CT imaging features of symptomatic and asymptomatic floating aortic thrombus

AIM

To present the computed tomography (CT) imaging features of floating aortic thrombus with emphasis on clinical and radiographic predictors for systemic shower emboli.

MATERIALS AND METHODS

A retrospective computerised search for patients with protruding thoracic aortic thrombus on CT was conducted. Clinical and demographic characteristics were retrieved from medical files. Patients were divided into two groups: symptomatic and asymptomatic, based on the presence or absence of documented systemic emboli at the time of diagnosis or during follow-up. CT imaging features were analysed: location and extent of systemic emboli, presence or absence of thrombus insertion calcification, percentage of thrombus circumference that is attached to the aortic wall and thrombus volume. Clinical and demographic variables and CT imaging features were analysed as potentially associated with symptomatic emboli.

RESULTS

The symptomatic group included 6/15 (40%) patients and the asymptomatic group included 9/15 (60%) patients. Patients in the symptomatic group were significantly younger (symptomatic: 53.3±11.7 years, asymptomatic: 76.9±8.4 years, p=0.003). All the symptomatic patients were women (100%), while 2/9 (22.2%) of the asymptomatic patients were women, (p=0.007). A non-calcified insertion site was more frequent in the symptomatic group (symptomatic 4/6 [66.7%] versus asymptomatic group 1/9 [11.1%], p=0.011). The percentage of thrombus circumference attached to the aortic wall was significantly smaller in symptomatic patients (symptomatic: 31.8±8.4%, asymptomatic: 43.7±5%, p=0.003).

CONCLUSION

The imaging features of symptomatic floating thrombus include a narrow base of attachment and lack of insertion calcification. Free-floating thrombus should be actively sought and diagnosed or excluded when performing CT andiography for emboli.

Acute viral hepatitis (C - genotype 6a and B) acquired during kidney transplantation by two patients and review of the literature

Two patients were contaminated by hepatitis during kidney transplantation from unrelated living donors, performed abroad in 2006. One patient died from fulminant hepatitis C (the first case of virus genotype 6a diagnosed in Israel) 2 months after transplantation and the other developed acute hepatitis B with YMDD to YVDD mutation necessitating life-long antiviral therapy. The dilemma of antiviral therapy in transplant recipients is discussed in this paper. Patients awaiting kidney transplantation by far outnumber the kidneys available for cadaver transplantation. International trade with living non-related kidneys has therefore become common. Comorbid conditions, although significant, are often ignored. After transplantation, the first patient presented with a picture of fulminant hepatitis C; immunosuppressive medication was tapered rapidly. This patient subsequently died from hepatic failure. The patient with active hepatitis B with YVDD mutation is receiving ongoing treatment by lamivudine and adefovir.

Adenosine is upregulated during peritonitis and is involved in downregulation of inflammation

Loss of function of the peritoneal membrane is associated with peritonitis. Adenosine levels in sites of inflammation were shown to increase and exhibit immunoregulatory effects. Our aim was to elucidate the regulatory role of adenosine during peritonitis and to test the involvement of peritoneal mesothelial cells (PMC) in adenosine regulation. In a mice model of Escherichia coli peritonitis, the adenosine A(2A) receptor (A(2A)R) agonist (CGS21680) prevented leukocyte recruitment and reduced tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6) levels. Peritonitis induced the elevation of adenosine with a peak at 24 h. Analysis of adenosine receptor levels on peritoneum showed that A(1) receptor (A(1)R) protein levels peak at 12 h after inoculation and then return to baseline at 24 h, whereas high affinity A(2A)R protein levels peak at 24 h concomitantly with the peak of adenosine concentration. Low affinity A(2B) receptor (A(2B)R) levels elevated slowly, remaining elevated up to 48 h. In human PMC (HPMC), the early cytokines, IL-1-alpha, and TNF-alpha upregulated the A(2B) and A(2A) receptors. However, interferon-gamma (IFN-gamma) upregulated the A(2B)R and decreased A(2A)R levels. Treatment with the A(2A)R agonist reduced IL-1-dependent IL-6 secretion from HPMC. In conclusion, the kinetics of adenosine receptors suggest that at early stage of peritonitis, the A(1)R dominates, and later its dominance is replaced by the G stimulatory (Gs) protein-coupled A(2A)R that suppresses inflammation. Early proinflammatory cytokines are an inducer of the A(2A)R and this receptor reduces their production and leukocyte recruitment. Future treatment with adenosine agonists should be considered for attenuating the damage to mesothelium during the course of acute peritonitis.

