RESUMO
The compound "ADE" is an injectable oil for veterinary use which contains large amounts of vitamins A, D and E. The parenteral application in humans leads to a granuloma reaction which triggers hypercalcemia. A 42-year-old man was admitted with lower limb pain, nephrolithiasis and nephrocalcinosis. Laboratory tests revealed creatinine 4.59 mg/dl, calcium 13.3 mg/dl and parathormone 13.8 pg/ml. He underwent an ureterolithotripsy, stent placement, intravenous crystalloid fluids, and corticosteroid. He improved symptoms, kidney function and normalized serum calcium. The "ADE"-induced hypercalcemia diagnosis can be challenging. The early diagnosis may avoid negative outcomes.
O composto "ADE'' é um óleo veterinário injetável que contém grandes quantidades de vitaminas A, D e E. A aplicação parenteral causa reação granulomatosa e hipercalcemia. Um homem de 42 anos foi admitido com dor no membro inferior, nódulos musculares endurecidos, nefrolitíase e nefrocalcinose. O laboratório revelou creatinina 4,59 mg/dl, cálcio 13,3 mg/dl e paratormônio 13,8 pg/ml. Foi tratado com ureterolitotripsia, cateter duplo-J, cristaloide intravenoso e corticoterapia. Ele apresentou melhora dos sintomas, função renal e normalizou cálcio. O diagnóstico da hipercalcemia pelo "ADE'' pode ser desafiador. O diagnóstico precoce pode evitar desfechos negativos.
Assuntos
Humanos , Masculino , Adulto , Injúria Renal Aguda , Hipercalcemia , Nefrolitíase , NefrocalcinoseRESUMO
Background: hypercalcemia mediated by a silicone-induced granulomatous reaction is a condition that, despite being rare, must be remembered since there is an increasing demand for aesthetic procedures among the general population. It is necessary to rule out other causes of hypercalcemia, such as hyperparathyroidism, hypercalcemia of malignancy, infectious and non-infectious granulomatous diseases, as well as the use of drugs. Case presentation: We present a patient with a history of large amounts of silicone implants who was admitted to a hospital presenting hypercalcemia and chronic kidney disease. A skin biopsy revealed a granulomatous foreign body reaction associated with exogenous siliconomatous material. Treatment with corticosteroids was initiated, with partial renal function improvement, with no renal replacement therapy needed. Conclusion: Patients with silicone implants should be carefully monitored for renal function and may be informed to avoid nephrotoxic agents as there is sufficient evidence that this type of aesthetic procedure can trigger hypercalcemia and CKD.
Introdução: a hipercalcemia mediada por uma reação granulomatosa induzida por silicone é uma condição que, apesar de rara, deve ser lembrada, pois há uma demanda crescente por procedimentos estéticos na população em geral. É necessário descartar outras causas de hipercalcemia, como hiperparatireoidismo, hipercalcemia da malignidade, doenças granulomatosas infecciosas e não infecciosas, bem como o uso de medicamentos. Relato de caso: apresentamos um paciente com histórico implante de grandes quantidades de silicone, que foi admitido em um hospital apresentando hipercalcemia e doença renal crônica (DRC). A biópsia de pele revelou reação granulomatosa tipo corpo estranho associada a material siliconomatoso exógeno. Foi iniciado tratamento com corticosteroides, com melhora parcial da função renal, sem necessidade de terapia renal substitutiva. Conclusão: os pacientes com implantes de silicone devem ser cuidadosamente monitorados quanto à função renal e devem ser informados para evitar agentes nefrotóxicos, pois há evidências suficientes de que esse tipo de procedimento estético pode desencadear hipercalcemia e DRC.
Assuntos
Granuloma , Hipercalcemia , Próteses e Implantes , SiliconesRESUMO
Introduction: Chronic Kidney Disease (CKD) is a relevant comorbidity from clinical and public health perspectives. Infections are an important cause of death in those patients. Although rare, fungal infections are increasing in incidence. Case report: a 45-year-old female patient with CKD due to systemic lupus erythematosus (SLE) was admitted to a tertiary hospital due to a bloodstream infection (BSI) caused by Cryptococcus laurentii. She received treatment with anidulafungin with good initial response but presented clinical and laboratory worsening after a few days, and the treatment was switched to amphotericin B. The hemodialysis access was changed. Chest tomography, echocardiogram, eye fundus examination, and cerebrospinal fluid study did not show changes. After 32 days of amphotericin B, the patient presented clinical improvement and was discharged to take oral fluconazole for three (3) months. Conclusion: BSI due to Cryptococcus laurentii is rare in patients on chronic hemodialysis with a high potential for complications. Physicians should have clinical suspicion for those infrequent infections infractions, and culture evaluation should always be performed. The diagnosis is still a challenge, as well as the therapeutic regimen.
