Visualization of the renal vein during pyelography after nephrostomy: a case report

<p>Abstract</p> <p>Introduction</p> <p>We present a case of pyelovenous backflow after nephrostomy. To the best of our knowledge, this is the first documented case of renal vein visualization after a nephrostomic placement.</p> <p>Case presentation</p> <p>A 55-year-old Caucasian man presented with symptoms of pyelonephritis with an obstructing ureteral stone. A nephrostomy was performed. During an injection of contrast agent in his left caliceal system, his left renal vein was visualized. A repeat pyelography with an injection contrast material at low pressure failed to show the same finding. This radiological finding is due to the occurrence of "pyelovenous backflow".</p> <p>Conclusion</p> <p>This phenomenon is usually described in the setting of renal vein thrombosis, renal vein hypertension due to the "nutcracker phenomenon", or a reduced renal blood flow. Examination by microscopy shows the presence of tears in the fornix of the pelvic cavity that extend into the kidney parenchyma. Five types of renal backflow are described in the literature: pyelovenous, pyelolymphatic, pyelotubular, pyelointerstitia and pyelosinus. Injection of contrast material at high pressure may cause a fornix to flow into the tubules, or cause its rupture and flow into the venous system.</p

Pseudoleukocytosis secondary to hepatitis C-associated cryoglobulinemia: a case report

<p>Abstract</p> <p>Introduction</p> <p>Laboratory tests play a central role in assessing a patient and orienting the diagnostic evaluation. We report a case where the discrepancy between the manual and automatic cell count gave a hint to the final diagnosis.</p> <p>Case presentation</p> <p>A 55-year-old Caucasian man, known to have hepatitis C, was admitted with acute respiratory failure secondary to acute pulmonary edema and diffuse petechial rash of the lower extremities for the previous 2 months. The initial laboratory tests showed acute renal failure (creatinine of 2.6 mg/dL). During his hospital stay, the patient had a fluctuating white blood cell count with a recorded value of 96,000 cells/mL. On a peripheral smear, the blood cell count was in the normal range. The acute renal failure was secondary to membranoproliferative glomerulonephritis secondary to essential mixed cryoglobulinemia diagnosed by biopsy. The complete blood count values, performed by Beckman/Coulter GenS, were falsely high due to precipitation of plasma cryoglobulins at room temperature. This spurious leukocytosis was previously described in several case reports, but values as high as 96,000 cells/mL were never reported.</p> <p>Conclusion</p> <p>The presence of cryoglobulins in the blood creates a clinical challenge for the interpretation of several laboratory tests. Pseudoleukocytosis secondary to cryoglobulinemia has been observed in several reported cases with white blood cell counts up to 54,000 cells/mL at room temperature and 85,600 cells/mL at 4°C. If the cryoglobulin precipitates rapidly, aggregated cryoglobulin particles may be interpreted as blood cells. We report the first patient with pseudoleukocytosis secondary to hepatitis C cryoglobulinemia with a spurious leukocytosis of 96,000 cells/mL at room temperature. Other laboratory tests could also be affected: underestimation of true erythrocyte sedimentation rate, pseudothrombocytosis and pseudolymphocytosis. The precipitation can remove the hepatitis C virus and the antibody of cryoglobulins from serum leading to a false negative result. Any discrepancy between the automated and manual white blood cell count should lead to the suspicion of cryoglobulinemia in the clinical setting.</p

Hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention - 'modern' milk alkali syndrome: a case report

We report a case of a patient presenting with a triad of hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention. It is the classical presentation of the “modern” milk alkali syndrome that presents several characteristics distinguishing it from the “old” syndrome described secondary to peptic ulcer disease treatment. Milk alkali syndrome affects middle-aged female patients taking over-the-counter calcium carbonate. Clinically, these patients present in an acute hypercalcemia crisis, responding rapidly to hydration. The phosphorus level is normal to low. Bisphosphonate should be used cautiously due to the risk of symptomatic hypocalcemia

