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de Boisriou I, Ellouze S, Kassasseya C, Feral-Pierssens AL, Gerlier C, Chauvin A, Beaune S, Dubreucq E, Pereira L, Chocron R, Khellaf M, Mariotte É, Zafrani L, Peyrony O. Misdiagnosis of thrombotic microangiopathy in the emergency department: a multicenter retrospective study. Intern Emerg Med 2024; 19:115-124. [PMID: 37914919 DOI: 10.1007/s11739-023-03457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/08/2023] [Indexed: 11/03/2023]
Abstract
To estimate the rate of inappropriate diagnosis in patients who visited the ED with thrombotic microangiopathy (TMA) and to assess the factors and outcomes associated with emergency department (ED) misdiagnosis. Retrospective multicenter study of adult patients admitted to the intensive care unit (ICU) for TMA from 2012 to 2021 who had previously attended the ED for a reason related to TMA. Patient characteristics and outcomes were compared in a univariate analysis based on whether a TMA diagnosis was mentioned in the ED or not. Forty patients were included. The diagnosis of TMA was not mentioned in the ED in 16 patients (40%). Patients for whom the diagnosis was mentioned in the ED had more frequently a request for schistocytes research, and therefore had more often objectified schistocytes. They also had more frequently a troponin dosage in the ED (even if the difference was not significant), an ECG performed or interpreted, and were admitted more quickly in the ICU (0 [0-0] vs 2 [0-2] days; P = 0.002). Hemoglobin levels decreased significantly in both groups, and creatinine levels increased significantly in the misdiagnosis group between ED arrival and ICU admission. In patients with a final diagnosis of TTP, the time to platelets durable recovery was shorter for those in whom the diagnosis was mentioned in the ED without reaching statistical significance (7 [5-11] vs 14 [5-21] days; P = 0.3).
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Affiliation(s)
| | - Sami Ellouze
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Christian Kassasseya
- Emergency Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Camille Gerlier
- Emergency Department, Groupe Hospitalier Paris-Saint-Joseph, Paris, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sebastien Beaune
- Emergency Department, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Versailles St Quentin- UFR Simone Veil santé, Montigny-le-Bretonneux, France
| | - Evelyne Dubreucq
- Emergency Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Pereira
- Emergency Department, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Richard Chocron
- Emergency Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMR-S970, Paris Cardiovascular Research Center, Team "Integrative Epidemiology of Cardiovascular Diseases", Université Paris Cité, Paris, France
| | - Mehdi Khellaf
- Emergency Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Éric Mariotte
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France.
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Schmidt T, Huber TB. [Thrombotic microangiopathy]. Med Klin Intensivmed Notfmed 2023; 118:14-20. [PMID: 36633606 DOI: 10.1007/s00063-022-00984-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023]
Abstract
In the emergency room, patients with anemia and thrombocytopenia are common. Although these findings can often be explained by the medical situation, thrombotic microangiopathy is an important differential diagnosis. In this case, occlusion of the smallest vessels consequently leads to functional impairment of the affected organs. Patients generally present with symptoms of organ dysfunction, e.g., in the kidney or brain. Characteristically, Coombs-negative fragmentation of erythrocytes with hemolysis occurs in the area of the occluded vessels. Lactate dehydrogenase levels are elevated, and platelets and haptoglobin are reduced. Differential diagnoses beyond thrombotic microangiopathy that should be considered are numerous and diverse in their pathophysiology. Rapid workup is needed, because sometimes a specific treatment must be initiated rapidly. For example, thrombotic thrombocytopenic purpura leads to death in about 90% of patients if left untreated. However, by reconstitution of the underlying deficiency of the so-called ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) by plasma separation, survival can be ensured in most cases. Complement-mediated hemolytic uremic syndrome should also be considered and, if suspected, treated with complement inhibition. In many cases, however, thrombotic microangiopathy reflects a disorder elsewhere and may be a manifestation of severe hypertension or a coagulation disorder, such as disseminated intravascular coagulation or antiphospholipid syndrome. It can also be observed as a consequence of drug therapies or metabolic derangement. Systemic workup is therefore necessary for rapid clarification of differential diagnoses.
