Sanjay Vikrant

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.

Acute renal failure following multiple honeybee stings.

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Deep vein thrombosis complicating severe hypernatremia, rhabdomyolysis, and acute renal failure in a patient with untreated seizure disorder

We report a 22-year-old male patient with untreated seizure disorder, presenting with increased frequency of seizures followed by encephalopathy. Laboratory evaluation showed severe hypernatremia (175 meq/l sodium), rhabdomyolysis, and acute renal failure (ARF). Excessive insensible water loss in hot and humid weather, associated with an inability to obtain adequate water replacement, led to a hyperosmolar state (plasma osmolality, 398 mOsm/kg). He was vigorously treated with hypotonic fluid supplement and, further, needed dialysis therapy (peritoneal dialysis followed by hemodialysis) for acute renal insufficiency. The patient survived without any neurological sequelae, but the clinical course was complicated by acute deep vein thrombosis. This case represents what we believe is a unique report in the literature of severe hypernatremia developing via the pathogenic mechanism outlined above and the complication of acute peripheral venous thrombosis, which has not been reported in adults. The purpose of this report is to emphasize hyperosmolarity as a newly described cause of rhabdomyolysis, ARF, and a hypercoagulable state.

Monitor lizard bite-induced acute kidney injury – a case report

Abstract Envenomations by venomous lizards are rare. Monitor lizard bite-induced acute kidney injury (AKI) is a previously unreported complication in humans. A 55-year-old female was bitten on her right leg during farming activity by a monitor lizard (Varanus bengalensis). The patient experienced severe local pain and bleeding from the wound, coagulopathy, hemolysis, rhabdomyolysis, sepsis, and AKI. Patient was treated with supportive care and peritoneal dialysis but succumbed to a sudden cardiac arrest. Post mortem kidney biopsy revealed pigment induced-acute tubular injury. AKI after monitor lizard envenomation is caused by acute tubular injury in the setting of intravascular hemolysis, rhabdomyolysis and sepsis. Coagulopathy and direct nephrotoxicity may be the other contributory factors in causing AKI.

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.

Microbiological aspects of peritonitis in patients on continuous ambulatory peritoneal dialysis.

The objective of the study was to identify the microbiological spectrum and drug-sensitivity pattern of peritonitis in patients on continuous ambulatory peritoneal dialysis. This was a prospective study done over a period of a year-and-a-half at a tertiary-care hospital in a hilly state of India. The effluent dialysate bags from 36 consecutive patients with peritonitis were studied. One hunderd ml dialysate fluid was processed under aseptic conditions by lysis centrifugation method. Microscopy and culture was done from the deposits for bacteriological, fungal, and mycobacterial isolates. They were identified by colony morphology and their biochemical reactions. Drug susceptibility testing was done by Kirby-Bauer disc diffusion method. In 36 dialysates, 33 (91.6%) dialysates were culture-positive and in 3 (8.4%), the culture was negative. A total of 36 microorganisms were isolated in 33 cultures. Among the 36 microorganisms, 19 (52.8%) isolates were gram-positive, 10 (27.8%) were gram-negative, 5 (13.9%) were fungi, and 2 (5.6%) were mycobacterial isolates. All gram-positive organisms were sensitive to ampicillin, amoxi-clavulanic acid, cefazolin, clindamycin, and vancomycin. Neither a methicillin-resistant Staphylococci aureus nor a vancomycin-resistant Enterococcus was isolated in gram-positive isolates. Gram-negative organisms were sensitive to ciprofloxacin, ceftriaxone, ceftazidime, cefepime, gentamicin, piperacillin–tazobactam and imipenem. One of the gram-negative isolate was an extended spectrum beta-lactamase producer. Gram-positive peritonitis was more frequent than gram-negative peritonitis in our continuous ambulatory peritoneal dialysis patients. Mycobacterial causes were responsible for peritonitis in patients with culture-negative peritonitis which was not responding to the conventional antimicrobial therapy.

Severe hyperbilirubinemia and acute renal failure associated with hepatitis E in a patient whose glucose-6-phosphate dehydrogenase levels were normal.