Warburg′s effect on solid tumors

Lactic acidosis is the result of imbalance between the systemic formation of lactate and its hepatic metabolism. In cancer patients, lactic acidosis is mainly associated with hematologic malignancies (leukemia and lymphomas) and the mechanism is known as Warburg′s effect. We report a 76-year-old male known to have hypertension and coronary artery disease, who presented with abdominal distension and lactic acidosis. His initial evaluation showed multiple liver masses that were biopsied and the patient was diagnosed with undifferentiated carcinoma of unknown primary, involving the liver. The patient had progression of lactic acidosis leading to his death on day-15. As the lactic acidosis was not in the setting of hypoxia or hemodynamic instability, we made the diagnosis of malignancy-associated type B lactic acidosis, also known as the Warburg′s effect. Warburg′s effect can occur in solid cancer if the tumor involves the liver. It has bad prognostic implications. The use of intravenous bicarbonate as a temporary measure is of controversial benefit, as it can potentially worsen the metabolic acidosis and its use should be limited to patients with very low pH. In cancer patients, the use of lactatebased intravenous fluids can be potentially harmful and can increase the risk of tumor metastasis, at least in animal malignancy models

Obinutuzumab as treatment for ANCA-associated vasculitis

International audienceAbstract Objectives Rituximab is a standard of care therapy for patients with ANCA-associated vasculitis. When rituximab is contraindicated, or in the case of refractory disease, other treatments are needed. Obinutuzumab is another anti-CD20 antibody for the treatment of haematological malignancies that may induce a deeper B cell depletion compared with rituximab. This article reviews three cases of patients with ANCA-associated vasculitis who were treated with obinutuzumab due to their history of anaphylactic reactions to rituximab. Methods Case series of three patients with ANCA-associated vasculitis treated with obinutuzumab. Results One female patient with microscopic polyangiitis and two male patients with granulomatosis with polyangiitis received obinutuzumab. The treatment was well-tolerated in all patients despite previous anaphylactic reaction to rituximab. Treatment with obinutuzumab was effective in (i) inducing disease remission, (ii) inducing total B cell depletion, and (iii) resulting in undetectable serum titres of ANCA. All three patients were re-treated with obinutuzumab for maintenance of remission. Conclusion Obinutuzumab appears to be a safe and efficacious therapy for patients with ANCA-associated vasculitis who have had refractory disease or a history of anaphylaxis to rituximab. Prospective studies comparing rituximab to obinutuzumab in ANCA-associated vasculitis patients are warranted

Effects of Parathyroid Hormone on Immune Function

Parathyroid hormone (PTH) function as immunologic mediator has become interesting with the recent usage of PTH analogue (teriparatide) in the management of osteoporosis. Since the early 1980s, PTH receptors were found on most immunologic cells (neutrophils, B and T cells). The in vitro evaluations for a possible role of PTH as immunomodulator have shown inconsistent results mainly due to methodological heterogeneity of these studies: it used different PTH formulations (rat, bovine, and human), at different dosages and different incubating periods. In some of these studies, the lymphocytes were collected from uremic patients or animals, which renders the interpretation of the results problematic due to the effect of uremic toxins. Parathyroidectomy has been found to reverse the immunologic defect in patients with high PTH levels. Nonetheless, the clinical significance of these findings is unclear. Further studies are needed to define if PTH does have immunomodulatory effects

It Could Be Worse But It Should Be Better: COVID-19 and The Lebanese Radiology Departments Preparedness.

An unprecedented sanitary challenge is threatening human beings due to COVID-19 pandemic. There is no light at the end of the tunnel concerning treatment and worries from a possible second wave start to arise even before the end of the first one. We conducted a multicenter study to reassess the different aspects of radiology departments’ preparedness in Lebanon stating the points of strength and more importantly depicting the points of weakness. Lessons were then extracted to be more prepared for possible future similar circumstances