Severe hypercalcaemia with normal serum calcitriol in a diabetic patient with chronic renal failure, autoimmune hepatitis and disseminated tuberculosis

Definite and probable septic pericarditis in hemodialysis

INTRODUCTION

Although the incidence of septic pericarditis in hemodialysis populations is less frequent in the modern antibiotic era, it is still a cause of death partly because diagnosis is sometimes difficult and uncertain.

METHODS

From 2002 to 2006, 12 out of a total of 12,213 maintenance hemodialysis patients were referred for management of septic pericarditis. Patients were diagnosed as either definite or probable septic pericarditis. A definite diagnosis of septic pericarditis is based on the discovery of pathogenic bacteria in pericardial effusion, whereas a probable diagnosis is based on the proof of bacterial infection elsewhere in a patient with otherwise unexplained pericarditis, or appropriate response to a trial of systemic antibiotics.

RESULTS

Four (33.3%) patients were diagnosed as definite pericarditis, whereas eight (66.7%) patients as probable pericarditis. It was found that although oxacillin-resistant Staphylococcus aureus (ORSA) (4/12 or 33.3%) and tuberculous (4/12 or 33.3%) pericarditis were common, salmonella pericarditis (2/12 or 16.7%) was also not uncommon. Pericardiocentesis, or pericardial window with pericardiectomy, was performed in three (25%) and two (16%) of patients with cardiac tamponade, respectively. Two patients died because of severe ORSA (1/12 or 8%) and salmonella (1/12 or 8%) sepsis. Finally, there were four (33%) patients who developed constrictive pericarditis after follow-up.

CONCLUSIONS

These data are important because the spectrum of septic pericarditis was clearly different between Taiwan and other developed countries. Furthermore, it is the only report in which patients were diagnosed as either definite or probable septic pericarditis, therefore improving the sensitivity of diagnosis as in the case of tuberculous pericarditis.

Mycobacterium microti infection associated with spindle cell pseudotumour and hypercalcaemia: a possible link with an infected alpaca

A 44-year-old woman who had recently been on immunosuppressive therapy presented with malaise, cough, fever, weight loss, lymphadenopathy, severe hypercalcaemia and a paratracheal mass on imaging. The initial impression was of disseminated malignancy, and lymphoma was suspected. A mediastinal biopsy showed a mycobacterial spindle cell pseudotumour containing acid and alcohol fast bacilli (AAFB). Sputum microscopy demonstrated AAFBs, confirmed as Mycobacterium tuberculosis complex by PCR. Prolonged culture grew Mycobacterium microti, an organism often associated with disease in small rodents and llamas. M microti isolates from postmortem samples of an alpaca at a nearby farm were genetically indistinguishable. Although the patient had not visited the farm, concurrent illness in her adopted stray cat suggested a possible zoonotic connection. The patient responded to antituberculous therapy, and rehydration and pamidronate for hypercalcaemia. We believe the hypercalcaemia was caused by a similar mechanism to raised calcium levels sometimes seen in tuberculosis.

Incidental primary hyperparathyroidism in a hypercalcaemic woman with tuberculous peritonitis

We report on a 51-year-old woman with initial hypercalcaemia and unknown ascites. In spite of unyielding laparoscopy, laparotomy showed findings compatible with tuberculous peritonitis (TBP). Unexpectedly, a series of examinations eventually revealed the concurrence of hyperparathyroidism due to a parathyroid adenoma. Anti-tuberculous regimen was given and was uneventful. However, hypercalcaemia was not decreased but sustained at a high level even after anti-tuberculous therapy for 3 months. Parathyroidectomy was performed with subsequent normalisation of hypercalcaemia. The aetiology of hypercalcaemia in a patient with an explored disease able to cause this electrolyte abnormality such as TBP may be a coexistent occult parathyroid adenoma.