1
|
Srinivasan S, Raju B, Nair R, Hegde A, Johnson S, Menon G. Brown Tumor of the Dorsal Spine With Hemorrhage Causing Acute Neurological Deterioration: A Rare Presentation of Secondary Hyperparathyroidism. Cureus 2024; 16:e63645. [PMID: 39092321 PMCID: PMC11292460 DOI: 10.7759/cureus.63645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/04/2024] Open
Abstract
Brown tumor due to secondary hyperparathyroidism in chronic kidney disease is a well-established entity. Brown tumor of the spine with hemorrhage causing acute neurological deficit is a rare entity. A 35-year-old gentleman, with chronic kidney disease (CKD) on dialysis, presented with acute paraplegia and loss of lower limb sensation and bowel and bladder control. Imaging revealed a T8 vertebral body expansile lytic lesion with collapse, exaggerated kyphosis, and cord compression. He underwent an emergency decompressive laminectomy and transpedicular corpectomy of T8, with posterior stabilization. Histopathology revealed lobular clusters of osteoclast-like multinucleated giant cells with background of which was possibly the reason for acute neurological deterioration in this case. Brown tumors of the spine can mimic lytic lesions of the spine like myeloma and metastasis. Suspicion must be raised given in the setting of CKD and hyperparathyroidism. They can present with hemorrhage and acute neurological deficit, which warrants urgent surgical intervention for optimal outcomes.
Collapse
Affiliation(s)
| | - Bharat Raju
- Neurosurgery, Kasturba Medical College, Manipal, Manipal, IND
| | - Rajesh Nair
- Neurosurgery, Kasturba Medical College, Manipal, Manipal, IND
| | - Ajay Hegde
- Neurosurgery, Manipal Hospitals, Bangalore, IND
| | | | - Girish Menon
- Neurosurgery, Kasturba Medical College, Manipal, Udupi, IND
| |
Collapse
|
2
|
Liu Z, Yang H, Tan H, Song R, Zhang Y, Zhao L. Brown tumor of the cervical spine with primary hyperparathyroidism: A case report and literature review. Medicine (Baltimore) 2023; 102:e32768. [PMID: 36820584 PMCID: PMC9907965 DOI: 10.1097/md.0000000000032768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
RATIONALE Brown tumor (BT), an uncommon focal lytic bone tumor, is a non-neoplastic and reactive process caused by increased osteoclastic activity and fibroblastic proliferation in primary or secondary hyperparathyroidism. Vertebral tumor causing neural compression is relatively rare, especially in the cervical spine. PATIENT CONCERNS A 29-year-old man developed neck pain and arm radicular pain 4 months ago, with the level of serum calcium significantly higher than normal. Computed tomography scan of the cervical spine revealed an expansile lytic lesion occupying the C6 body, left pedicle, and left lamina of C5-6. DIAGNOSES Osteoclastoma according to imaging and histopathological results. INTERVENTIONS A laminectomy of C5-6 was performed. OUTCOMES One month later, he was re-hospitalized due to nausea and vomiting and the serum calcium, was still, kept at a high level. Additionally, the parathormone (PTH) was greatly higher than normal. BT with primary hyperparathyroidism due to the parathyroid tumor was considered. After the surgery of the right parathyroid gland was performed, serum calcium and PTH both decreased, and computed tomography showed good recovery. LESSONS BTs might be misdiagnosed as other giant cell tumors, thus when giant cell tumors are considered, serum calcium and PTH examination may be needed to exclude BTs.
Collapse
Affiliation(s)
- Zirui Liu
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hao Yang
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongyu Tan
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruipeng Song
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liang Zhao
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- * Correspondence: Liang Zhao, Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (e-mail: )
| |
Collapse
|
3
|
Mirzashahi B, Vosoughi F, Besharaty S, Satehi SH. Missed C5 vertebral brown tumor causing spinal cord compression and myelopathy: A case report and literature review. Clin Case Rep 2022; 10:e05331. [PMID: 35127095 PMCID: PMC8795921 DOI: 10.1002/ccr3.5331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/28/2021] [Accepted: 01/14/2022] [Indexed: 11/17/2022] Open
Abstract
We aim to report a patient with vertebral brown tumor in the context of a primary hyperparathyroidism presented by shoulder pain. This is the first report of C5 brown tumor involvement in a primary hyperparathyroid patient and emphasizes the consideration of cervical vertebral evaluation in patients with persistent shoulder pain.