Introdução: a doença renal crônica (DRC) é uma comorbidade relevante do ponto de vista clínico e de saúde pública. As infecções configuram importante causa de morte nesses pacientes. Embora raras, as infecções por fungos têm incidência crescente. Relato de caso: uma paciente do sexo feminino, 45 anos, com DRC por lúpus eritematoso sistêmico (LES) foi internada em hospital terciário devido à infecção de corrente sanguínea (ICS) por Cryptococcus laurentii. Recebeu tratamento com anidulafungina com boa resposta inicial, porém, devido à piora clínica e laboratorial, o tratamento foi modificado para anfotericina B, assim como foi realizada a troca do acesso para hemodiálise. A tomografia de tórax, o ecocardiograma, o exame de fundo de olho e o estudo do líquido cefalorraquidiano não evidenciaram alterações. Após 32 dias de anfotericina B, a paciente apresentou melhora clínica e recebeu alta hospitalar com fluconazol via oral por 3 meses. Conclusão: a ICS por Cryptococcus Laurentii é rara nos pacientes em hemodiálise crônica, porém com alto potencial de complicações. Há a necessidade de suspeição clínica e avaliação por culturas, sendo o diagnóstico ainda um desafio, bem como o esquema terapêutico.
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Fungemia , Insuficiência Renal Crônica , Cryptococcus , Lúpus Eritematoso SistêmicoRESUMO
A giant bladder stone is rare and is usually defined as "giant" if its weight is over 100g. We describe a 43-year-old man who presented with urinary sepsis, hypotension, abdominal pain, and a vesicocutaneous urinary fistula. Laboratory tests showed hemoglobin 6.6 g/dL, leukocytes 22,700/mm³, creatinine 7.29mg/dL (eGFR 8.8mL/min/1.73m2), urea 181 mg/dL, serum pH 6.99 and bicarbonate 6 meq/L. Abdominal tomography showed bilaterally reduced cortical thickness of the kidneys and a bladder stone of 6x6x11 cm. He was treated with antibiotic therapy, dialysis, and open cystolithotomy. Clinical improvement was observed, despite kidney disease persistence, with chronic dialysis therapy.
Cálculos gigantes na bexiga são raros e são definidos como "gigantes" quando o peso é superior a 100g. Apresentamos um homem de 43 anos com sepse urinária. O exame físico revelou hipotensão, dor abdominal e fístula urinária vesicocutânea. O laboratório mostrou hemoglobina 6,6 g/dL, leucócitos 22.700/mm³, creatinina 7,29 mg/dL (TFGe 8,8mL/min/1,73m2), ureia 181 mg/dL, pH sérico 6,99 e bicarbonato 6 meq/L. A tomografia abdominal mostrou redução da espessura cortical dos rins bilateralmente e cálculo vesical de 6x6x11 cm. Foi tratado com antibioticoterapia, diálise e cistolitotomia aberta. Melhora clínica foi observada, apesar de persistência da doença renal, com terapia dialítica crônica.
Assuntos
Humanos , Masculino , AdultoRESUMO
Immune thrombocytopenia (ITP) is an acquired cause of thrombocytopenia characterized by the presence of autoantibodies against platelets. It may be primary or secondary to several conditions. We present the case of a 63-year-old woman with a diagnosis of immune thrombocytopenia refractory to conventional therapy. After she was tested for secondary causes of ITP, a diagnosis of acute cytomegalovirus (CMV) infection was made. She was treated with ganciclovir and presented normalization of platelet count. CMV-related Immune Thrombocytopenia should always be considered in certain cases of refractory ITP. If the diagnosis of ITP secondary to acute CMV infection is made, specific antiviral therapy with ganciclovir should be considered. In these cases, immunosuppressive agents, such as steroids, may worsen the ITP and should be tapered or withdrawn as rapidly as feasible.
A Púrpura Trombocitopênica Imune (PTI) é uma causa de trombocitopenia adquirida caracterizada pela presença de autoanticorpos contra plaquetas. A doença pode ser primária ou secundária a diversas condições. Apresentamos o caso de uma mulher de 63 anos com diagnóstico de PTI refratária à terapêutica convencional. A investigação de causas secundárias evidenciou infecção aguda por citomegalovírus (CMV). A paciente foi tratada com ganciclovir e evoluiu com normalização no nível de plaquetas. A PTI relacionada ao CMV deve sempre ser investigada em pacientes com PTI refratária, sendo a terapia antiviral específica com ganciclovir o tratamento de escolha. Nestes casos, os agentes imunossupressores, como os corticosteroides, podem piorar a PTI e devem ser reduzidos gradualmente ou retirados o mais rapidamente possível.