Surveillance of chronic haemodialysis-associated infections in southern Israel

During a 12-month surveillance period, haemodialysis (HD) patients in southern Israel were categorised according to the type of vascular access site (VAS), i.e., arteriovenous (AV) fistula, synthetic AV graft, and cuffed or non-cuffed vascular catheters. Endpoints, expressed as cases/100 patient-months, were: incidence of hospital admission; antibiotic therapy; bloodstream infection (BSI); and VAS infection. These were compared to Centers for Disease Control (CDC) surveillance data, overall and by VAS type. In total, 2568 patient-months were analysed. The VAS distribution differed significantly from CDC data for fistulas (72% vs. 31%), grafts (12% vs. 41%), cuffed catheters (11% vs. 25%) and non-cuffed catheters (5% vs. 3%) (p < 0.0001 in all cases). Of 151 admissions, 32% resulted from infection, for which 112 antibiotic courses (22% vancomycin) were given. There were 16 BSIs, three involving resistant strains. The incidences of admission, antibiotic therapy, BSI and VAS infection were significantly lower overall, compared to CDC rates, as were most VAS-specific endpoints. These differences may be explained by VAS type distribution, although other factors may also be involved. Reporting regional or national surveillance data may allow a standardised comparison of the incidence of HD-associated infections.

Intraocular pressure during haemodialysis: a review

OBJECTIVES

Although several works in the past have examined the effect of haemodialysis (HD) on intraocular pressure (IOP), reported findings, theories, and conclusions are very different. The objectives of this article are to resume the reported evidence of IOP changes during HD, to review the proposed hypothesis of HD influence on IOP, and to determine if ophthalmic examination is imperative in HD patients.

METHODS

We analysed the peer-reviewed English literature and selected all possible relevant articles.

RESULTS

The influence of HD on IOP is not clear, and even in recent studies opposite findings can be found.

CONCLUSIONS

Future studies are needed to clarify the effects of HD on IOP. In patients with glaucoma or with predisposed narrow angles, or eyes with impaired aqueous outflow, the possibility of acute IOP rise during HD could be much more frequent than in normal patients. So in these patients, a more strict ophthalmic scheduled examination seems to be feasible.

Liesegang rings in hemorrhagic urine

Myriad Liesegang rings were encountered in the urine of a 43-year-old patient who was diagnosed as having idiopathic hematuria, emanating from the left ureter or kidney. Erythrocytes and the Liesegang rings spontaneously disappeared from the urine within 4 weeks. We are unaware of a report of a similar observation. Lack of descriptions may be due to underreporting or reflect true rarity of Liesegang rings in the urine. It is suggested that Liesegang rings may precipitate in the hemorrhagic urine as they do in diverse blood-imbibed tissues.

Increased coagulation factor levels leading to allograft renal vein thrombosis

A patient with end-stage kidney disease is described, who lost his renal allograft in the early post-transplant period due to allograft renal vein thrombosis. Prior to transplantation, he had been treated by hemodialysis and lost several vascular accesses because of thrombosis. A search for potential thrombophilic factors disclosed a unique combination of increased clotting factor levels, i.e. FVIII, FIX, FXI and homocysteine. More common hereditary and acquired hypercoagulability factors have been excluded in this patient. While clotting factor deficiencies are well known causes of hemophilia, their levels should also be measured in the workup of transplant candidates with a history of multiple vascular access thrombosis.

Severe Coombs'-negative autoimmune hemolytic anemia in a kidney transplant patient

BACKGROUND/AIM

Few cases are found in the literature regarding autoimmune hemolytic anemia which is Coombs' test positive in kidney transplant patients, although hemolytic uremic syndrome due to cyclosporin and FK506 has been well described. In the following, we describe a case of severe life-threatening Coombs' test negative autoimmune hemolytic anemia after kidney transplantation.

METHODS

Soon after undergoing renal transplantation, the patient presented with hemolytic anemia. Kidney biopsy, routine Coombs' test, gel filtration and flow-cytometric assay were undertaken.

RESULTS

Kidney biopsy ruled out hemolytic uremic syndrome; although Coombs' test and gel filtration assay were negative, flow cytometry revealed circulating antierythrocytic autoantibodies.

