Occult solitary fibrous tumour of the pleura presenting as recurrent spontaneous pneumothorax

A woman in her 30s, non-smoker, presented at the emergency department two times because of spontaneous pneumothorax. The first episode was treated with small bore catheter drainage, while during the second episode-occurring only 1 week later-thoracoscopic talcage was attempted. The postoperative course was characterised by slow clinical and radiological resolution, and recurrence 3 days after discharge. Eventually, multiportal video-assisted thoracoscopic exploration identified an interfissural solid mass. Resection and further work-up revealed the diagnosis of 'low-risk' solitary fibrous tumour (SFT) stage pT1N0M0. The interdisciplinary tumour board advised no adjuvant therapy. A CT thorax was scheduled in 1 year for follow-up. The patient was discharged without complications and has had no recurrences of pneumothorax at 6 months of follow-up. This report shows that SFT can easily be missed on initial presentation and should be considered in the differential diagnosis of pneumothorax, especially when frequently recurring.

Severe Hypertriglyceridemia After Use of Bempedoic Acid

Bempedoic is a new drug for the management of hypercholesterolemia, approved since 2020 by the EMA for use in Europe. In this case report, we describe a 65-year-old woman with sudden worsening of hypertriglyceridemia after the introduction of bempedoic acid. Triglyceride levels normalized quickly on withdrawal of the drug. With this case report, we want to reveal a possible association between bempedoic acid and the paradoxical occurrence of hypertriglyceridemia. Furthermore, we want to emphasize the limited evidence regarding the use of bempedoic acid in patients with pre-existing hypertriglyceridemia.

LEARNING POINTS

Bempedoic acid is a new drug with a proven positive effect on LDL reduction and cardiovascular outcomes.Metabolic adverse events, especially hyperuricemia and gout, following the use of bempedoic acid are well documented.The current literature provides very limited evidence regarding the use of bempedoic acid in patients with pre-existing hypertriglyceridemia, so caution is advised regarding use of this drug this population.

Clinicopathological characteristics and disease chronicity in native kidney biopsies in Flanders

Background

The Flemish Collaborative Glomerulonephritis Group (FCGG) registry provides complete population data on kidney disease epidemiology in the region of Flanders (Belgium), as it captures all native kidney biopsies performed in its population of 6.5 million inhabitants.

Methods

From 2017 until 2019, 2054 adult kidney biopsies were included from 26 nephrology centers (one biopsy per patient). Data on nephrotic and nephritic syndrome were available in 1992 and 2026 biopsies, respectively. In a subgroup of 898 biopsies containing ≥10 glomeruli from 2018 to 2019, disease chronicity was graded using the Mayo Clinic Chronicity Score (MCCS). The association between clinical variables and MCCS was determined using simple and multiple linear regression models.

Results

Nephrotic syndrome (present in 378 patients, 19.0%) was most frequently caused by minimal change disease in younger patients (18-44 years), membranous nephropathy in older patients (45-74 years) and amyloidosis in the elderly (>75 years). Nephritic syndrome (present in 421 patients, 20.8%) was most frequently caused by immunoglobulin A nephropathy (IgAN) in younger patients (18-64 years) and ANCA-associated vasculitis (AAV) in older patients (>64 years). AAV and IgAN were the most frequent underlying diagnoses in biopsies in which crescents were identified. In multivariable analysis, acute and chronic kidney disease and diagnoses of diabetic kidney disease, nephrosclerosis and hyperoxaluria/hypercalcemic nephropathy were associated with the highest MCCS increases.

Conclusions

The FCGG registry validates data from previous Western European registries and provides a snapshot of disease chronicity in the whole biopsied Flemish population.

Epidemiology of native kidney disease in Flanders: results from the FCGG kidney biopsy registry

Background

The Flemish Collaborative Glomerulonephritis Group (FCGG) registry is the first population-based native kidney biopsy registry in Flanders, Belgium. In this first analysis, we report on patient demographics, frequency distribution and incidence rate of biopsied kidney disease in adults in Flanders.

Methods

From January 2017 to December 2019, a total of 2054 adult first native kidney biopsies were included. A ‘double diagnostic coding’ strategy was used, in which every biopsy sample received a histopathological and final clinical diagnosis. Frequency distribution and incidence rate of both diagnoses were reported and compared with other European registries.

