Uraemia, psychosis, young patient: an uncommon link (original) (raw)

Case 13-2020: A 29-Year-Old Man with High Blood Pressure, Renal Insufficiency, and Hematuria

New England Journal of Medicine

A 29-year-old white man was evaluated at the nephrology clinic of this hospital because of hypertension, renal insufficiency, and hematuria. Eight months before the current evaluation, at a physical examination performed for employment, the patient was told he had high blood pressure; no further evaluation was performed. One month before the current evaluation, he was seen by his primary care physician at another institution for a routine physical examination. A review of systems was reportedly negative. The temperature was 36.3°C, the heart rate 67 beats per minute, the blood pressure 175/100 mm Hg, and the oxygen saturation 99% while he was breathing ambient air. Examination of the skin revealed a rash consistent with rosacea and a small cyst on the back; the remainder of the examination was normal. The blood level of hemoglobin was 10.7 g per deciliter (normal range, 14.0 to 18.0), hematocrit 31.5% (normal range, 40.0 to 54.0), urea nitrogen 37 mg per deciliter (13.2 mmol per liter; normal range, 9 to 20 mg per deciliter [3.2 to 7.1 mmol per liter]), creatinine 3.1 mg per deciliter (274 μmol per liter; normal range, 0.7 to 1.3 mg per deciliter [62 to 115 μmol per liter]), potassium 4.5 mmol per liter (normal range, 3.5 to 5.1), albumin 3.7 g per deciliter (normal range, 3.3 to 5.0), and glucose 86 mg per deciliter (4.8 mmol per liter; normal range, 70 to 99 mg per deciliter [3.9 to 5.5 mmol per liter]). A screening test for human immunodeficiency virus types 1 and 2 was negative. Amlodipine therapy was started. Six days later, dark urine developed. After 4 days, the patient was evaluated by his primary care physician. He reported no dysuria, urinary frequency, obstructive urinary symptoms, antecedent trauma, or vigorous exercise. Examination was notable for a blood pressure of 148/100 mm Hg. The blood level of urea nitrogen was 46 mg per deciliter (16.4 mmol per liter), creatinine 3.5 mg per deciliter (309 μmol per liter), and potassium 5.7 mmol per liter. Other laboratory test results were essentially unchanged from 10 days earlier. A urinalysis was notable for From the Departments of Medicine (A.

Fever and Prostatic Mass in a Young Man

Journal of Urology, 1978

Dr. Jacob Rajfer. A 35-year-old black man was admitted to the hospital because of fever and rectal pain. The patient was a confirmed drug addict who, at the age of 26, was admitted to another hospital for a left herniorrhaphy. During that hospitalization the diagnosis of left epididymitis was made and an excretory urogram (IVP) was performed. The patient was then told that he had 2 normal kidneys. Approximately 6 months before the current hospitalization the patient sustained a stab wound to the left upper quadrant of the abdomen and underwent an exploratory celiotomy that resulted in a splenectomy because of a splenic laceration. No urological studies were done. About 4 months later the patient was treated at another hospital with intramuscular penicillin for acute prostatitis and left epididymitis. Symptoms subsided but recurred 4 days before the current hospitalization. When he was seen here he complained of fever, chills, dysuria and rectal discomfort that was exacerbated by defecation. He denied any history of gonorrhea and stated that he had not self-administered drugs intravenously for the last 2 years. The remainder of the history was unremarkable. When the patient was admitted to the hospital his temperature was 103F, pulse rate was 80, blood pressure was 110/60 and respirations were 24. He appeared to be in mild distress and diaphoretic, and he complained of perinea! pain and occasional chills. The head, lungs and heart were normal. Previous operative incisions were present on the abdomen. The extremities demonstrated healed needle tracks along the veins. The penis was circumcised. The right vas deferens, epididymis and testis were normal, and the left vas deferens and testis were normal. There was a 1 ½ cm. semi-firm, tender lesion in the left cauda epididymis. The perineum was tender. Rectal examination revealed what was considered to be a soft, large and extremely tender prostate gland. Neurologic examination was normal. Laboratory studies revealed a white cell count (WBC) of 27,000, with a shift to the left. Urinalysis demonstrated 10 WBCs per high power field and 1 plus bacteria. The blood urea nitrogen was 13 and the serum creatinine was 1.3. The patient was hydrated immediately and started intravenously on ampicillin and gentamicin. The urine culture yielded greater than 100,000 colonies per milliliter of Serratia marcescens. Blood cultures were negative. After 48 hours of intensive antibiotic treatment a fluctuant mass was palpable on rectal examination and the presumptive diagnosis of prostatic abscess was made. Consequently, the patient was taken to the operating room for transurethral drainage of the ab-* Chief Resident in Urology, The Johns Hopkins Hospital.

