Vv Sainaresh

Carotid‐jugular arteriovenous fistula: A case report of an iatrogenic complication following internal jugular vein catheterization for hemodialysis access

We report a case of diabetic end‐stage renal disease patient who presented with a right common carotid artery jugular arteriovenous fistula as a complication of the insertion of a polyurethane double‐lumen hemodialysis catheter into the right internal jugular vein .On physical examination of the neck, a pulsating mass with a palpable thrill and a bruit was noted in the right subclavicular region. The diagnosis was confirmed by color doppler ultrasonography of the neck and carotid angiography. The review of the literature suggests the occurrence of this complication as rather rare. The fistula was successfully repaired surgically. It is emphasized that while securing the access, a thorough physical examination with a special emphasis on seeking any neck swellings, thrill, and bruit along with routine use of vascular doppler for securing dialysis access is recommended.

Malplacement of hemodialysis permcatheter into anterior mediastinum following innominate vein perforation.

A 54-year-old woman was refereed to us for the management of diabetic chronic kidney disease needing renal replacement therapy. She underwent hemodialysis elsewhere earlier through right internal jugular vein (IJV) catheter that was removed recently in view of poor blood flows. ADoppler evaluation of the neck vessels was suggestive of partial thrombosis of right IJV. She was undertaken for the placement of cuffed Quinton Maxid permcatheter into the left IJV. Doppler guidance was used to puncture left IJV, and the permcatheter was positioned in place using modified Seldinger technique. The procedure was well tolerated, and 5–10 ml dark-colored venous blood was aspirated and injected from both ports with mild resistance. A postprocedure posteroanterior chest X-ray was suggestive of straight decent of the catheter in the left paramedian location (Fig. 1). As this was suggestive of deviation from the normal course, in order to delineate the anatomy, a contrast computerized tomography (CT) was performed. The same was suggestive of the presence of permcatheter tip outside the vascular lumenas a result of puncture of innominate vein with subsequentmigration into theanteriormediastinum (Fig. 2). The permcatheter was removed uneventfully with expert help from Department of Cardiothoracic and vascular surgery. Tunneled cuffed catheters are increasingly used when permanent vascular access is difficult to secure. However, cannulation of the central veins with large caliber catheters may be associated with increased complications (1), especially when one is attempting the same on the left side. One such complication is perforation of the large vessels during cannulation (2), which although rare has been associated with catastrophic events. The current NKF-KDOQI guidelines

Acute Kidney Injury in Patients with Pyogenic Liver Abscess

Abstract Incidence of acute kidney injury (AKI) in patients with pyogenic liver abscess is rare. In our study we found AKI in 32.6% of patients with liver abscess. Majority of the patients were in their fifties and sixties. As per acute kidney injury network trial criteria, renal failure was in stage 1 in 26.6%, stage 2 in 40%, and stage 3 in 33.3% of the patients. Dialysis support was needed in 26%. All patients except one recovered from AKI.

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.

Bilateral renal cortical necrosis in acute pancreatitis.

A 22-year-old male with no premorbid illness presented to emergency with vomiting, peri umbilical abdominal pain with pain radiating to the back following an alcoholc binge. He developed oliguria followed by anuria over two days. On examination, he was hemodynamically stable (BP – 120/80 mm of Hg) and had tenderness in the epigastrium and right hypochondriac areas. Investigations revealed neutrophilic leucocytosis (14200 per μl), severe renal failure (Serum creatinine: 13.4 mg/dl) and elevated pancreatic enzymes (serum amylase: 397 U/L, lipase 210 U/L, normal values being 20-96 U/L and 3-43 U/L respectively), elevated LDH (1802 U/L, normal being 115-221 U/L). Contrast enhanced Computed tomography of the abdomen [Figure 1] revealed diffuse and bilateral cortical hypodense areas surrounded by capsular enhancement in both kidneys, which is characteristic of renal cortical necrosis. He received general supportive management, antibiotics and dialysis support. Patient left the hospital against advice on the third hospital day. Figure 1 Contrast enhanced CT of the abdomen showing diffuse hypodense areas in the cortex surrounded by capsular enhancement in both the kidneys

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.

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