P. Sriramnaveen

Fatal poisoning by isoniazid and rifampicin

Isoniazid and rifampicin are used for management of tuberculosis. Acute poisoning due to isoniazid overdose is associated with repetitive generalized tonic-clonic seizures and severe metabolic acidosis. In toxic doses, rifampicin is known to produce hepatic, renal, hematological disorders, and convulsions. Sometimes, it may produce red man syndrome. We report a case of fatal poisoning with isoniazid and rifampicin. The case was characterized by late presentation, lactic acidosis, and renal failure.

Management of Guillain-Barré syndrome with plasmapheresis or immunoglobulin: our experience from a tertiary care institute in South India.

Abstract Guillain–Barré syndrome (GBS), an acute inflammatory demyelinating polyneuropathy is the most common generalized paralytic disorder. The objective was to study the outcome of disability grade in two groups of GBS treated with plasmapheresis alone and treated with IVIg alone. A retrospective analysis of all consecutive patients with GBS, admitted in our intensive care unit during the period of 3 years, 2009–2012 were included in the study. All patients of GBS who were to be treated with plasmapheresis or IVIg, the modality of management were always decided at their preference and consent after explaining the modalities to patient/family. The plasma exchange done was ∼200–250 mL of plasma per kilogram weight in five sessions (40–50 mL/kg per session) within 7–14 days. The replacement fluid contained 100 mL of 20% albumin diluted in 1000 mL of normal saline and 1000 mL of fresh frozen plasma. IVIg was administered as 0.4 g/kg body weight daily for 5 days. Our observations brought out the following, both the plasmapheresis and IVIg treatments were effective in reducing the disability grade amongst all time points, i.e., at presentation, immediate post-therapy and after 4 weeks. There was a marginal superiority in plasmapheresis over IVIg effect. However, whether the delay in presentation as noted in our study probably would have contributed to this effect was conjectural.

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 Kidney Injury Due to Emphysematous Pyelonephritis on a Horseshoe Kidney

Emphysematous pyelonephritis (EPN) in association with horseshoe kidney is a rare observation. The review of literature revealed only a single report of this nature.1 Keeping this in view, we describe a diabetic patient who was found to have EPN in horseshoe kidney. Horseshoe kidney is a renal fusion anomaly with male predominance and prevalence being 1 in 400 births. In this anomaly the kidneys are connected by a parenchymatous or fibrous isthmus that crosses the midline. Embryologically the abnormality originates between the fourth and sixth weeks of gestation when the inferior portion of the metanephric blastema fuses before the ascent and rotation of the kidneys. The isthmus of the fused tissue encroaches on the inferior mesenteric artery, preventing further migration of the kidneys. In imaging the features of horseshoe kidney include caudal renal position, malrotation with reversed longitudinal axis of each kidney, and anterior extra renal pelvis. Horseshoe kidney is associated with an increased rate of infection, obstruction, stone formation, and renal tumors.2

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.

Sternal tuberculosis in a patient with chronic kidney disease

Sternum is generally regarded as resistant to infections and thus is an infrequent site of osteomyelitis. Involvement of sternum by Mycobacterium tuberculosis is rare. Sternal tuberculosis in chronic kidney disease (CKD) was not reported till date. We report a 40-year-old patient with stage IV CKD, who presented with sternal and cervical lymphnodal tuberculosis.

Gall Stone Ileus with Acute Kidney Injury—A Case Report

Abstract Gall stone ileus is a rare serious complication of cholelithiasis. We report a case of cholecystoduodenal fistula presenting as gall stone ileus with acute kidney injury which was managed successfully.

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