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Affiliation(s)
- Tilman Schmidt
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Tobias B Huber
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Saito K, Matsumoto M. [The frontline of TMA management]. Rinsho Ketsueki 2022; 63:463-470. [PMID: 35662172 DOI: 10.11406/rinketsu.63.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thrombotic microangiopathy (TMA) is a pathological condition characterized by platelet thrombi-induced generalized microvascular occlusion, thrombocytopenia, and microangiopathic hemolytic anemia. TMA includes the life-threatening diseases thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). TTP is different from HUS in that it has a severe deficiency in ADAMTS13 activity. Congenital TTP is caused by a lack of plasma ADAMTS13 activity caused by genetic mutations, and acquired TTP is caused by a secondary deficiency caused by autoantibodies. In Japan the only product approved for the treatment of congenital TTP is fresh frozen plasma containing ADAMTS13. Recombinant ADAMTS13 may provide a new treatment option for congenital TTP. The first-line treatment for acquired TTP is plasma exchange. Rituximab treatment should be considered for patients who are refractory or have relapsed. Caplacizumab is a nanobody that specifically targets von Willebrand factor. ISTH recently published guidelines recommending that caplacizumab be added to the initial treatment for acquired TTP. Atypical HUS (aHUS) is related with the dysregulation of the complement alternative pathway. Eculizumab, a monoclonal antibody that inhibits C5, was the first drug approved for aHUS, and it was found to be well-tolerated by patients and effective in clinical use. TMA is classified based on its etiology, and specific treatments for targeting various etiologies are now available.
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Affiliation(s)
- Kenki Saito
- Department of Blood Transfusion Medicine, Nara Medical University
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Gholizad-Kolveiri S, Hooman N, Alizadeh R, Hoseini R, Otukesh H, Talebi S, Akouchekian M. Whole exome sequencing revealed a novel homozygous variant in the DGKE catalytic domain: a case report of familial hemolytic uremic syndrome. BMC Med Genet 2020; 21:169. [PMID: 32838746 PMCID: PMC7446132 DOI: 10.1186/s12881-020-01097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 07/28/2020] [Indexed: 11/13/2022]
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by microangiopathic hemolytic anemia caused by small vessel thrombosis, thrombocytopenia, and renal failure. The common cause of aHUS is a dysregulation in the alternative complement pathway. Mutations in none complement genes such as diacylglycerol kinase epsilon (DGKE) can also result in this syndrome. Case presentation Here, we report on a 19-year-old female with the clinical diagnosis of aHUS, who has unaffected consanguineous parents and an older sibling who was deceased from aHUS when she was seven months old. We performed whole exome sequencing (WES) followed by evaluation of detected variants for functional significance, using several online prediction tools. Next, in order to confirm the detected pathogenic variant in proband and segregation analysis in her family, Sanger sequencing was done. The novel variant was analyzed in terms of its impact on the protein 3-dimensional structure by computational structural modeling. The results revealed that the proband carried a novel homozygous missense variant in DGKE located in exon 6 of the gene (NM_003647.3, c.942C > G [p.Asn314Lys]), and in silico analysis anticipated it as damaging. Protein computational study confirmed the influence of potential pathogenic variant on structural stability and protein function. Conclusion We suggest that some variations in the catalytic domain of DGKE like p.Asn314Lys which can cause alterations in secondary and 3-D structure of protein, might lead to aHUS.
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Affiliation(s)
- Soraya Gholizad-Kolveiri
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran
| | - Nakysa Hooman
- Department of Pediatric Nephrology, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Alizadeh
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran
| | - Rozita Hoseini
- Department of Pediatric Nephrology, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Otukesh
- Department of Pediatric Nephrology, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Talebi
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran.
| | - Mansoureh Akouchekian
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran.
