Hypercalcemia And Multiple Osteolytic Lesions In A Child With Disseminated Paracoccidioidomycosis And Pulmonary Tuberculosis

Objective: To describe the case of a child with paracoccidioido-mycosis who presented hypercalcemia with multiple osteolytic lesions. Description: A 6-year-old boy was admitted with a one-month history of fever and hepatosplenomegaly. On admission, he looked sick, pale, and had disseminated lymphadenopathy and hepatosplenomegaly. The laboratory findings included anemia (hemoglobin = 6.8 g/dl), eosinophilia (1,222/mm 3), thrombocytopenia (102,000/mm 3), and hypoalbumlnemia (serum albumin = 2.2 g/dl). Paracoccidioides brasiliensis was identified in bone marrow examination. In the second week after admission, the patient presented joint pain, poor activity and difficulty in walking. He presented hypercalcemia (maximum value = 14.9 mg%) and reduction in renal function, which lasted for two weeks. On the 42nd day after admission, his chest X-ray showed lytic lesions in clavicle, scapula, ribs, and humerus, with bilateral slipped capital humeral epiphysis. The patient presented nephrocalcinosis and nephrolithiasis, reduction in creatinine clearance and evidence of tubular lesions. At the end of the second month after admission, Mycobacterium tuberculosis was isolated in gastric lavage. The child received treatment for paracoccidioidomycosis and tuberculosis and has not had any sequelae for 3 years. Comments: The development of symptomatic hypercalcemia leading to renal lesion, associated with multiple osteolytic lesions, had never been described in paracoccidioidomycosis. Although pulmonary tuberculosis was diagnosed and could be related to hypercalcemia, the sudden onset of hypercalcemia and its normalization without specific treatment for tuberculosis suggests that bone lysis was the most important factor in the genesis of hypercalcemia. Copyright © 2005 by Sociedade Brasileira de Pediatria.814349352Brummer, E., Castaneda, E., Restrepo, A., Paracoccidioidomycosis: An update (1993) Clin Microbiol Rev, 6, pp. 89-117Bittencourt, A.L., Andrade, J.A., Filho, S.P., Paracoccidioidomycosis in a four-year-old boy (1986) Mycopathologia, 93, pp. 55-59Castro, R.M., Del Negro, G., Particularidades clínicas da paracoccidioidomicose na criança (1976) Rev Hosp Clin Fac Med, 31, pp. 194-198Hildebrando, T.M., Filho, N.A., Filho, F.Q., Costa, O., Miasaki, N., Mira, J.G., Paracoccidioidomicose na criança. Aspectos clínicos e laboratoriais em 25 casos (1987) J Pediatr, 63, pp. 92-97Londero, A.T., Melo, I.S., Paracoccidiodomycosis in childhood - A critical review (1983) Mycopathologia, 82, pp. 49-55Suva, A.F., (1976) Contribuição aos Estudos da Paracoccidioidomicose no Paraná e das Lesões Ósseas e Articulares Paracoccidióidicas [Tese de Livre Docência], , Curitiba (PR): Universidade Federal do ParanáPereira, R.M., Bucaretchi, F., Barison, E.M., Tresoldi, A.T., Paracoccidioidomycosis in children: Clinical presentation, follow-up and outcome (2004) Rev Inst Med Trop, 46, pp. 127-131. , S. PauloAdams, J.S., Gacad, M.A., Characterization of 1 α hydroxylation of vitamin D3 sterols by cultured alveolar macrophages from patients with sarcoidosis (1985) J Exp Med, 161, pp. 755-765Abbasi, A.A., Chemplavil, J.K., Muller, B.F., Arnstein, A.R., Hypercalcemia in active pulmonary tuberculosis (1979) Ann Intern Med, 90, pp. 324-328Bilezikian, J.P., Etiologies and therapy of hypercalcemia (1989) Endocrinol Metab Clin North Am, 18, pp. 389-414Murray, J.J., Heim, C.R., Hypercalcemia in disseminated histoplasmosis (1985) Am J Med, 78, pp. 881-884Silva, L.C., Ferrari, T.C., Hypercalcaemia and paracoccidioidomycosis (1998) Trans R Soc Trop Med Hyg, 92, p. 187Daher, R.R., Wasconcelos, W.M., Cardoso, V.M., Fígado e blastomicose sul-americana (1973) J Bras Med, 25, pp. 83-90Nahomi, N., Icterícia obstrutiva na doença de Lutz (1962) A Propósito de Dois Casos, 62, pp. 1243-1254. , Hospital (Rio de Janeiro)Pinto, W.P., (1980) Contribuição ao Estudo do Comprometimento Hepático na Paracoccidioidomicose [Dissertação], , São Paulo (SP): Universidade de São PauloDel Negro, G., Outras lesões. 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The effect of bacterial lipopolysaccharide on gastric emptying in rats suffering from moderate renal insufficiency