Collapse
Affiliation(s)
- Babak Mirzashahi
- Orthopedic Surgery DepartmentImam Khomeini HospitalTehran University of Medical SciencesTehranIran
| | - Farzad Vosoughi
- Orthopedic Surgery DepartmentImam Khomeini HospitalTehran University of Medical SciencesTehranIran
| | - Saied Besharaty
- Orthopedic Surgery DepartmentImam Khomeini HospitalTehran University of Medical SciencesTehranIran
| | - Sadegh Hasani Satehi
- Orthopedic Surgery DepartmentImam Khomeini HospitalTehran University of Medical SciencesTehranIran
| |
Collapse
|
4
|
Jia Q, Gao X, Zhou Z, Lan B, Zhao J, Liu T, Yang X, Wei H, Xiao J. Urgent surgery for spinal instability or neurological impairment caused by spinal brown tumors occurring in the context of end-stage renal disease. J Neurosurg Spine 2019; 30:850-857. [PMID: 30835712 DOI: 10.3171/2018.12.spine181044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal instability or neurological impairment caused by spinal brown tumors (BTs) with end-stage renal disease (ESRD) is an acute condition that needs urgent surgery. There is not much published information on BTs of the mobile spine given the rarity of the disease, and the literature shows inconsistent treatment options and ambiguous follow-up information. The aim of the present study was to elucidate the clinical features, anesthesia management, and surgical treatment for this rare disease through long-term follow-up observations. METHODS Clinical, laboratory, radiological, and perioperative data on 6 consecutive patients with spinal BTs who had been admitted to the authors' institution between 2010 and 2016 were retrospectively reviewed. The literature on spinal BT with secondary hyperparathyroidism was also reviewed. Summaries of the clinical features and anesthesia management are provided. RESULTS The mean age of the 6 patients was 45.5 years (range 35-62 years). Lesions were located in the cervical segment (2 cases) and thoracic segment (4 cases). Localized pain was the most common complaint, and pathological fracture occurred in 5 patients. Elevation of serum alkaline phosphate (AKP) and parathyroid hormone (PTH) was a common phenomenon. Four patients underwent circumferential resection and 2 underwent laminectomy, with parathyroidectomy performed in all patients. The anesthesia process was uneventful for all patients. The mean follow-up was 33 months (range 26-40 months). No spinal lesion progression occurred in any patient. The Karnofsky Performance Status score improved to 80-90 by 3 months after surgery. CONCLUSIONS Although uncommon, spinal BTs should be a diagnostic consideration in patients with ESRD. The thoracic spine is the most frequently affected site. ESRD is not a contraindication for surgery; with the assistance of experienced anesthesiologists, urgent surgery is the preferred option to alleviate neurological impairment and restore spinal stability.
Collapse
Affiliation(s)
- Qi Jia
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Xin Gao
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Zhenhua Zhou
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Bin Lan
- 2Medical Center of Military Unit 32151, Xingtai, Hebei, People's Republic of China
| | - Jian Zhao
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Tielong Liu
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Xinghai Yang
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Haifeng Wei
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Jianru Xiao
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| |
Collapse
|
5
|
Arsalanizadeh B, Westacott R. Osteoclastomas ('brown tumours') and spinal cord compression: a review. Clin Kidney J 2015; 6:220-3. [PMID: 26019852 PMCID: PMC4432455 DOI: 10.1093/ckj/sft021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 02/14/2013] [Indexed: 01/08/2023] Open
Abstract
Brown tumours are an uncommon manifestation of primary and secondary hyperparathyroidism. There are numerous case reports of brown tumours arising in various parts of the skeleton. They can therefore present a wide range of clinical manifestations. A recent case highlighted the need for heightened awareness of the diagnosis and prompted a literature review.
Collapse
Affiliation(s)
| | - Rachel Westacott
- John Walls Renal Unit , University Hospitals of Leicester, Leicester General Hospital , Leicester , UK
| |
Collapse
|
6
|
Brown tumor of the cervical spines: a case report with literature review. Asian Spine J 2015; 9:110-20. [PMID: 25705344 PMCID: PMC4330206 DOI: 10.4184/asj.2015.9.1.110] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/28/2013] [Accepted: 01/08/2014] [Indexed: 11/17/2022] Open
Abstract
To report a rare case of axis brown tumor and to review literature of cervical spine brown tumor. Brown tumor is a rare bone lesion, incidence less than 5% in primary hyperparathyroidism. It is more common in secondary hyperparathyroidism with up to 13% of cases. Brown tumor reactive lesion forms as a result of disturbed bone remodeling due to long standing increase in parathyroid hormones. Cervical spine involvement is extremely rare, can be confused with serous spine lesions. To date, only four cases of cervical spine involvement have been reported. Three were due to secondary hyperparathyroidism. Only one was reported to involve the axis and was due to secondary hyperparathyroidism. This is the first reported case of axis brown tumor due to primary hyperparathyroidism. A case report of brown tumor is presented. A literature review was conducted by a Medline search of reported cases of brown tumor, key words: brown tumor, osteoclastoma and cervical lesions. The resulting papers were reviewed and cervical spine cases were listed then classified according to the level, cause, and management. Only four previous cases involved the cervical spine. Three were caused by secondary hyperparathyroidism and one was by primary hyperparathyroidism which involved the C6. Our case was the first case of C2 involvement of primary hyperparathyroidism and it was managed conservatively. Brown tumor, a rare spinal tumor that presents with high PTH and giant cells, requires a high level of suspicion.