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Guerra JA, Zhang C, Bard JE, Yergeau D, Halasa N, Gómez-Duarte OG. Comparative genomic analysis of a Shiga toxin-producing Escherichia coli (STEC) O145:H25 associated with a severe pediatric case of hemolytic uremic syndrome in Davidson County, Tennessee, US. BMC Genomics 2020; 21:564. [PMID: 32807093 PMCID: PMC7437938 DOI: 10.1186/s12864-020-06967-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/03/2020] [Indexed: 12/02/2022] Open
Abstract
Background Shiga toxin-producing E. coli (STECs) are foodborne pathogens associated with bloody diarrhea and hemolytic uremic syndrome (HUS). Although the STEC O157 serogroup accounts for the highest number of infections, HUS-related complications and deaths, the STEC non-O157, as a group, accounts for a larger proportion of STEC infections and lower HUS cases. There is limited information available on how to recognize non-O157 serotypes associated with severe disease. The objectives of this study were to describe a patient with STEC non-O157 infection complicated with HUS and to conduct a comparative whole genome sequence (WGS) analysis among the patient’s STEC clinical isolate and STEC O157 and non-O157 strains. Results The STEC O145:H25 strain EN1I-0044-2 was isolated from a pediatric patient with diarrhea, HUS and severe neurologic and cardiorespiratory complications, who was enrolled in a previously reported case-control study of acute gastroenteritis conducted in Davidson County, Tennessee in 2013. The strain EN1I-0044-2 genome sequence contained a chromosome and three plasmids. Two of the plasmids were similar to those present in O145:H25 strains whereas the third unique plasmid EN1I-0044-2_03 shared no similarity with other STEC plasmids, and it carried 23 genes of unknown function. Strain EN1I-0044-2, compared with O145:H25 and O157 serogroup strains shared chromosome- and plasmid-encoded virulence factors, including Shiga toxin, LEE type III secretion system, LEE effectors, SFP fimbriae, and additional toxins and colonization factors. Conclusions A STEC O145:H25 strain EN1I-0044-2 was isolated from a pediatric patient with severe disease, including HUS, in Davidson County, TN. Phylogenetic and comparison WGS analysis provided evidence that strain EN1I-0044-2 closely resembles O145:H25, and confirmed an independent evolutionary path of STEC O145:H25 and O145:H28 serotypes. The strain EN1I-0044-2 virulence make up was similar to other O145:H25 and O157 serogroups. It carried stx2 and the LEE pathogenicity island, and additional colonization factors and enterotoxin genes. A unique feature of strain EN1I-0044-2 was the presence of plasmid pEN1I-0044-2_03 carrying genes with functions to be determined. Further studies will be necessary to elucidate the role that newly acquired genes by O145:H25 strains play in pathogenesis, and to determine if they may serve as genetic markers of severe disease.