Results

The median age at biopsy was 61.1 years (interquartile range, 46.1–71.7); male patients were more prevalent (62.1%) and biopsy incidence rate was 129.3 per million persons per year. Immunoglobulin A nephropathy was the most frequently diagnosed kidney disease (355 biopsies, 17.3% of total) with a similar frequency as in previously published European registries. The frequency of tubulointerstitial nephritis (220 biopsies, 10.7%) and diabetic kidney disease (154 biopsies, 7.5%) was remarkably higher, which may be attributed to changes in disease incidence as well as biopsy practices. Discordances between histopathological and final clinical diagnoses were noted and indicate areas for improvement in diagnostic coding systems.

Conclusions

The FCGG registry, with its ‘double diagnostic coding’ strategy, provides useful population-based epidemiological data on a large Western European population and allows subgroup selection for future research.

Symmetric polyneuropathy after viral symptomatology - not always Guillain-Barré Syndrome

Introduction: Guillain-Barré Syndrome usually presents with ascending symmetric polyneuropathy, typically preceded by a viral infection. Despite the low incidence, physicians will often include Guillain-Barré Syndrome in their differential diagnosis. However, another underlying cause of polyneuropathy known as ANCA-associated vasculitis (AAV) is even more rare than Guillain-Barré Syndrome and therefore is usually overlooked. AAV has a broad spectrum of symptomatology and sometimes presents only with neurological complaints. If treated inappropriately, AAV can be lethal.Case report: In this case report, we describe a 72-year-old man presenting with complaints of symmetric polyneuropathy and paresis of both legs, initially diagnosed as Guillain-Barré Syndrome. During his treatment with intravenous immunoglobulins, he developed acute renal failure. Further investigations showed ANCA positive pauci-immune acute glomerulonephritis. This, in combination with eosinophilia and sinusitis, led to a final diagnosis of Eosinophilic Granulomatosis with Polyangiitis EGPA (Churg-Strauss disease). Induction therapy was initiated using glucocorticoids, cyclophosphamide and temporary plasmapheresis, followed by maintenance therapy with azathioprine complicated by bone marrow suppression. Azathioprine was discontinued and monotherapy with low-dose glucocorticoids was continued with the recovery of bone marrow function, good clinical condition and no relapse of vasculitis at 14 months follow-up.Conclusion: Physicians should be aware of the possible presentations of AAV. When suspected, indirect immunofluorescence assay for ANCA should be performed. When AAV is diagnosed, induction therapy should be administered as soon as possible, followed by maintenance therapy and careful follow-up, as patients are at risk for opportunistic infections, bone marrow toxicity or relapse.

Tissue is the issue: when a second biopsy reveals the true diagnosis

We describe the case of a woman with minimal glomerular changes on initial kidney biopsy. On long-term follow-up, the patient developed nephrotic proteinuria and a second kidney biopsy was performed, which revealed focal segmental glomerulosclerosis (FSGS). Findings from electron microscopy (EM) examination suggested a genetic form of FSGS. Next-generation sequencing showed heterozygosity for a mutation in COL4A3. Collagen IV nephropathies can be linked to late-onset FSGS. By establishing a genetic cause of FSGS, immunosuppressive treatment can be avoided. This case emphasizes the importance of re-biopsy in cases of a non-explained rise in proteinuria. EM can be helpful in differentiating between primary and secondary FSGS and informing treatment strategies. In cases of adult-onset FSGS that cannot be categorized by clinical–pathological assessment, genetic testing should be considered.

Fibrin sheet covering subclavian or femoral dialysis catheters

The existence of a sheet around a single lumen dialysis catheter tip, which provokes a valve mechanism, is proved by the observation that several times during the replacement procedure of a dialysis catheter, a sheet surrounding the surface of the catheter is removed with the dialysis catheter. This sheet is grey, approximately 1 mm thick and 30 mm long and consists of fibrin and thrombocytes. Bacteriological examinations were always negative. The existence of the sheet in vivo is demonstrated by digitalized angiography during the removal procedure for single lumen dialysis catheters. Rarely, only the sheet is removed with the catheter. It all other instances, the sheet is stripped off and remains in the subcutaneous tunnel or in the vascular bed without causing much clinical discomfort in most patients. Occasionally an episode of cough, dyspnea, hypotension, retrosternal oppression or hemoptae after removing the single lumen dialysis catheter, suggest pulmonary embolism or lung infarction.