71-Year-Old Woman With Fever and Altered Mental Status

Mayo Clinic Proceedings, 2007

A 71-year-old woman with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia was hospitalized at our institution because of a sudden change in mental status. Two months previously, she had been hospitalized elsewhere for nausea, vomiting, and diarrhea. At that time, a duodenal ulcer and acute renal failure attributed to volume depletion were diagnosed, although renal biopsies performed during hospitalization showed focal segmental glomerulosclerosis with collapsing features, acute tubular necrosis, and thrombotic microangiopathy with glomerular capillary wall remodeling (double contours). No medication was administered for the renal failure. A dialysis catheter was placed and dialysis initiated, but the patient's symptoms persisted. During the next 2 months, she experienced an 11.25-kg weight loss. Two days before the current admission, the patient noted neck and shoulder pain after sleeping on a new pillow and took benzodiazepine for symptom relief. During the 24 hours before admission, her daughter noted a change in behavior, somnolence, and during the last few hours before presentation, agitation and confusion. The patient did not have chills, dysuria, or pain.

Fever, nephrotic syndrome, and rapidly progressive renal failure

Kidney International, 2007

CASE PRESENTATION A 52-year-old African woman, living in France since 5 years, presented with dyspnea and pyrexia. She had a 1-month history of sore throat treated with amoxicillin, migratory polyarthralgia, drenching night sweats, and an evanescent, maculo-papular, non-pruritic rash mainly on her limbs lasting less than 1 week at a time. She denied smoking, alcohol abuse, and illicit drugs use. She had no risk factors for HIV. Examination on admission revealed a temperature of 39.51C, tachycardia, a blood pressure of 120/70 mm Hg, pallor, jaundice, splenomegaly, and bilateral inflammation of knee and ankle joints with synovitis, and severe tenderness of the wrist with signs of fluid overload. There was no sign of meningeal irritation, no focal neurological deficit and normal fundus examination. There were fine crepitations involving the left lung base. Heart sounds were normal on auscultation with no murmur. She was admitted for analgesia and antibiotics pending the results of infective screens and blood tests. Peripheral smear showed no malarial parasite. Her coagulation profile was normal and there was no biochemical evidence of hemolysis. Biochemistry values are summarized in Table 1. Human Immunodeficiency Virus serology, plasma HIV viral load, and p24 determination were negative. Serologies for, hepatitis B and C, Parvovirus B19, cytomegalovirus, Epstein-Barr virus, leptospira, bartonella, rickettsia, chlamydia, mycoplasma pneumoniae, legionella, Widal test, rapid malaria test, toxoplasma, and syphilis were all negative. Brucella agglutination test and leishmania leukococentration were also negative. Hemoglobin electrophoresis ruled out sickle cell disease. Laboratory evaluation for systemic or malignant diseases, including rheumatoid factor, antibodies to double-stranded deoxyribonucleic acid, smooth muscle cell, liver/kidney microsomal, mitochondrial, anti-cardiolipin, anti-Scl, antineutrophilic cytoplasmic antibody, anti-Ro, anti-La, anti-SM, anti-ribonucleoprotein, anti-Jo-1, and anti-glomerular basement membrane antibodies were all negative. Immunological parameters were noncontributory with polyclonal hypergammaglobulinemia, normal immunoglobulin (Ig) A, IgM, complement levels, and negative cryoglobulinemia. Chest X-ray was normal. Renal ultrasound showed enlarged, swollen kidneys measuring 12.6 cm in length each. Total body computed tomography revealed splenomegaly, with the rest of the scan being unremarkable. This association between a nephrotic syndrome, fever, cutaneous lesions, pharyngitis and arthralgias suggested the diagnoses of either postinfectious or membranoproliferative glomerulonephritis. A first trans-jugular kidney biopsy was then performed (Figure 1). Trans-thoracic echocardiography suspected the presence of mitral valve endocarditis. Despite empirical treatment with Cefotaxim and gentamicin, she did not improve. The maculo-papular rash on her limbs persisted alongside with high fevers. Bone marrow biopsy and aspiration revealed moderately hyper-cellular marrow with trilineage maturation, and increased number of macrophages, however, without hemophagocytosis. Repeated serologies and cultures were negative. A second trans-oesophageal echocardiography revealed that the systolic function and chamber sizes were normal; there was no valvular dysfunction, evidence of vegetations, nor pericardial effusion. Her renal function worsened (creatinine peaking at 600 mmol/l 1 week later) and hemodialysis became necessary. Suspecting a rapidly progressive glomerulonephritis, of postinfectious or vasculitic nature, a second trans-jugular kidney biopsy was performed (Figures 2 and 3). At this stage we were faced with a severely ill 52-year-old African woman presenting with pyrexia of unknown origin, migratory polyarthopathy, fleeting maculopapular rash, pancytopenia, and rapidly progressive glomerulonephritis with renal failure requiring renal support.