The objective of the present study was to evaluate the response of rats suffering from moderate renal insufficiency to bacterial lipopolysaccharide (LPS, or endotoxin). The study involved 48 eight-week-old male SPF Wistar rats (175-220 g) divided into two groups of 24 animals each. One group underwent 5/6 nephrectomy while the other was sham-operated. Two weeks after surgery, the animals were further divided into two subgroups of 12 animals each and were fasted for 20 h but with access to water ad libitum. One nephrectomized and one sham-treated subgroup received E. coli LPS (25 µg/kg, iv) while the other received a sterile, pyrogen-free saline solution. Gastric retention (GR) was determined 10 min after the orogastric infusion of a standard saline test meal labeled with phenol red (6 mg/dl). The gastric emptying of the saline test meal was studied after 2 h. Renal function was evaluated by measuring the plasma levels of urea and creatinine. The levels of urea and creatinine in 5/6 nephrectomized animals were two-fold higher than those observed in the sham-operated rats. Although renal insufficiency did not change gastric emptying (median %GR = 26.6 for the nephrectomized subgroup and 29.3 for the sham subgroup), LPS significantly retarded the gastric emptying of the sham and nephretomized groups (median %GR = 42.0 and 61.0, respectively), and was significantly greater (P<0.01) in the nephrectomized rats. We conclude that gastric emptying in animals suffering from moderate renal insufficiency is more sensitive to the action of LPS than in sham animal

The effect of bacterial lipopolysaccharide on gastric emptying in rats suffering from moderate renal insufficiency

The objective of the present study was to evaluate the response of rats suffering from moderate renal insufficiency to bacterial lipopolysaccharide (LPS, or endotoxin). The study involved 48 eight-week-old male SPF Wistar rats (175-220 g) divided into two groups of 24 animals each. One group underwent 5/6 nephrectomy while the other was sham-operated. Two weeks after surgery, the animals were further divided into two subgroups of 12 animals each and were fasted for 20 h but with access to water ad libitum. One nephrectomized and one sham-treated subgroup received E. coli LPS (25 µg/kg, iv) while the other received a sterile, pyrogen-free saline solution. Gastric retention (GR) was determined 10 min after the orogastric infusion of a standard saline test meal labeled with phenol red (6 mg/dl). The gastric emptying of the saline test meal was studied after 2 h. Renal function was evaluated by measuring the plasma levels of urea and creatinine. The levels of urea and creatinine in 5/6 nephrectomized animals were two-fold higher than those observed in the sham-operated rats. Although renal insufficiency did not change gastric emptying (median %GR = 26.6 for the nephrectomized subgroup and 29.3 for the sham subgroup), LPS significantly retarded the gastric emptying of the sham and nephretomized groups (median %GR = 42.0 and 61.0, respectively), and was significantly greater (P<0.01) in the nephrectomized rats. We conclude that gastric emptying in animals suffering from moderate renal insufficiency is more sensitive to the action of LPS than in sham animal

Plasmapheresis As A Therapy For Relapsed Focal Segmental Glomerulosclerosis (fsgs) After Kidney Transplantation: Case Report And A Review Of The Literature [plasmaférese Como Tratamento De Glomeruloesclerose Segmentar Focal (gesf) Recorrente Após Transplante Renal. Relato De Caso E Revisão Da Literatura]