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Affiliation(s)
- Julio A Guerra
- International Enteric Vaccine Research Program, Division of Infectious Diseases, Department of Pediatrics, University at Buffalo, The State University of New York (SUNY), Jacobs School of Medicine and Biomedical Sciences, 875 Ellicott St. Office 6090, Buffalo, NY, 14203, USA
| | - Chengxian Zhang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jonathan E Bard
- UB Genomics and Bioinformatics Core, Center of Excellence in Bioinformatics, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Donald Yergeau
- UB Genomics and Bioinformatics Core, Center of Excellence in Bioinformatics, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Natasha Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Oscar G Gómez-Duarte
- International Enteric Vaccine Research Program, Division of Infectious Diseases, Department of Pediatrics, University at Buffalo, The State University of New York (SUNY), Jacobs School of Medicine and Biomedical Sciences, 875 Ellicott St. Office 6090, Buffalo, NY, 14203, USA. .,Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Lavrek D, Lava SAG, Milani GP, Simonetti GD, Bianchetti MG, Giannini O. Hemolytic-uremic syndrome after Escherichia coli urinary tract infection in humans: systematic review of the literature. J Nephrol 2018; 31:919-24. [PMID: 30328581 DOI: 10.1007/s40620-018-0543-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/29/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intestinal infections caused by a shigatoxin-positive Escherichia coli (mostly of the serogroups O26, O45, O103, O111, O121, O145 and especially O157) are a common cause of hemolytic-uremic syndrome. Hemolytic-uremic syndrome was first linked with an E. coli urinary tract infection 40 years ago. METHODS We conducted a systematic review of the literature addressing the association between E. coli urinary tract infection and hemolytic-uremic syndrome. RESULTS For the final analysis, we retained 23 original reports published since 1979. Five unselected pediatric case series addressed the possible occurrence of hemolytic-uremic syndrome after an acute symptomatic E. coli urinary tract infection among 266 cases and found the mentioned association in 8 (3.0%) cases. We also found 28 individual cases (17 females and 11 males) of hemolytic-uremic syndrome preceded by an E. coli urinary tract infection: 16 children aged from 2 days to 6.0 years and 12 adults aged from 22 to 75 years. Testing for shigatoxin, performed in 19 cases, was positive in 15 cases. E. coli serotyping was performed in 18 cases: testing for serotype O157, O103 and O145 was positive in one, one and two cases, respectively, while testing for serotype O26, O45, O111 and O121 was always negative. CONCLUSIONS Hemolytic-uremic syndrome rarely occurs after an acute E. coli urinary tract infection. It affects both children and adults and is mostly caused by germs that are shigatoxin-positive.
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Tekgündüz E, Yılmaz M, Erkurt MA, Kiki I, Kaya AH, Kaynar L, Alacacioglu I, Cetin G, Ozarslan I, Kuku I, Sincan G, Salim O, Namdaroglu S, Karakus A, Karakus V, Altuntas F, Sari I, Ozet G, Aydogdu I, Okan V, Kaya E, Yildirim R, Yildizhan E, Ozgur G, Ozcebe OI, Payzin B, Akpinar S, Demirkan F. A multicenter experience of thrombotic microangiopathies in Turkey: The Turkish Hematology Research and Education Group (ThREG)-TMA01 study. Transfus Apher Sci 2018; 57:27-30. [PMID: 29503132 DOI: 10.1016/j.transci.2018.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Thrombotic microangiopathies (TMAs) are rare, but life-threatening disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) associated with multiorgan dysfunction as a result of microvascular thrombosis and tissue ischemia. The differentiation of the etiology is of utmost importance as the pathophysiological basis will dictate the choice of appropriate treatment. We retrospectively evaluated 154 (99 females and 55 males) patients who received therapeutic plasma exchange (TPE) due to a presumptive diagnosis of TMA, who had serum ADAMTS13 activity/anti-ADAMTS13 antibody analysis at the time of hospital admission. The median age of the study cohort was 36 (14-84). 67 (43.5%), 32 (20.8%), 27 (17.5%) and 28 (18.2%) patients were diagnosed as thrombotic thrombocytopenic purpura (TTP), infection/complement-associated hemolytic uremic syndrome (IA/CA-HUS), secondary TMA and TMA-not otherwise specified (TMA-NOS), respectively. Patients received a median of 18 (1-75) plasma volume exchanges for 14 (153) days. 81 (52.6%) patients received concomitant steroid therapy with TPE. Treatment responses could be evaluated in 137 patients. 90 patients (65.7%) achieved clinical remission following TPE, while 47 (34.3%) patients had non-responsive disease. 25 (18.2%) non-responsive patients died during follow-up. Our study present real-life data on the distribution and follow-up of patients with TMAs who were referred to therapeutic apheresis centers for the application of TPE.