Collapse
|
7
|
Callus R, Pullicino R, Buhagiar L, Mizzi A. Lower back pain in a patient on long-term haemodialysis. BMJ Case Rep 2014; 2014:bcr-2014-205110. [PMID: 25100814 DOI: 10.1136/bcr-2014-205110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Roberta Callus
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | | | - Louis Buhagiar
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Adrian Mizzi
- Department of Medical Imaging, Mater Dei Hospital, Msida, Malta
| |
Collapse
|
8
|
Tayfun H, Metin O, Hakan S, Zafer B, Vardar AF. Brown tumor as an unusual but preventable cause of spinal cord compression: Case report and review of the literature. Asian J Neurosurg 2014; 9:40-4. [PMID: 24891890 PMCID: PMC4038866 DOI: 10.4103/1793-5482.131074] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Brown tumor (BT), also known as osteoclastoma, may appear in the context of primary and secondary hyperparathyroidism. Spinal cord compression due to the BT is extremely rare. We present here an unusual case of BT involving thoracal spine and mandible. A 26-year-old woman, who had been on hemodialysis for chronic renal failure for over 6 years, got admitted with dorsal pain and progressive weakness in her lower extremities and gait disturbances. Neurological examination revealed spastic paraparesis and symmetrically hyperactive tendon reflex in the lower extremities. She had hypoesthesia under T10 level. On physical examination, a swelling on the left side of her jaw was also detected. Magnetic resonance imaging (MRI) showed cord compression due to an extradural mass lesion at T8 level. A computerized tomography (CT) scan showed that this expansile lytic lesion was caused by the collapse of vertebra corpus (T8) at that level. CT of the mandible revealed an expansile lytic lesion on left arm of the mandible. Laboratory findings were nearly normal except parathormone level elevation to 1289 pg/mL (normal 30-70 pg/mL). Ultrasound examination showed enlargement of the parathyroid glands. The patient underwent an emergency decompression and stabilization surgery. The lesion was fragile and reddish in appearance and was easy to aspirate. The tumor was reported as "BT." Her weakness in the lower extremities improved in the early postoperative period. Following surgical intervention, the patient was transferred to nephrology clinic for additional medical treatment.
Collapse
Affiliation(s)
- Hakan Tayfun
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Orakdöğen Metin
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Somay Hakan
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Berkman Zafer
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | | |
Collapse
|
9
|
Agrawal L, Habib Z, Emanuele NV. Neurologic disorders of mineral metabolism and parathyroid disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:737-48. [PMID: 24365349 DOI: 10.1016/b978-0-7020-4087-0.00049-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Disorders of mineral metabolism may cause neurologic manifestations of the central and peripheral nervous systems. This is because plasma calcium stabilizes excitable membranes in the nerve and muscle tissue, magnesium is predominantly intracellular and is required for activation of many intracellular enzymes, and extracellular magnesium affects synaptic transmission. This chapter reviews abnormalities in electrolytes and minerals which can be associated with several neuromuscular symptoms including neuromuscular irritability, mental status changes, cardiac and smooth muscle changes, etc.
Collapse
Affiliation(s)
- Lily Agrawal
- Division of Endocrinology and Metabolism, Loyola University Medical Center, Maywood, IL, USA.
| | - Zeina Habib
- Division of Endocrinology and Metabolism, Loyola University Medical Center, Maywood, IL, USA
| | - Nicholas V Emanuele
- Division of Endocrinology and Metabolism, Loyola University Medical Center, Maywood, IL, USA; Endocrinology Section, Edward Hines Jr. VA Hospital, Hines, IL, USA
| |
Collapse
|
10
|
Karagoz A, Turkmen K, Yazici R, Arslan S, Baktık S, Karanis MIE, Altintepe L, Guney I. An exceedingly rare localization of a brown tumor in a hemodialysis patient. Hemodial Int 2012; 17:660-3. [PMID: 23216908 DOI: 10.1111/hdi.12002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Brown tumor, which is seen in the context of hyperparathyroidism, is defined as a uremic bone disease characterized by increased osteoclastic activity and fibroblastic proliferation in the involved bone. In chronic renal failure, there is an excessive parathyroid hormone secretion due to hypocalcemia, hyperphosphatemia, and vitamin D deficiency. Brown tumor of the femur, facial bones, mandible, sternum, ribs, and pelvis are rare, whereas, it rarely involves sacrum. Here, we presented a brown tumor of the sacrum that developed secondary to parathyroid hyperplasia in a patient receiving hemodialysis.