CONCLUSIONS

Our findings indicate that flow cytometry may be an efficient method in the diagnosis of hemolysis of unknown origin in transplant patients. We further hypothesize that the underlying mechanism of autoimmune hemolytic anemia is related to the passenger B lymphocytes in the graft.

Renal transplant dysfunction due to severe aorto-iliac atherosclerosis in the presence of patent renal transplant artery

We report a case of progressive deterioration in renal function and decreased renal graft perfusion induced by extensive aorto-iliac atherosclerotic lesions proximal to a patent renal graft artery. Significant improvement in kidney graft function followed left axillo-femoral bypass graft surgery, which to the best of our knowledge, has never been performed previously for permanent maintenance of renal transplant perfusion.

Cefuroxime-induced encephalopathy

We describe four patients who developed an encephalopathic syndrome characterized by obtundation or stupor, myoclonic jerks, and asterixis in association with cefuroxime therapy. Three patients had renal failure. These cases suggest that cefuroxime in overdose or in conventional doses in patients with renal failure can cause a reversible encephalopathy. This syndrome may have been unrecognized because it usually occurs in severely ill patients with additional causes for encephalopathy.

Inhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract (Sambucus nigra L.) during an outbreak of influenza B Panama

A standardized elderberry extract, Sambucol (SAM), reduced hemagglutination and inhibited replication of human influenza viruses type A/Shangdong 9/93 (H3N2), A/Beijing 32/92 (H3N2), A/Texas 36/91 (H1N1), A/Singapore 6/86 (H1N1), type B/Panama 45/90, B/Yamagata 16/88, B/Ann Arbor 1/86, and of animal strains from Northern European swine and turkeys, A/Sw/Ger 2/81, A/Tur/Ger 3/91, and A/Sw/Ger 8533/91 in Madin-Darby canine kidney cells. A placebo-controlled, double blind study was carried out on a group of individuals living in an agricultural community (kibbutz) during an outbreak of influenza B/Panama in 1993. Fever, feeling of improvement, and complete cure were recorded during 6 days. Sera obtained in the acute and convalescent phases were tested for the presence of antibodies to influenza A, B, respiratory syncytial, and adenoviruses. Convalescent phase serologies showed higher mean and mean geometric hemagglutination inhibition (HI) titers to influenza B in the group treated with SAM than in the control group. A significant improvement of the symptoms, including fever, was seen in 93.3% of the cases in the SAM-treated group within 2 days, whereas in the control group 91.7% of the patients showed an improvement within 6 days (p < 0.001). A complete cure was achieved within 2 to 3 days in nearly 90% of the SAM-treated group and within at least 6 days in the placebo group (p < 0.001). No satisfactory medication to cure influenza type A and B is available. Considering the efficacy of the extract in vitro on all strains of influenza virus tested, the clinical results, its low cost, and absence of side-effects, this preparation could offer a possibility for safe treatment for influenza A and B.

Successful treatment of secondary hyperparathyroidism in hemodialysis patients with oral pulse 1-alpha-hydroxy-cholecalciferol therapy

We have used high-dose oral pulse therapy with 1 alpha-hydroxycholecalciferol (1 alpha-OH-D3) to treat 40 hemodialysis patients suffering form secondary hyperparathyroidism. Forty patients with intact parathyroid hormone (PTH) levels of > 150 pg/ml were treated with 4 micrograms oral 1 alpha-OH-D3 twice weekly for 1 year. The mean PTH level was 515 +/- 50 pg/ml prior to treatment, which fell to 191 +/- 42 pg/ml after 6 months of treatment (p < 0.00001), and to 164 +/- 39 pg/ml after 12 months of treatment. Patients with very high PTH levels (> 800 pg/ml) suppressed less well than patients with lower levels (150-300 pg/ml). The therapeutic end point of PTH < 100 pg/ml was achieved in 23 patients (58%). The main side effect of the treatment was hypercalcemia, but this was symptomatic in only 3 patients, all above the age of 70 years. In summary, oral high-dose pulse therapy with 1 alpha-OH-D3 was highly effective in suppressing PTH levels in hyperparathyroid hemodialysis patients, and side effects were relatively few.

