit = –1.347 + [0.212 × sex (male = 1, female = 0)] + (0.032 × age) + [1.551 × ln(Cr)] + [0.391 × ln(hours since ingestion)] + [1.076 × ln(plasma PQ μg/mL)]. With this equation, the sensitivity and specificity were 86.5% and 98.7%, respectively. Conclusion Age, ln(Cr), ln(time), and ln(PQ) were important prognostic factors in PQ poisoning, and our equation can be helpful to predict the survival in acute PQ poisoning patients.

Comparison of clinical characteristics of patients with acute kidney injury after intravenous versus inhaled colistin therapy

Background The aim of this study was to investigate the incidence and clinical characteristics of intravenous (IV) or inhaled (IH) colistin-associated acute kidney injury (AKI) using the Risk, Injury, Failure, Loss, End-stage Renal Disease criteria. Methods From 2010 to 2014, 160 patients were treated with IV or IH colistin. Of these, we included 126 patients who received colistin for > 72 hours for the treatment of pneumonia and compared the incidence and clinical characteristics of patients in the IV (n = 107) and IH (n = 19) groups. Results The patients included 104 men and 22 women, with a mean age of 69 years (range, 24–91 years). The mortality rate was 45%, and AKI occurred in 75 (60%) patients. At the end of therapy, the bacteriologic cure rate was 66%. There were no differences in the clinical characteristics between the IV and IH groups except for age. In comparison with patients in the IV group, the patients in the IH group were older (74 ± 8 vs. 68 ± 12 years, P = 0.026). The incidence of AKI was not different between the 2 groups (62 vs. 47%, P = not significant), and there was no difference in the severity of AKI according to the Risk, Injury, Failure, Loss, End-stage Renal Disease criteria. Of the 83 patients with AKI, 6 and 1 patients underwent renal replacement therapy, respectively. Conclusion The incidence of AKI in patients with colistin therapy is 60% in our center. It seems that IH colistin therapy could not be better in safety than IV colistin therapy.

Acute interstitial nephritis induced by Solanum nigrum

Acute interstitial nephritis (AIN) is an important cause of reversible acute kidney injury and pathologically characterized by inflammatory infiltrate in the renal interstitium. Solanum nigrum (S. nigrum) is a medicinal plant member of the Solanaceae family. Although S. nigrum has been traditionally used to treat various ailments such as pain, inflammation, and fever, it has also been reported to have a toxic effect, resulting in anticholinergic symptoms. However, there have been no reports of AIN caused by S. nigrum. Here, we report the first case of biopsy-confirmed AIN after ingestion of S. nigrum. The patient was successfully treated using corticosteroid therapy.

Clinical severity of drug-induced hyponatremia: thiazides vs. psychotropics.

BACKGROUND The aim of this study was to investigate the clinical characteristics of patients with hyponatremia who received thiazide diuretics, psychotropic drugs, or both. METHODS From 2007 to 2013, 266 patients were diagnosed with hyponatremia (P-Na < 135 mol/L) associated with thiazide diuretics (T), psychotropic drugs (P), or both (C). We compared clinical characteristics among the thiazide (T) group (n = 93), the psychotropic drug (P) group (n = 83), and the combination (C) group (n = 90). RESULTS There were no differences in clinical characteristics except for correction time among the three groups. We evaluated the clinical severity among the three groups through initial serum sodium levels (mild: > 125 mmol/L, moderate: 120 - 125 mmol/L, severe: < 120 mmol/L), patient symptoms (mild: general weakness, moderate: nausea or vomiting, severe: syncope or seizure). There were no significant differences in the incidence of severe hyponatremia on the basis of initial serum sodium levels (73.1% vs. 67.5% vs. 71.1%, p = 0.710) and symptoms (20.4% vs. 30.1% vs. 17.8%, p = 0.192) among groups. However, correction time was significantly longer in group C than in groups T or P (41.98 ± 26.89 vs. 34.91 ± 23.96 vs. 51.10 ± 43.86 mg/dL, p = 0.026). CONCLUSION Although patients in group C did not have clinical features that were any more severe than those of the other two groups in terms of initial serum sodium levels and symptoms, correction time was significantly longer for group C than for groups T or P. Therefore, it is of utmost importance to closely monitor patients who receive a thiazide and psychotropic drug simultaneously.