Collapse
Affiliation(s)
- Ali Karagoz
- Department of Nephrology, Meram Training and Research Hospital, Konya, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Sunder S, Verma H, Venkataramanan K. Cervical tumoral calcinosis with secondary hyperparathyroidism in a chronic hemodialysis patient. Hemodial Int 2012; 17:458-62. [PMID: 23072397 DOI: 10.1111/j.1542-4758.2012.00760.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Tumoral calcinosis is an uncommon and severe complication of chronic renal failure. It is generally associated with the presence of a high-serum calcium-and-phosphorus product. We report here a case of a patient on maintenance hemodialysis who presented with progressively increasing, solitary, tumor-like swelling over the nape of the neck. A 50-year-old female on thrice weekly maintenance hemodialysis for the last 3 years presented with a small swelling over the nape of the neck that had been progressively increasing over the last 1 year to cricket ball size. The patient was investigated and diagnosed as having tumoral calcinosis. The metastatic calcification occurring in the patient was most likely related to high calcium × phosphate product with coexistent secondary hyperparathyroidism possibly aggravated by vitamin D therapy. The patient was treated with withdrawal of vitamin D therapy, strict control of serum phosphate levels with noncalcemic phosphate binders, and subtotal parathyroidectomy. The neck swelling started decreasing in size after 2 months of parathyroidectomy and there was marked clinical improvement with drop in serum parathormone levels, over a period of 6 months. After 2 years of parathyroidectomy, the neck swelling again started increasing in size with increase in serum parathormone levels. The patient was treated with cinacalcet and the neck swelling gradually decreased in size along with control of serum parathormone and phosphate levels.
Collapse
Affiliation(s)
- Sham Sunder
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, and Dr. Ram Manohar Lohia Hospital, New Delhi, India.
| | | | | |
Collapse
|
12
|
Neild GH, Jha R, Gude D, Mandal S, Batta R. Tackling the 'brown' frown. Clin Kidney J 2012; 5:176-177. [PMID: 29497525 PMCID: PMC5783214 DOI: 10.1093/ckj/sfs014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 01/30/2012] [Indexed: 11/14/2022] Open
Affiliation(s)
- G H Neild
- Department of Nephrology, Medwin Hospitals, Hyderabad, India
| | - Ratan Jha
- Department of Nephrology, Medwin Hospitals, Hyderabad, India
| | - Dilip Gude
- Department of Nephrology, Medwin Hospitals, Hyderabad, India
| | | | | |
Collapse
|
13
|
Brown tumor of the cervical spine: a case report and review of the literature. Clin Rheumatol 2010; 30:419-24. [DOI: 10.1007/s10067-010-1608-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Accepted: 10/13/2010] [Indexed: 10/18/2022]
|
14
|
Kampschreur LM, Hoogeveen EK, op den Akker JW, Beutler JJ, Beems T, Dorresteijn LDA, de Sévaux RGL. A haemodialysis patient with back pain: brown tumour as a cause of spinal cord compression under cinacalcet therapy. NDT Plus 2010; 3:291-295. [PMID: 28657067 PMCID: PMC5477967 DOI: 10.1093/ndtplus/sfq052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 03/21/2010] [Accepted: 03/22/2010] [Indexed: 11/16/2022] Open
Abstract
A 43-year-old haemodialysis patient was admitted to hospital because of paroxysmal pain in the upper abdominal region radiating to the back. Laboratory tests showed severe hyperparathyroidism [intact parathyroid hormone (iPTH) 69 pmol/L; reference range: 1.3-6.8 pmol/L], hypercalcaemia (2.79 mmol/L), hyperphosphataemia (1.6 mmol/L) and elevated serum total alkaline phosphatase (200 U/L). After developing a disturbed sensation and paraesthesia in both feet, epidural compression of the spinal cord was suspected. Magnetic resonance imaging showed a tumour that severely compressed the myelum of the thoracic spine. Histological investigation revealed a brown tumour or osteoclastoma, an erosive bony lesion caused by increased osteoclastic activity and peritrabecular fibrosis. A brown tumour is a benign tumour that is a rare complication of severe renal hyperparathyroidism. The brown tumour developed despite a 1-year treatment of the patient with cinacalcet, which, however, did not result in a major decrease in serum iPTH concentration (from 110 to 69 pmol/L: 37% reduction). Urgent decompressive neurosurgery and subtotal parathyroidectomy resulted in a complete recovery.
Collapse
Affiliation(s)
| | - Ellen K. Hoogeveen
- Department of Nephrology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Jeroen W. op den Akker
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jaap J. Beutler
- Department of Nephrology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Tjemme Beems
- Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Ruud G. L. de Sévaux
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|