To the Editor Hepatitis E virus (HEV) is the commonest cause of acute viral hepatitis in the world, usually manifesting as a mild, self-limiting illness [1]. Development of acute renal failure (ARF) is a very rare complication in patients with acute hepatitis E (AHE) [2–4]. The most reported cases occurred in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is the most common enzyme disorder worldwide. AHE in the presence of G6PD deficiency may be associated with complications such as severe anemia, hemolysis, ARF, hepatic encephalopathy, and even death. We report a unique case of ARF associated with AHE in a patient with normal G6PD levels. A 56-year-old male patient was admitted to the hospital with 2-week history of yellowish discoloration of eyes along with anorexia, nausea, and easy fatigability. The patient was known to be hypertensive and occasionally consumed alcohol. There was no history of liver or renal disease. Patient was deeply jaundiced. Patient had tender hepatomegaly but no splenomegaly or free fluid on abdominal examination. There were no features of chronic liver disease or acute liver failure. Results of investigations are shown in Fig. 1. Viral markers for hepatitis A (IgM anti-HAV), B (HBsAg), and C (IgG anti-HCV) and human immunodeficiency virus (HIV) were negative, but IgM anti-HEV was strongly positive. Abdominal ultrasound was normal. Patient was diagnosed with AHE associated with ARF. Patient was provided supportive care for hepatitis and given hemodialysis for ARF. The patient remained nonoliguric throughout the course of the illness. Kidney biopsy was not performed due to prolonged coagulation. Patient showed steady improvement but succumbed to sudden cardiorespiratory arrest. Severe intravascular hemolysis precipitated by AHE results in ARF in patients with G6PD deficiency [2, 3]. This was unlikely in our patient because there was no evidence of hemolysis and G6PD levels were normal. ARF in liver disease is most often caused by hepatorenal syndrome or acute tubular necrosis (ATN) [5]. Hyperbilirubinemia can decrease effective blood volume by a reduction in total peripheral vascular resistance and sensitize renal vasculature to circulating vasoconstricting stimuli and cause vasoconstriction. The combined effect may lead to redistribution of cardiac output away from the kidney. Further, hepatic dysfunction may increase nephrotoxic substances, e.g., bile salts, which may have a toxic effect on the renal tubules by a nonspecific detergent effect [5]. Hyperbilirubinemia and retained biliary nephrotoxic substances along with a possible direct toxicity of the virus [4] can lead to ARF in AHE even in absence of G6PD deficiency. ARF may contribute to the mortality rate in HEV infection. S. Vikrant (&) Departments of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh 171001, India e-mail: sanjayvikrant@rediffmail.com

Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single center from north India.

♦ Objective: There is a paucity of published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of continuous ambulatory PD (CAPD) in India in 1991. The purpose of this study is to report long-term clinical outcomes of PD patients at a single center. ♦ Design: Retrospective study. ♦ Setting: A government-owned tertiary-care hospital in North India. ♦ Patients: Patients who were initiated on CAPD between October 2002 and June 2011, and who survived and/or had more than 6 months’ follow-up on this treatment with last follow-up till December 31, 2011, were studied. ♦ Results: A total of 60 patients were included in the analysis. The mean age of the patients was 60.2 ± 9.2 years. The majority (65%) of the patients lived in rural areas. A high proportion (47%) were diabetic and 62% had ≥ 2 comorbidities. Total duration on peritoneal dialysis treatment was 1,773 patient-months (148 patient-years) with a mean duration of 29.6 ± 23 patient-months and median duration of 25 patient-months (range 6 - 110 patient-months). Overall patient and technique survival at 1, 2, 3, 4 and 5 years was 77%, 53%, 25%, 15%, and 10% respectively. Patient survival of diabetics vs non-diabetics at 1, 2, 3, 4, and 5 years was 68% vs 84%, 54% vs 53%, 14% vs 34%, 11% vs 19%, and 11% vs 13%, respectively. The mortality in non-diabetics (16/32) was less than that in diabetic (18/28) patients (p = not significant). The main cause of mortality in these patients was cardiac followed by sepsis. There were 58 episodes of peritonitis. The rate of peritonitis was 1 episode per 30.6 patient-months or 0.39 episodes per patient-year. Furthermore, the total number of episodes of peritonitis and number of episodes of peritonitis per patient were higher in the non-survival group (p < 0.05). The incidence of tuberculosis (TB), herpes zoster (HZ) and hernias was 15%, 10% and 5% respectively. ♦ Conclusion: The study reports long-term outcomes of the PD patients, the majority of whom were elderly with a high burden of comorbidities. There was a high proportion of diabetics. The survival of diabetic vs non-diabetic and elderly vs non-elderly PD patients was similar in our study. The mortality in non-diabetics was less than that in diabetic patients. TB and HZ were common causes of morbidity. Peritonitis was associated with mortality in these patients.

Nephrotic syndrome in a patient with situs inversus totalis

Situs inversus totalis is a rare congenital anomaly that often occurs concomitantly with other disorders. A spectrum of renal abnormalities of patients with situs inversus has been reported. Developmental anomalies, including agenesis, dysplasia, hypoplasia, ectopia, polycystic kidney, and horseshoe kidney, have been reported. The association of situs inversus with nephrotic syndrome is very rare. We report the first known case of situs inversus totalis with nephrotic syndrome caused by primary focal segmental glomerulosclerosis, and the possible mechanism of this association.