Prognostic Factors in Cholinesterase Inhibitor Poisoning

Background Organophosphates and carbamates are insecticides that are associated with high human mortality. The purpose of this study is to investigate the prognostic factors affecting survival in patients with cholinesterase inhibitor (CI) poisoning. Material/Methods This study included 92 patients with CI poisoning in the period from January 2005 to August 2013. We divided these patients into 2 groups (survivors vs. non-survivors), compared their clinical characteristics, and analyzed the predictors of survival. Results The mean age of the included patients was 56 years (range, 16–88). The patients included 57 (62%) men and 35 (38%) women. When we compared clinical characteristics between the survivor group (n=81, 88%) and non-survivor group (n=11, 12%), there were no differences in renal function, pancreatic enzymes, or serum cholinesterase level, except for serum bicarbonate level and APACHE II score. The serum bicarbonate level was lower in non-survivors than in survivors (12.45±2.84 vs. 18.36±4.73, P<0.01). The serum APACHE II score was higher in non-survivors than in survivors (24.36±5.22 vs. 12.07±6.67, P<0.01). The development of pneumonia during hospitalization was higher in non-survivors than in survivors (n=9, 82% vs. n=31, 38%, P<0.01). In multiple logistic regression analysis, serum bicarbonate concentration, APACHE II score, and pneumonia during hospitalization were the important prognostic factors in patients with CI poisoning. Conclusions Serum bicarbonate and APACHE II score are useful prognostic factors in patients with CI poisoning. Furthermore, pneumonia during hospitalization was also important in predicting prognosis in patients with CI poisoning. Therefore, prevention and active treatment of pneumonia is important in the management of patients with CI poisoning.

A case of peritoneal dialysis-associated peritonitis by Rothia mucilaginosa

Rothia muciliaginosa (R. mucilaginosa) is a facultative, Gram-positive coccus that is considered to be part of the normal flora of the mouth and respiratory tract. There are sporadic reports of the organism causing endocarditis in patients with heart valve abnormalities, as well as meningitis, septicemia, and pneumonia associated with intravenous drug abuse. However, it is an unusual pathogen in cases of peritoneal dialysis (PD)-associated peritonitis. Although R. mucilaginosa is generally susceptible to penicillin, ampicillin, cefotaxime, imipenem, rifampicin, and glycopeptides, there are no guidelines for the treatment of PD-associated peritonitis. Herein, we report a case of PD-associated peritonitis due to R. mucilaginosa that was resolved with intraperitoneal antibiotic treatment.

Hypothermia-induced acute kidney injury in an elderly patient.

Hypothermia, defined as an unintentional decline in the core body temperature to below 35℃, is a life-threatening condition. Patients with malnutrition and diabetes mellitus as well as those of advanced age are at high risk for accidental hypothermia. Due to the high mortality rates of accidental hypothermia, proper management is critical for the wellbeing of patients. Accidental hypothermia was reported to be associated with acute kidney injury (AKI) in over 40% of cases. Although the pathogenesis remains to be elucidated, vasoconstriction and ischemia in the kidney were considered to be the main mechanisms involved. Cases of AKI associated with hypothermia have been reported worldwide, but there have been few reports of hypothermia-induced AKI in Korea. Here, we present a case of hypothermia-induced AKI that was treated successfully with rewarming and supportive care.

Microscopic polyangiitis with crescentic glomerulonephritis initially presenting as acute pancreatitis

