Manjusha Yadla

Post-partum bilateral renal cortical necrosis in antiphospholipid syndrome and systemic lupus erythematosus

In the presence of systemic lupus erythematosus or related autoimmune disorders, antiphospholipid syndrome (APS) is termed secondary APS. Pregnancy-related renal failure due to SAPS is rarely reported in the literature. We present the case of a young primgravida woman with bilateral renal cortical necrosis due to secondary APS in late pregnancy.

Assessment of early response to treatment in extrapulmonary tuberculosis: Role of FDG-PET

1. Sekhri V, Sanal S, Delorenzo LJ, Aronow WS, Maguire GP. Cardiac sarcoidosis: A comprehensive review. Arch Med Sci 2011;7:546-54. 2. Mostard RL, Prompers L, Weijers RE, van Kroonenburgh MJ, Wijnen PA, Geusens PP, et al. F-18 FDG PET/CT for detecting bone and bone marrow involvement in sarcoidosis patients. Clin Nucl Med 2012;37:21-5. 3. Kim SK, Im HJ, Kim W, Kim TS, Hwangbo B, Kim HJ. F-18 fluorodeoxyglucose and F-18 fluorothymidine positron emission tomography/computed tomography imaging in a case of neurosarcoidosis. Clin Nucl Med 2010;35:67-70.

Malposition of hemodialysis catheter in left superior intercostal vein.

Malposition of hemodialysis catheter needs to be identified promptly. Straight descent of left side internal jugular catheter mandates a thorough evaluation than unnecessary apprehensions. We report an unusual case of straight descent of hemodialysis catheter into superior intercostal vein.

Epitrochlear mass in a patient on maintenance hemodialysis—Kimura disease

Kimura disease is a rare benign inflammatory disorder presenting as subcutaneous masses or lymphnodal mass in the cervical region. Kimura disease is reported sparsely in patients on maintenance hemodialysis. We report an unusual location of Kimura disease in a patient on maintenance hemodialysis, who had a prolonged, persistent asymptomatic eosinophilia.

Acute bilateral non-obstructive bacterial pyelonephritis with acute kidney injury in the elderly: role of non-invasive studies in its diagnosis

Nine elderly patients who presented with features suggestive of acute pyelonephritis were studied with the help of laboratory and imaging investigations. All patients had acute kidney injury of variable severity at presentation. Renal imaging helped us in revealing bilateral involvement and the findings are discussed. The infection was treated with appropriate antibiotics. Because of severe renal failure, five patients were supported with hemodialysis, of them, three became dialysis independent. The remaining two patients were dialysis dependent at discharge. However, none of them came to us for follow-up.

Malignant hypertension with protracted but not definitive oligoanuric acute kidney failure.

Malignant hypertension (MHTN) is diagnosed when a patient presents with accelerated hypertension and multiorgan compromise including severe retinopathy. The renal manifestations may be oliguric renal failure or rapidly progressive renal failure. Oliguria in MHTN occurs as a consequence of malignant nephrosclerosis, microangiopathic haemolytic anemia, polyarteritis nodosa, lupus, acute cortical necrosis and scleroderma. However, acute kidney insufficiency (AKI) may be seen in the absence of systemic disease or of nephropathy. The clinical presentation of anuria with MHTN is rare, and in such situations renal recovery is unlikely. There are few case studies reporting reversible renal failure in MHTN [1–16]. A literature search supports the view that the entity of reversible anuric renal failure in MHTN is recognized by early clinical presentation (with anuria/oliguria), the presence of normal sized kidneys, normal main renal arteries and kidney biopsy without significant vascular changes. Herein, we report two such cases with anuria due to MHTN who recovered after remaining on haemodialysis for an average 2 months.

