Knotted ureteral stent is rare yet tedious complication that might represent a treatment challenge to the endourologist. Only twelve cases of knotted stent have been reported. Different management options have been reported, including simple traction, ureteroscopy, percutaneous removal, and open surgery. In this paper, we present the successful untying of the knot using ureteroscopy with holmium laser.
Hyponatremia is a complex process caused by dysregulation of total body sodium and total body water that can be seen in hypovolemic, euvolemic, and hypervolemic states. Rapid correction of hyponatremia can also lead to serious complications. The development of V2 antagonists, such as tolvaptan, has changed and simplified the management of dilutional hyponatremia by allowing the targeting of antidiuretic hormone (ADH) action and blocking its effect on the V2 receptor. This will decrease the synthesis and relocation of aquaporin 2 to the cortical collecting duct apical membrane. Tolvaptan is approved to be used in euvolemic and hypervolemic hyponatremia, specifically in the syndrome of inappropriate antidiuretic hormone secretion and heart failure. The SALT-1 and SALT-2 studies suggested a starting dose of 15 mg of tolvaptan based on pharmacokinetic data, and while this is an effective dose, multiple studies have shown that patients can overcorrect with this starting dose. At least 1 case of osmotic demyelination-the dreaded complication of overly rapid hyponatremia correction-has been observed with tolvaptan use. While strategies for rapid attenuation of this overcorrection exist, and are discussed, starting tolvaptan at a lower dose of 7.5 mg initially and up-titrating even within the first day is another strategy that can avoid overcorrection. This was noted to be especially important in cases of hyponatremia due to the syndrome of inappropriate ADH secretion. We note that this approach can more slowly correct the hyponatremia with less attendant neurological risks than the currently recommended minimum starting dose of tolvaptan.
Mycobacterium avium-intracellulare (MAI) complex is a common opportunistic infection that generally occurs in patients with a CD4 cell count less than 75. Current recommendations for prophylaxis include using a macrolide once a week, while treatment usually requires a multidrug regimen. Disseminated MAI infections often occur in patients who are not compliant with prophylaxis or their highly active antiretroviral therapy (HAART). Many manifestations of MAI infection are well documented in human immunodeficiency virus (HIV) patients, including pulmonary and cutaneous manifestations, but other unusual manifestations such as pericarditis, pleurisy, peritonitis, brain abscess, otitis media, and mastoiditis are sporadically reported in the infectious diseases literature. This case report is of a 22-year-old female who contracted HIV at a young age and who was subsequently noncompliant with HAART, MAI prophylaxis, and prior treatment for disseminated MAI infection. Unsurprisingly, the patient developed recurrent disseminated MAI infection. The patient’s presentation was atypical, as she developed severe otomastoiditis and posterior reversible encephalopathy syndrome. The posterior reversible encephalopathy syndrome was thought to be due to the disseminated MAI infection or to immune reconstitution inflammatory syndrome. The infection was confirmed to be secondary to MAI by culture of the mastoid bone. Microbiological analysis of the MAI strain cultured showed resistance to several first-line antibiotics used for prophylaxis against and treatment of MAI. This was likely due to the patient’s chronic noncompliance. Otomastoiditis secondary to MAI is extremely rare in adults and has been reported in only four case reports and one case series previously. Improved clinician education in the diagnosis, treatment, and, most important, prevention of MAI and other opportunistic infections is needed. Greater HIV screening, appropriate HAART medication administration, and availability of infectious disease specialists is needed in at-risk populations to help prevent such serious infections. Patient education and greater access to care should serve to prevent medication nonadherence and to enhance affordability of HAART and prophylactic antibiotics.
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