Assuntos
Humanos , Feminino , Pessoa de Meia-IdadeRESUMO
ABSTRACT A wide spectrum of renal complications can occur with acute and chronic use of cocaine. Most cases are related to rhabdomyolysis, but other mechanisms are malignant hypertension, renal ischemia, and rapidly progressive glomerulonephritis (RPGN) associated-ANCA vasculitis. In recent years, the use of cocaine adulterated with levamisole has been associated with ANCA vasculitis and pauci-immune RPGN. RPGN is clinically manifested as a nephritic syndrome with a rapid and progressive decline in renal function, and its histopathological finding is the presence of crescents in more than 50% of the glomeruli. We report a case of a 38-year-old man chronic user of cocaine, alcohol, and cigarettes who had red urine, oliguria, swollen legs and eyelids, as well as the uremic symptoms anorexia, emesis, and mental confusion. He was admitted with acute kidney injury and performed six hemodialysis sessions during the first 16 days of hospitalization and then was transferred to a tertiary hospital for diagnostic investigation. Tests of ANF (antinuclear factor), ANCA, anti-DNA, serology for hepatitis B, C, and HIV virus were negative. A renal percutaneous biopsy revealed crescentic glomerulonephritis with mild tubular atrophy. The patient underwent pulse therapy with methylprednisolone (for 3 days) and cyclophosphamide. Then he maintained daily prednisone and monthly intravenous cyclophosphamide and evolved with progressive improvement of renal function.
RESUMO Um amplo espectro de complicações renais pode ocorrer com o uso agudo e crônico de cocaína. A maioria dos casos está relacionada à rabdomiólise, mas outros mecanismos são hipertensão maligna, isquemia renal e glomerulonefrite rapidamente progressiva (GNRP) associada à vasculite por ANCA. Nos últimos anos, o uso de cocaína adulterada com levamisol tem sido associado à vasculite por ANCA e GNRP pauci-imune. A GNRP se manifesta clinicamente como uma síndrome nefrítica, com um declínio rápido e progressivo da função renal, e seu achado histopatológico é a presença de crescentes em mais de 50% dos glomérulos. Relatamos um caso de um homem de 38 anos, usuário crônico de cocaína, álcool e cigarros que apresentava urina vermelha, oligúria, pernas e pálpebras inchadas, além dos sintomas urêmicos, anorexia, êmese e confusão mental. Foi internado com lesão renal aguda e realizou seis sessões de hemodiálise durante os primeiros 16 dias de internação, e depois foi transferido para um hospital terciário para investigação diagnóstica. Os testes de ANF (fator antinuclear), ANCA, anti-DNA, sorologia para vírus da hepatite B, C e HIV foram negativos. Uma biópsia percutânea renal revelou glomerulonefrite crescente, com leve atrofia tubular. O paciente foi submetido à pulsoterapia com metilprednisolona (por 3 dias) e ciclofosfamida. Em seguida, ele manteve a prednisona diária e a ciclofosfamida intravenosa mensal e evoluiu com melhora progressiva da função renal.
Assuntos
Humanos , Masculino , Adulto , Cocaína , Injúria Renal Aguda/induzido quimicamente , Glomerulonefrite , Nefrite , Anticorpos Anticitoplasma de Neutrófilos , RimRESUMO
A wide spectrum of renal complications can occur with acute and chronic use of cocaine. Most cases are related to rhabdomyolysis, but other mechanisms are malignant hypertension, renal ischemia, and rapidly progressive glomerulonephritis (RPGN) associated-ANCA vasculitis. In recent years, the use of cocaine adulterated with levamisole has been associated with ANCA vasculitis and pauci-immune RPGN. RPGN is clinically manifested as a nephritic syndrome with a rapid and progressive decline in renal function, and its histopathological finding is the presence of crescents in more than 50% of the glomeruli. We report a case of a 38-year-old man chronic user of cocaine, alcohol, and cigarettes who had red urine, oliguria, swollen legs and eyelids, as well as the uremic symptoms anorexia, emesis, and mental confusion. He was admitted with acute kidney injury and performed six hemodialysis sessions during the first 16 days of hospitalization and then was transferred to a tertiary hospital for diagnostic investigation. Tests of ANF (antinuclear factor), ANCA, anti-DNA, serology for hepatitis B, C, and HIV virus were negative. A renal percutaneous biopsy revealed crescentic glomerulonephritis with mild tubular atrophy. The patient underwent pulse therapy with methylprednisolone (for 3 days) and cyclophosphamide. Then he maintained daily prednisone and monthly intravenous cyclophosphamide and evolved with progressive improvement of renal function.
Assuntos
Injúria Renal Aguda , Cocaína , Glomerulonefrite , Nefrite , Injúria Renal Aguda/induzido quimicamente , Adulto , Anticorpos Anticitoplasma de Neutrófilos , Humanos , Rim , MasculinoRESUMO
INTRODUCTION: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. METHODS: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. RESULTS: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. CONCLUSIONS: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.