Multifocal skeletal tuberculosis

A 54-year-old diabetic, hypertensive smoker (60 pack years) with chronic kidney disease Stage V and on dialysis, presented with hoarseness and weight loss. His hemoglobin was 9 g/dL, erythrocyte sedimentation rate (ESR) 60 mm at the first hour, blood urea 7 mmol/L and serum creatinine 70 µmol/L. Computed tomography (CT) of the chest showed a mass in the hilum of the left lung and enlarged mediastinal and cervical lymph nodes. Meanwhile, he developed a high-grade fever, low back pain and painful fixed flexion of both hip joints. The X-rays of both hip joints and the lumbosacral spine were normal. In clinical assessment, bronchogenic carcinoma with skeletal secondaries was suspected. The results of the 18-F Fluoro deoxy glucose (FDG) Positron Emission Tomography (PET)-CT scan showed increased tracer uptake in the mediastinal and cervical lymph nodes, left lung hilum, dorsal vertebrae, bilateral iliacus muscles, bilateral hip joints and acetabulum of the right femur (Figure 1). Fine-needle aspiration of the left iliacus muscle revealed pus with plenty of polymorphs. Tuberculosis (TB) polymerase chain reaction evaluation of the pus was positive. He was initiated on antituberculosis treatment. Mycobacterium TB (MTB) was grown after 6 weeks. The diagnosis was multifocal skeletal TB (MFSTB). Fig. 1. 18-F FDG PET-CT maximum intensity projection (MIP) image, showing the increased FDG localization in multiple musculoskeletal lesions and lymph nodes. MFSTB is an entity where osteoarticular lesions occur simultaneously at two or more locations [1]. MFSTB constitutes less than 5% of skeletal TB. MFSTB is more common in those who are immunocompromised, or on hemodialysis [1]. The radiological evaluation reveals multiple destructive lesions in the bone, which may be confused with secondary or primary osseous lesions. Hence, the diagnosis of MFSTB is ultimately confirmed on histopathology or on microbiological studies. In our patient, lymph nodes and multiple skeletal sites were involved. Microbiological evaluation confirmed MTB. In conclusion, in the presence of multiple skeletal lesions in patients on dialysis, MFSTB should be considered in the differential diagnosis. MFSTB is a great mimicker of malignancy and hence requires early confirmation.

Metastatic calcinosis cutis in patients of end-stage renal disease.

1 Weismann RE, Tobin RW. Arterial embolism occurring during systemic heparin therapy. AMA Arch Surg. 1958; 76:219–225. 2 Syed S, Reilly RF. Heparin-induced thrombocytopenia: A renal perspective. Nat Rev Nephrol. 2009; 5:501–511. 3 Tholl U, Greinacher A, Overdick K, Anlauf M. Lifethreatening anaphylactic reaction following parathyroidectomy in a dialysis patient with heparin-induced thrombocytopenia. Nephrol Dial Transplant. 1997; 12:2750–2755.

Serendipitous discovery of mediastinal tuberculous lymphadenitis in a patient on maintenance hemodialysis.

To the Editor: A 55-year-old man, a patient with polycystic kidney disease on maintenance hemodialysis, on pretransplant evaluation presented with recurrent mixed urinary tract infections with gram-positive and gram-negative organisms despite repeated courses of antibiotics. Urine for acid fast bacillus smear, culture, and tuberculosis-polymerase chain reaction (TB-PCR) were negative. Abdominal ultrasound and contrast-enhanced computed tomography (CT) did not give a clue regarding localization of infection. Hence, the patient was subjected to 18F-fludeoxyglucose (F)-positron emission tomography (PET)/CT scan, which revealed increased metabolic activity in the upper and lower poles of the right kidney as well as in the upper pole of the left kidney (Figures 1 and 2). The aspirate from the cyst was negative for bacteria in both smear and culture. The aspirate was further studied for the possibility of tuberculosis by Ziehl–Nielsen staining, culture, and TB-PCR, the results of which were all negative, However, the PET/CT scan evaluation revealed increased metabolic activity in the mediastinal lymph nodes (Figures 3 and 4). On further evaluation, contrastenhanced CT showed peripherally enhancing lymph nodes with central necrosis in pretracheal, right hilar, and subcarinal lymph nodes. Fine needle aspiration of the mediastinal lymph nodes showed epithelioid cell clusters. The aspirate did not show acid fast bacilli smear. TB-PCR could not be performed. Mantoux test was strongly positive with a 20-mm induration. The presence of central low attenuation with peripheral rim enhancement in the mediastinal lymph nodes suggests that it is tuberculous in etiology, and the central low attenuation corresponds to caseation necrosis on histopathology. Mediastinal lymphadenopathy may occur as a complication of pulmonary tuberculosis or as a primary disease