Priyanka Koshy

Rare occurrence of fatal Candida haemulonii peritonitis in a diabetic CAPD patient.

Abstract A 68-year-old diabetic chronic kidney disease patient on continuous ambulatory peritoneal dialysis for two years developed Candida haemulonii peritonitis without any predisposing factors. There is no effective treatment for this fungus. A peritoneal biopsy showed morphological changes of acute inflammation and chronicity.

Diagnostic dilemma of ultrafiltration failure in a continuous ambulatory peritoneal dialysis patient.

A 42-year-old male with chronic kidney disease (CKD), stage 5 on continuous ambulatory peritoneal dialysis (CAPD) using a swan-neck double-cuff Tenckhoff catheter presented with abdominal pain, vomiting, nausea and reduced appetite for 1 month, along with a poor dialysate outflow and ultrafiltration failure (< 400mL/day) for 20 days. As stated by the patient, dialysate effluent was clear. Abdominal examination was unremarkable. After a 6-hour dwell, the dialysate showed a leucocyte count of 0.17 x 109/L (170 cells) with 0.75 (75%) neutrophils and 0.24 (24%) lymphocytes, Gram stain negative, acid-fast bacilli (AFB) smear negative and no growth on Lowenstein and Jensen culture medium. The Mantoux test done was unremarkable. Blood urea nitrogen was 12 mmol/L (33 mg/dL), serum creatinine 954 μmol/L (10.8 mg/dL), hemoglobin (Hb) 88 g/L (8.8 g/dL), erythrocyte sedimentation rate (ESR) 140 mm/hr, serum albumin 24 g/L(2.4 g/dL), electrolytes were normal. As the outflow was slow, an erect X-ray of the abdomen showed migration of the catheter (Figure 1), and a laproscopic examination showed intraperitoneal catheter with fibrinous exudates and adhesions (Figure 2), which were released. A peritoneal biopsy was done that showed granuloma with Langhans’ type giant cell suggestive of tuberculosis (Figure 3), and the biopsy specimen stained with Ziehl Neelsen stain showed acid-fast tubercle bacillus (Figure 4). A computed tomography (CT) of the chest showed left basal pulmonary scarring, small calcified right apical nodule, and calcified mediastinal nodules suggestive of pulmonary tuberculosis sequelae. The patient was initiated on rifampicin 450 mg OD, pyrazinamide 750 mg BID, ciprofloxacin 500 mg BID, isoniazid 150 mg OD, along with vitamin B6. Dialysate flow and ultrafiltration improved 7 days after starting the medication and the dialysate cell count returned to normal.

Renal allograft eosinophilia: An unusual presentation of sudden graft dysfunction

We present a case of sudden allograft dysfunction 11 months after renal transplantation which presented as severe peripheral and allograft eosinophilia and was managed as a case of an acute cellular rejection with significant interstitial graft eosinophilic infiltration. Patient had partial response to antirejection therapy and eventually ended up in a chronic allograft dysfunction.

Early recurrence of IgA nephropathy in a young adult: Transplant recipient

A 20-year-old male with hypothyroidism, chronic kidney disease Stage V due to hypertension, and Henoch–Schonlein purpura (IgA vasculitis) underwent a live-related renal transplant in 2015 with mother as a donor. He was inducted with single dose thymoglobulin 75 mg following which he was initiated on triple immunosuppressive therapy – prednisolone 25 mg once a day, tacrolimus 2.5 mg in the morning and 3 mg in the night, and mycophenolate mofetil 750 mg BID. On the 5th day of transplantation, he noticed purpuric rashes in the forearm and thigh associated with hematuria. He had good graft function. Renal allograft biopsy on sixth post operative day showed recurrence of IgA nephropathy (IgAN).

A maintenance hemodialysis diabetic patient with unexplained pulmonary and gastrointestinal involvement

A 50‐year‐old man with diabetes mellitus with diabetic retinopathy, peripheral neuropathy, hypertension, and end‐stage renal disease on maintenance hemodialysis, presented with persistent cough and hiccups, continued to be unwell with weight loss, poor appetite, and recurrent respiratory symptoms such as wheezing and cough. Whole body positron emission tomography‐computed tomography scan showed metabolically active lesions in liver, stomach/lesser sac, pancreas, and left sixth rib. As he had repeated bilateral transudative pleural effusion, left mini thoracotomy with pleural biopsy showed no evidence of granuloma or malignancy. Upper gastroscopy showed tiny gastric polyp; biopsy revealed benign lesion. Left posterior rib biopsy from the lesion and iliac crest biopsy showed no evidence of malignancy or granuloma. Further evaluation showed plasma chromogranin A −5737 μg/L (<100 μg/L) with a repeat value of 6950 μg/L (<100 μg/L). He was initiated on oral sunitinib 25 mg once a day and injection octreotide 20 mg subcutaneously once a month. The plasma chromogranin A level and his symptoms, however, showed an initial improvement, but gradually worsened after 4 months despite being on treatment. After 6 months, the patient developed a gangrenous lesion of his glans penis with necrosis. Due to severe pain on conservative measures, penectomy with perineal urethrostomy was performed. Biopsy of the lesion showed blood vessels with intimal calcifications and thrombosis suggesting penile necrosis.