Elevated superoxide generation in mononuclear phagocytes by treatment with 1 alpha hydroxyvitamin D3: changes in kinetics and in oxidase cytosolic factor p47

The effect of 1 alpha-hydroxyvitamin D3 (1 alpha OHD3) treatment on the superoxide production of phagocytic cells in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) was studied. A 3-day treatment of CAPD patients with 3 micrograms per day of 1 alpha OHD3 (high-dose treatment) significantly increased NADPH oxidase and killing activities in peritoneal macrophages and peripheral blood monocytes (P < 0.001) as compared with low-dose (0.25 microgram/day of 1 alpha OHD3) treatment or nontreatment. The high oxidase activity observed in macrophages and monocytes after the treatment with 1 alpha OHD3, correlated significantly to the increase in the amount of the cytosolic factor p47 of the NADPH oxidase as detected by western blotting analysis. Superoxide production by the peripheral blood neutrophils of these patients only slightly increased with 1 alpha OHD3 treatment, and the amount of p47 was not affected by 1 alpha OHD3 administration. In order to evaluate the significance of the oxidase cytosolic factor in dictating oxidase activity, a reconstitution of NADPH oxidase was conducted by mixing macrophage cytosols and membranes in a cell-free system. The addition of macrophage cytosol from patients on high-dose treatment to macrophage membranes from patients in all of the categories of treatment resulted in significantly higher (P < 0.001) superoxide production as opposed to the macrophage cytosol from nontreated patients. These results suggest that 1,25(OH)2D3 causes an increase in NADPH oxidase activity in the peritoneal macrophages and monocytes of CAPD patients by inducing synthesis and elevating the amount of the cytosolic factor p47.(ABSTRACT TRUNCATED AT 250 WORDS)

[Calcific periarthritis in patients with endstage renal disease on chronic dialysis]

2 patients with end-stage renal disease undergoing dialysis developed calcific periarthritis. A 25-year-old man on hemodialysis developed arthritis of 2 right metacarpophalangeal joints and a 65-year-old man on chronic ambulatory peritoneal dialysis suffered from pain and tenderness in the left buttock. Treatment with nonsteroidal antiinflammatory drugs in the first case and periarticular injection of methylprednisolone (Depomedrol) in the second were successful.

Extreme hypermagnesemia due to ingestion of Dead Sea water

We describe 3 patients who developed extreme hypermagnesemia due to ingestion of water of the Dead Sea, which would have been fatal were it not for the protective effects of the accompanying hypercalcemia. We emphasize the clinical features of this condition and the importance and effectiveness of early hemodialysis as the main modality of treatment.

Dialysis in renal failure casued by amyloidosis of familial Mediterranean fever. A report of ten cases

Ten unselected patients with renal failure casued by amyloidosis associated with FMF were treated by regular hemodialysis therapy from 1969 to 1974. They were compared to age-matched control patients treated by hemodialysis in the same unit during the same period, who were suffering from renal failure caused by other disease. Mortality in FMF and control patients was 30% with no significant difference in mean survival, shunt life, serum albumin or hemoglobin levels between the two groups. There was no significant difference in blood pressure measured predialysis or postdialysis in patients with FMF or in controls. The synthetic ACTH stimulation test showed adequate or elevated adrenocortical function. It is concluded that life can be prolonged up to 3 1/2 years by hemodialysis in renal failure caused by amyloidosis complicating FMF, and that renal failure casued by FMF is not a contraindication to regular hemodialysis therapy.

The aetiology of senile osteoporosis: secondary hyperparathyroidism due to renal failure

The aetiology of senile osteoporosis was investigated in a series of elderly normal persons (mean age 76.8 years) who were compared to 18-19 year old normal controls. Osteoporosis was estimated by standard radiological morphometric and densitometric techniques, in the metacarpals and thoraco-lumbar vertebrae. Serum parathyroid hormone levels were significantly higher in the elderly group, and correlated well with morphometric and densometric measurements of osteoporosis. Creatinine clearance was reduced in seven out of nine of the elderly group, and correlated well with the degree of osteoporosis. Serum thyrocalcitonin levels were reduced in the elderly. Tubular reaborption of phosphate and TmP/GFR were in the hyperparathyroid range in the elderly group and correlated well with the degree of osteoporosis. The hypothesis is advanced that the osteoporosis of old age is a result of parathyroid overactivity, caused by asymptomatic chronic renal failure. The suggestion is made that a diet low in phosphorus might reduce the incidence of osteoporosis in old age by reducing the parathyroid overactivity.