Focal segmental glomerulosclerosis (FSGS) is a renal disease characterized by a nephrotic syndrome frequently evolving to endstage renal failure. At this stage, renal transplantation, using either cadaver or live donors, is the only therapeutic option. However, after renal transplantation relapse is high, at a rate of 50% on average. The cause seems to be related to a peripheral humoral factor responsible for increasing glomerular permeability. The clearance of this factor by apheresis is today considered a good therapeutic option. We describe the case of a 12-year-old male patient, with relapsed FSGS after renal transplantation, who was treated by plasmapheresis. After five procedures a sustained improvement in the renal function was obtained. Reports published on plasmapheresis for the treatment of FSGS before and after renal transplantation are still limited to short-term results involving a small number of patients. Some predictive factors for good responses were identified by several investigators including the early start of treatment after relapse and lower ages. The number of plasmapheretic procedures to reach remission varies widely, and should be determined on a case to case basis. Another possibility presented by some investigators is prophylactic plasmapheresis, but this still lacks evidence on efficacy. This case report is an example of FSGS with a good response to plasmapheretic procedures, showing a potential benefit of this treatment. However, further controlled studies involving a higher number of patients are necessary.292193197Wehrmann, M., Bohle, A., Held, H., Schumm, G., Kendziorra, H., Pressler, H., Long-term prognosis of focal sclerosing glomerulonephritis. An analysis of 250 cases with particular regard to tubulointerstitial changes (1990) Clin Nephrol, 33 (3), pp. 115-122Datta, A.R., Sakhuja, V., Minz, M., Joshi, K., Chugh, K.S., Recurrent focal segmental glomerulosclerosis after renal transplantation (1991) Int J Artif Organs, 14 (2), pp. 99-101Artero, M., Biava, C., Amend, W., Tomlanovich, S., Vincenti, F., Recurrent focal glomerulosclerosis: Natural history and response to therapy (1992) Am J Med, 92 (4), pp. 375-383Garcia, V., Abbud-Filho, M., Keitel, E., Neumann, J., Goldani, J.C., Recurrent focal glomerulosclerosis in renal allografts (1995) Transplant Proc, 27 (1), pp. 1084-1085Kim, E.M., Striegel, J., Kim, Y., Matas, A.J., Najarian, J.S., Mauer, S.M., Recurrence of steroid-resistant nephrotic syndrome in kidney transplants is associated with increased acute renal failure and acute rejection (1994) Kidney Int, 45 (5), pp. 1440-1445Stephanian, E., Matas, A.J., Mauer, S.M., Chavers, B., Nevins, T., Kashtan, C., Recurrence of disease in patients retransplanted for focal segmental glomerulosclerosis (1992) Transplantation, 53 (4), pp. 755-757Savin, V.J., Sharma, R., Sharma, M., McCarthy, E.T., Swan, S.K., Ellis, E., Circulating factor associated with increased glomerular permeability to albumin in recurrent focal segmental glomerulosclerosis (1996) N Engl J Med, 334 (14), pp. 878-883Sharma, M., Sharma, R., McCarthy, E.T., Savin, V.J., The FSGS factor: Enrichment and in vivo effect of activity from focal segmental glomerulosclerosis plasma (1999) J Am Soc Nephrol, 10 (3), pp. 552-561Matalon, A., Valeri, A., Appel, G.B., Treatment of focal segmental glomerulosclerosis (2000) Semin Nephrol, 20 (3), pp. 309-317Greenstein, S.M., Delrio, M., Ong, E., Feuerstein, D., Schechner, R., Kim, D., Plasmapheresis treatment for recurrent focal sclerosis in pediatric renal allografts (2000) Pediatr Nephrol, 14 (12), pp. 1061-1065Ohta, T., Kawaguchi, H., Hattori, M., Komatsu, Y., Akioka, Y., Nagata, M., Effect of pre-and postoperative plasmapheresis on posttransplant recurrence of focal segmental glomerulosclerosis in children (2001) Transplantation, 71 (5), pp. 628-633Belson, A., Yorgin, P.D., Al-Uzri, A.Y., Salvatierra, O., Higgins, J., Alexander, S.R., Long-term plasmapheresis and protein A column treatment of recurrent FSGS (2001) Pediatr Nephrol, 16 (12), pp. 985-989Matalon, A., Markowitz, G.S., Joseph, R.E., Cohen, D.J., Saal, S.D., Kaplan, B., Plasmapheresis treatment of recurrent FSGS in adult renal transplant recipients (2001) Clin Nephrol, 56 (4), pp. 271-278Dall'Amico, R., Ghiggeri, G., Carraro, M., Artero, M., Ghio, L., Zamorani, E., Prediction and treatment of recurrent focal segmental glomerulosclerosis after renal transplantation in children (1999) Am J Kidney Dis, 34 (6), pp. 1048-1055Cheong, H.I., Han, H.W., Park, H.W., Ha, I.S., Han, K.S., Lee, H.S., Early recurrent nephrotic syndrome after renal transplantation in children with focal segmental glomerulosclerosis (2000) Nephrol Dial Transplant, 15 (1), pp. 78-81Pradhan, M., Petro, J., Palmer, J., Meyers, K., Baluarte, H.J., Early use of plasmapheresis for recurrent post-transplant FSGS (2003) Pediatr Nephrol, 18 (9), pp. 934-938Dantal, J., Baatard, R., Hourmant, M., Cantarovich, D., Buzelin, F., Soulillou, J.P., Recurrent nephrotic syndrome following renal transplantation in patients with focal glomerulosclerosis. A one-center study of plasma exchange effects (1991) Transplantation, 52 (5), pp. 827-831Ponticelli, C., Campise, M., Tarantino, A., The different patterns of response to plasmapheresis of recurrent focal and segmental glomerulosclerosis (2002) Transplant Proc, 34 (8), pp. 3069-307