To the Editor, Microscopic polyangiitis (MPA) is characterized by the involvement of a wide range of blood vessels including arterioles, venules, and capillaries. Necrotizing glomerulonephritis and alveolar hemorrhage are commonly seen in patients with MPA, which may concomitantly or sequentially involve the nervous or musculoskeletal systems as well as other organs including the skin, heart, eyes, and intestine [1]. However, symptomatic pancreatic involvement in cases of anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis is extremely rare [2]. We herein report a case of MPA with crescentic glomerulonephritis that initially presented as acute pancreatitis. A 59-year-old Korean woman visited the Emergency Department in Presbyterian Medical Center for evaluation of epigastric pain and vomiting. She had a 20-year history of type 2 diabetes mellitus. On admission, she had a temperature of 37°C, pulse rate of 105 beats per minute, blood pressure of 140/80 mmHg, and respiratory rate of 18 breaths per minute. Her eyes were sunken, and her skin turgor was diminished. Her blood urea nitrogen and serum creatinine levels were 12.5 mmol/L (reference, 2.8 to 7.1) and 640 µmol/L (reference, 50 to 110), respectively. Her serum creatinine level 1 month earlier was 50 µmol/L. Her serum concentration of C-reactive protein was 82.9 mg/L (reference, < 3), and her serum amylase and lipase levels were 825 U/L (reference, 28 to 100) and 927 U/L (reference, 13 to 60), respectively. Alanine aminotransferase and bilirubin were normal. A routine chest X-ray showed slight haziness in the bilateral lung fields. Both kidneys exhibited mildly increased renal parenchymal echogenicity and normal size. To evaluate for possible pancreatitis, we performed abdominal computed tomography (CT), which did not show any swelling of the pancreas. Additionally, her antinuclear antibody titer was normal. Under the clinical impression of acute kidney injury due to dehydration and pneumonia, the patient underwent treatment by appropriate hydration and antibiotics, such as ceftriaxone. We considered the cause of dehydration to be acute pancreatitis. However, her renal function did not improve and her urine output decreased from 1,200 to 200 mL/day on the fourth day of admission. As a result, hemodialysis was initiated. We performed further laboratory testing including complement levels, autoantibodies, and ANCA studies. The complement C3 and C4 levels were 0.78 g/L (normal, 0.76 to 1.39) and 0.14 g/L (normal, 0.12 to 0.37), respectively. Rheumatoid factor was elevated to 53.3 kIU/L (reference, 0 to 15). ANCA was positive in a perinuclear pattern with a titer of 1:640. In the enzyme immunoassay, anti-myeloperoxidase antibody was positive, but anti-proteinase 3 antibody was negative. Anti-glomerular basement membrane antibody was also negative. Following the clinical diagnosis of MPA, the patient was started on 1 g/day of intravenous methylprednisolone (21st day of hospitalization) for 3 days, followed by 60 mg/day of oral prednisone. Intravenous cyclophosphamide (750 mg) was administered on the 27th day of admission. Following immunosuppressive therapy, the patient’s fever subsided and her serum and lipase levels returned to normal (Fig. 1). On the 30th day of admission, a percutaneous renal biopsy was performed. On light microscopy, all six glomeruli showed segmental or global sclerosis with crescents. Both cellular (2/6, 33%) and fibrous crescents (4/6, 66%) were present. Small amounts of mesangial immunoglobulin M and C3 deposits were detected by immunofluorescence microscopy (Fig. 2). Plasmapheresis was initiated on day 40, at which time the patient had been maintained on hemodialysis three to four times per week since day 4 of hospitalization. During dialysis on day 50, she complained of cough and dyspnea. A chest CT scan showed multifocal ground-glass opacities in the bilateral lungs. Laboratory examination revealed neutropenia (absolute neutrophil count of 0.1 × 109; reference, > 1.5 × 109) and elevated C-reactive protein (120 mg/L). The patient was diagnosed with pneumonia and treated with intravenous antibiotics, including teicoplanin and meropenem. Despite these interventions, the patient died of septic shock on hospital day 60. Figure 1. Following immunosuppressive therapy, the serum amylase levels and C-reactive protein (CRP) concentration returned to normal. ST, steroid; Cyc, cyclophosphamide; PP, plasmapheresis; HD, hemodialysis. Figure 2. (A) Kidney biopsy (light microscopy). The glomerulus shows global sclerosis with fibrocellular crescent formation. The interstitium shows plasma cell and lymphocyte infiltration with mild fibrosis (PAS, ×200). (B) Small amounts of mesangial immunoglobulin ... Although digestive tract involvement has been reported in 30% to 56% of patients with MPA, pancreatic involvement in MPA is extremely rare [1]. In several cases of Wegener’s granulomatosis, which is another form of ANCA-associated vasculitis, acute pancreatitis was the initial manifestation [3]. However, few cases of acute pancreatitis in patients with MPA have been reported. Iwasa and Katoh [2] and Haraguchi et al. [4] reported cases of MPA identified on autopsy as crescentic glomerulonephritis and necrotizing pancreatitis, respectively. In our case, the patient presented with acute pancreatitis on admission, which improved after immunosuppressive treatment. To our knowledge, this is the first case report of acute pancreatitis as an initial manifestation of MPA in Korea. There is no literature to date regarding the clinical significance of MPA presenting as acute pancreatitis. We hypothesize that there may be two clinical implications in treating these patients. First, we initially thought that the cause of the acute kidney injury in our patient was dehydration due to pancreatitis and treated her condition with intravenous fluid resuscitation and antibiotics. However, her renal function did not improve, and the patient was later found to have MPA. Therefore, in cases of acute kidney injury and concomitant pancreatitis, it is important to consider the possibility of ANCA-associated vasculitis. Second, we propose that MPA presenting with pancreatitis might be a more severe form of MPA. Chawla et al. [3] reported that all patients who presented initially with pancreatitis had a rapidly progressive course with fulminant progression of Wegener’s granulomatosis. Among patients with MPA, two patients with pancreatic involvement reportedly died despite clinical remission [2,4]. Therefore, more careful monitoring may be needed in patients with MPA and acute pancreatitis. Immunosuppressive treatment with corticosteroids, azathioprine, and cyclophosphamide causes cellular immune dysfunction, which facilitates infection by intracellular pathogens such as fungi, viruses, and mycobacteria. Booth et al. [5] reported that development of leukopenia and pneumonia were the two most common adverse events in patients with vasculitis on immunosuppressive therapy and were closely associated with sepsis and death. The patient described in the present case report died of sepsis secondary to pneumonia. In summary, we have reported a case of MPA with crescentic glomerulonephritis presenting initially as acute pancreatitis. In cases of acute kidney injury and concomitant acute pancreatitis, it is important to evaluate the presence of ANCA-associated vasculitis.

Idiopathic retroperitoneal fibrosis associated with Hashimoto's thyroiditis in a patient with a single functioning kidney

Retroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of fibroinflammatory tissue around the abdominal aorta and ureteral entrapment in most cases. Idiopathic RPF is frequently reported in association with autoimmune diseases; however, there have been few reports of idiopathic RPF associated with Hashimotos thyroiditis. Here, we report a case of idiopathic RPF with Hashimotos thyroiditis in a patient with a single functioning kidney, which was successfully treated by corticosteroid therapy and transient intraureteral stent insertion with a double-J catheter.