Alarming Presentation of a Seemingly Common Condition in a Patient with Renal Impairment

Open Journal of Nephrology, 2013

We received a 23-year-old male, working in the Army for 18 months, with advanced renal impairment, haemoptysis and hyperkalemia. An impression of the pulmonary renal syndrome was made and he was managed aggressively with haemodialysis, plasma exchange and pulsing with methyl prednisolone. His condition improved, but the renal functions did not. The vasculitic workup including Extractable Nuclear Antigen (ENA) and Anti-Neutrophil Cytoplasmic Antibody (ANCA) which were sent on admission came out to be negative. As he apparently responded to the initial management protocol, he was subjected to renal biopsy which did not reveal any vasculitis but was consistent for end-stage renal disease. Subsequently he was subjected to lung biopsy which also was not supportive for vasculitis. However, we concluded that the initial pointers for Wegener's granulomatosis were misleading. The haemoptysis entirely subsided as the congestion improved. He was maintained on Haemodialysis three times per week schedule and discharged to the peripheral health care facility.

A 15-year-old girl with acute renal failure. Clinicopathologic conference

The Western journal of medicine, 1995

because for two months she had had nausea, vomiting, and malaise. Although the results of a routine urinalysis a year before her presentation had been normal, a urinalysis done by her private physician before admission showed 2+ glucose, 2+ protein, and numerous leukocytes. There was no history of recent analgesic or antibiotic administration. On physical examination she was thin, pale, pubertal, and appeared chronically ill. Her weight was 46 kg (101 lb), height 63 cm (5 ft 3 in), and blood pressure 130/80 mm of mercury. She had shotty left anterior cervical nodes. On examination of her abdomen, her liver could be palpated 2 cm below the right costal margin. The spleen tip was palpable on deep inspiration. Her extremities showed no edema. Laboratory values obtained on admission were as follows: serum sodium 139, potassium 3.3, chloride 102, and bicarbonate 16 mEq per liter; calcium, 2.50 mmol per liter (10.0 mg per dl); phosphorus, 2.07 mmol per liter (6.4 mg per dl); uric acid, 506 ,mol per liter (8.5 mg per dl); cholesterol, 4.40 mmol per liter (170 mg per dl); and glucose, 5.1 mmol per liter (92 mg per dl); liver function test values were normal. Blood urea nitrogen concentration was 41.1 mmol per liter (115 mg per dl), and serum creatinine level was 610 ,umol per liter (6.9 mg per dl). A urinalysis showed a specific gravity of 1.016, pH 6.0, 2+ protein, 1+ glucose, 0 to 50 leukocytes per high-power field, 0 to 2 coarse granular casts, and 2 to 5 granular casts. Urine chemistry levels were as follows: sodium, 59 mmol per day (59 mEq per 24 hours); and potassium, 35 mmol per day (35 mEq per 24 hours). A complete blood count elicited the following values: hemoglobin, 84 grams per liter (8.4 grams per dl), hematocrit, 0.24 (24%); mean corpuscular volume, 82 fl (82 VLm3); mean