Objectives:Central nervous system (CNS) involvement in antineutrophil cytoplasmic antibody (ANCA) -associated vasculitis is common, with hypertrophic pachymeninges, cerebrovascular events, hypophysitis, or posterior reversible encephalopathy syndrome (PRES) being the most common CNS presentations.Design and Methods:Case report.Results:A 73-year-old Japanese woman presented with a fever and cough. The patient had no relevant medical history. Her c-reactive protein (CRP) level increased to 22.38 mg/dl, and meropenem was initiated; however, her fever and CRP levels did not improve. Furthermore, creatinine level increased from 0.83 to 3.44 mg/dl during hospitalization. She was transferred to our hospital for evaluation of renal function deterioration. Her consciousness level was alert, and her blood pressure was 140/80 mm Hg. A renal biopsy was performed, and histological examination of the kidneys revealed diffuse pauci-immune necrotizing and crescentic glomerulonephritis. Myeloperoxidase (MPO) -ANCA was 2.9 IU/mL and proteinase 3 (PR3) -ANCA was negative. On the basis of these findings, the patient was diagnosed with ANCA-associated vasculitis. On the fourth hospital day, she was treated with 500 mg intravenous methylprednisolone, once daily, for 3 days, followed by oral prednisolone (40 mg; 0.8 mg/kg). Although her fever and CRP levels improved after the initiation of immunosuppressive therapy, she required renal replacement therapy on the eighth hospital day. Rituximab (500 mg) was administered on the ninth hospital day. Her blood pressure subsequently increased, with the systolic blood pressure being 190 mmHg, and consciousness suddenly deteriorated on the 11th hospital day. Head fluid-attenuated inversion-recovery (FLAIR) MRI showed multiple lesions with high signal intensity, and she was diagnosed with PRES. After intravenous administration of nicardipine and fluid removal by hemodialysis, her blood pressure decreased and her consciousness dramatically improved.Conclusion:In addition to the vascular endothelial damage associated with vasculitis itself, steroid therapy, renal failure, elevated blood pressure, and administration of rituximab are related to an increased susceptibility of PRES. In particular, steroid administration increases blood pressure due to fluid retention and can be a risk factor for the development of PRES, suggesting the need for adequate fluid management during steroid administration.
Background We experienced that some hemodialysis (HD) patients with coronavirus disease 2019 (COVID-19) exacerbated hypoxemia during HD. Though HD-induced hypoxemia has been reported, there have been no reports of HD-induced hypoxemia in patients with COVID-19 and its effect on prognosis of COVID-19. Methods Eleven HD patients admitted with COVID-19 from August 2020 to April 2021 were classified into the patients whose oxygen demand increased by more than 3 L/min with mask during HD (worsened group, n = 5) and others (not-worsened group, n = 6). The background, laboratory findings, severity of COVID-19 and prognosis were compared between the two groups. In addition, blood gases were measured before and after dialysis among HD patients admitted with COVID-19 on April 2021 (n = 3). Results There were no significant differences in backgrounds, except for a higher proportion of diabetes mellitus in worsened group (p = 0.04). Although laboratory findings were not significantly different on admission day, albumin and LDH levels 7 days after admission were significantly lower and higher in worsened group, respectively (p = 0.03 and < 0.01). The severity of COVID-19 and survival rate were significantly worse in worsened group (p = 0.01 and 0.03). The alveolar-arterial oxygen pressure difference (Aa-DO2) opened during HD in a patient with HD-induced hypoxemia, but did not open in patients without HD-induced hypoxemia. Conclusions There is a close relationship among HD-induced hypoxemia and poor prognosis of COVID-19. The HD-induced hypoxemia of patients with COVID-19 may be caused by ventilation/perfusion mismatching.
Peritonitis is one of the most important complications in patients with peritoneal dialysis (PD). Appropriate antibiotic treatment against PD-associated peritonitis is necessary to prevent PD catheter removal and withdrawal from PD. <i>Chryseobacterium indologenes</i> is a Gram-negative rod that occurs in the natural environment. <i>C. indologenes</i> is thought to acquire resistance to β-lactam drugs through the production of metallo-β-lactamase and to become resistant to antibiotic therapy through the formation of biofilms. Only a few cases of PD-associated peritonitis caused by <i>C. indologenes</i> have been reported to date, and appropriate treatment strategies have not been clarified. In the past, 5 cases of PD-associated peritonitis caused by <i>C. indologenes</i> have been reported and 2 patients required catheter removal because of recurrence or refractoriness. In this case, a 51-year-old man with PD-associated peritonitis caused by <i>C. indologenes</i> was treated with 2 susceptible antibiotics, including fluoroquinolones to prevent acquired resistance and biofilm formation. There was no recurrence, and catheter removal was not necessary in this case. Collectively, the present case highlighted that PD-associated peritonitis caused by <i>C. indologenes</i> should be treated with 2 susceptible antibiotics including fluoroquinolones for 3 weeks.
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