The immunologic response following several varieties of vaccination has been described as a potential trigger for the development of both de novo as well as recurrent minimal change disease (MCD). 1 There have been emerging cases, including that described by D'Agati Q2 et al., of MCD shortly after vaccination with the BNT162b2 vaccine (Pfizer-BioNTech). 2,3 We report, to the best of the authors' knowledge, the first case of MCD presenting as nephrotic syndrome following the Moderna mRNA-1273 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine.The patient, a 63-year-old woman, had a medical history that was significant only for hypertension and tobacco dependence. She had no prior history of renal disease. In April 2021, she presented to our hospital with a 4-week history of progressive anasarca, fatigue, periorbital edema, and dyspnea. The patient relayed that the edema and development of foamy urine appeared abruptly and occurred less than a week after having received the first (and only) dose of the Moderna mRNA-1273 SARS-CoV-2 vaccine (lot 006B21A). Vaccination was confirmed by cross-referencing her outpatient pharmacy, which administered the dose. Unfortunately, anti-S protein antibody titer is not available to report.Clinical and diagnostic evaluation also revealed newly uncontrolled hypertension (181/82 mm Hg) as well as mild acute kidney injury (serum creatinine, 1.48 mg/dl; baseline was 0.7 mg/dl). Hypoalbuminemia (0.7 g/dl), urinalysis with 3þ proteinuria (without microscopic hematuria), and hyperlipidemia (triglycerides, 221 mg/dl; total cholesterol, 450 mg/dl) were noted. Nephrotic syndrome was confirmed as the 24-hour urine collection revealed 13.4 g proteinuria. Renal biopsy was promptly performed. Pathology confirmed MCD, with mild acute tubular injury, although a focal acute interstitial nephritis was also present. Four of 69 sampled glomeruli were globally sclerosed. There was 10% tubulointerstitial fibrosis. The sampled glomeruli were found to have 100% foot process effacement (Figure 1).Treatment with conservative measures, including valsartan, 80 mg orally twice a day, for renin-angiotensinaldosterone system inhibition was initiated along with a loop diuretic. She was also given pulse methyl-prednisolone, 500 mg i.v. for 3 days, followed by 1 mg/kg prednisone orally. On the basis of other case reports and our experience with MCD, we anticipate a prompt response to these measures. 4 We have recommended the patient forgo the second scheduled dose of the Moderna mRNA-1273 SARS-CoV-2 vaccine. In addition, the authors believe further rechallenges or boosters of this particular vaccine in this patient would be unwise until this potential relationship is more clear. ACKNOWLEDGMENTS Q4Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal. AUTHOR CONTRIBUTIONSAuthor contributions were evenly divided, and included but not limite...
Calciphylaxis is a disabling and life-threatening complication that primarily affects patients who are dialysis dependent. This disease entity is characterized by calcification, intimal hypertrophy, and thrombosis of small vessels, which results in necrotizing, nonhealing ulcers. The development of these lesions portends a grim prognosis, as they are often accompanied by severe and sometimes fatal infectious complications. Although several strategies aimed at treating and preventing this affliction have been reported in the literature, the outcome for most patients with calciphylaxis remains quite poor. We describe an anuric hemodialysis patient who developed severe calciphylaxis that proved refractory to conventional treatment. Following extensive debridement of several wounds, intravenous sodium thiosulfate was utilized as an adjunctive therapy four times a week. Within 6 months, excellent wound healing ensued as well as a dramatic improvement in the lesions that were not previously resected. Aside from occasional nausea, these treatments were well tolerated, despite the development of an anion gap metabolic acidosis. After 34 months of continued treatment the patient remains free from disease recurrence and has demonstrated no untoward effect of prolonged therapy. In an effort to delineate the pharmacokinetics of this drug in a hemodialysis patient, serum thiosulfate levels were obtained 15 minutes after infusion as well as before and after subsequent dialysis treatments. Consistent with prior studies in anuric canines, we found measurable quantities of the drug more than 50 hours after treatment, in addition to a markedly elevated half life of 478 minutes. However, given the lack of significant toxicity, as well as a dramatic clinical improvement, we feel that sodium thiosulfate may have an important adjunctive role in the treatment of calciphylaxis in dialysis patients.
Background: Although rare, serum sickness-like reactions have been documented to occur following the administration of many antibiotics. Cefazolin, a first generation cephalosporin, is a commonly prescribed antibiotic which is considered to be generally safe and well tolerated. There have been no prior reports linking this drug with sickness-like reactions. We report a probable case of serum sickness-like reaction following a single dose of cefazolin.
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