Polyunsaturated fatty acids of the n-3 class in chronic dialysis

N-3 PUFAs are believed to 1) reduce serum lipids, 2) modify the complement activating system, 3) increase red blood cell elasticity, and 4) decrease thrombotic events. These four parameters were investigated in 19 chronic stabilized dialysis patients assessed by 1) the control of the serum lipids, 2) the degree of leukopenia 10 minutes after the start of dialysis, 3) the degree of red cell fragmentation (RCF) during dialysis, and 4) the reusability of the dialyzer. The patients were their own controls during four periods: 1) no PUFAs for longer than 6 months, 2) 4 x 425 mg of PUFAs/day for 6 weeks, 3) 6 x 425 mg PUFAs/day for 6 weeks, and 4) no PUFAs during at least 6 weeks. Previous diets and medications remained unchanged. It was concluded that there was no significant effect on serum lipids in the given dosages, and no effect on the degree of leukopenia, red blood cell elasticity or bleeding, and/or antithrombotic activity. No change was seen in insulinemia, fibrinogenemia, or arterial pressure. No serious side effects were noted other than a "fishy aftertaste."

Successful treatment of aortic rupture presenting as a syncope: the role of echocardiography in diagnosis

A syncope was the first symptom of aortic rupture in a patient with chronic arterial hypertension. This syncope was the consequence of an acute haemopericardium which resulted in a sudden drop of the cardiac output. Urgent echocardiographic examination in the emergency room made early diagnosis and life-saving pericardiocentesis possible.

Pseudo-Kaposi's sarcoma as a complication of Cimino-Brescia arteriovenous fistulas in hemodialysis patients

Pseudo-Kaposi's sarcoma is a skin lesion that is associated with chronic venous insufficiency and/or congenital arteriovenous fistulas. Theoretically, this lesion could also be expected in connection with hemodialysis vascular accesses. Nevertheless, this disease has been reported only once in conjunction with a Cimino-Brescia arteriovenous fistula, and no attention has been paid to the potential complications of this disease. In the present paper 3 cases are reported. In 1 patient pseudo-Kaposi's sarcoma was complicated by an infected open wound as a consequence of a trauma. In the 2 other patients, a skin biopsy was followed by local infection and retarded healing of the wound. Evaluation by fistulagraphy and/or Doppler revealed venous outflow stenosis in only 1 case. After reconstruction or ligation of the fistula, correction of the lesions was observed. It is concluded that pseudo-Kaposi's sarcoma can occur as a complication of Cimino-Brescia arteriovenous fistulas, necessitating early correction of the fistula. The performance of a skin biopsy might be associated with infection and delayed wound healing, so that this diagnostic procedure should only be performed in cases where the clinical diagnosis is not obvious.

Postoperative immunological response against contractile proteins after coronary bypass surgery

The pathogenesis of post-cardiac injury syndrome was studied prospectively in 62 patients who underwent coronary bypass grafting. Preoperative and serial postoperative titres of actin and myosin antibodies were measured by an enzyme linked immunosorbent assay. Perioperative cumulative release of serum aspartate and alanine aminotransferases, lactate dehydrogenase, and creatine kinase was calculated by approximation formulas that are used to estimate infarct size. Complete post-cardiac injury syndrome developed in eight (13%) patients and an incomplete syndrome developed in 16 (26%). There was a significant correlation between frequency and intensity of the syndrome and the ratio of postoperative to preoperative titres of actin and myosin antibodies. Furthermore, there was a significant correlation between the cumulative release of lactate dehydrogenase, serum aspartate aminotransferase, and creatine kinase and the number of coronary vessels that were grafted, but no correlation was found between the incidence of post-cardiac injury syndrome and the number of coronary bypasses grafted or between the cumulative enzyme release and the postoperative immunological response against the major contractile proteins, actin and myosin. The amount of enzymes released during coronary bypass surgery seems to be a good indicator of the extent of myocardial damage during operation but it does not determine either the incidence of post-cardiac injury syndrome or the postoperative immunological response against the main contractile proteins actin and myosin.