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Affiliation(s)
- Emre Tekgündüz
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey.
| | - Mehmet Yılmaz
- Gaziantep University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Mehmet Ali Erkurt
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Ilhami Kiki
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Ali Hakan Kaya
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Leylagul Kaynar
- Erciyes University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Inci Alacacioglu
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
| | - Guven Cetin
- Bezmialem University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul, Turkey
| | - Ibrahim Ozarslan
- Gaziantep University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Irfan Kuku
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Gulden Sincan
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Ozan Salim
- Akdeniz University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Antalya, Turkey
| | - Sinem Namdaroglu
- Bozyaka Education and Research Hospital, Hematology Clinic, Izmir, Turkey
| | - Abdullah Karakus
- Dicle University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Diyarbakir, Turkey
| | - Volkan Karakus
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Mugla, Turkey
| | - Fevzi Altuntas
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Ismail Sari
- Pamukkale University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Denizli, Turkey
| | - Gulsum Ozet
- Ankara Numune Education and Research Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Ismet Aydogdu
- Celal Bayar University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Manisa, Turkey
| | - Vahap Okan
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Emin Kaya
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Rahsan Yildirim
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Esra Yildizhan
- Erciyes University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Gokhan Ozgur
- Gulhane Military Medical Academy University, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Osman Ilhami Ozcebe
- Hacettepe University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Bahriye Payzin
- Katip Celebi University, Ataturk Training and Research Hospital, Hematology Clinic, Izmir, Turkey
| | - Seval Akpinar
- Sisli Hamidiye Etfal Education and Research Hospital, Hematology Clinic, Istanbul, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
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Chinchilla-López P, Cruz-Ramón V, Ramírez-Pérez O, Méndez-Sánchez N. Gastroenteritis in an adult female revealing hemolytic uremic syndrome: Case report. World J Gastroenterol 2018; 24:763-766. [PMID: 29456415 PMCID: PMC5807679 DOI: 10.3748/wjg.v24.i6.763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/15/2017] [Accepted: 12/20/2017] [Indexed: 02/06/2023] Open
Abstract
Nowadays acute gastroenteritis infection caused by Escherichia coli (E. coli) O157:H7 is frequently associated with hemolytic uremic syndrome (HUS), which usually developed after prodromal diarrhea that is often bloody. The abdominal pain accompanied by failure kidney is a suspicious symptom to develop this disorder. Their pathological characteristic is vascular damage which manifested as arteriolar and capillary thrombosis with abnormalities in the endothelium and vessel walls. The major etiological agent of HUS is enterohemorragic (E coli) strain belonging to serotype O157:H7. The lack of papers about HUS associated to gastroenteritis lead us to report this case for explain the symptoms that are uncommon. Furthermore, this report provides some strategies to suspect and make an early diagnosis, besides treatment approach to improving outcomes and prognosis for patients with this disorder.
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Affiliation(s)
| | - Vania Cruz-Ramón
- Liver Research Unit, Medica Sur Clinic and Foundation, Mexico City 14050, Mexico
| | - Oscar Ramírez-Pérez
- Liver Research Unit, Medica Sur Clinic and Foundation, Mexico City 14050, Mexico
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation, Mexico City 14050, Mexico
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Rigamonti D, Simonetti GD. Direct cardiac involvement in childhood hemolytic-uremic syndrome: case report and review of the literature. Eur J Pediatr 2016; 175:1927-1931. [PMID: 27659663 DOI: 10.1007/s00431-016-2790-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 09/12/2016] [Accepted: 09/14/2016] [Indexed: 11/28/2022]
Abstract
UNLABELLED Overhydration, hypertension, anemia, or dyselectrolytemias sometimes cause cardiovascular impairment in childhood hemolytic-uremic syndrome. Here, we report the case of a 4.5-year-old boy with hemolytic-uremic syndrome and sudden onset, 6 h later, of hemodynamic compromise secondary to a cardiac thrombotic micro-angiopathy. The child died. In the literature, we found 18 further cases with cardiac compromise ≤25 days after diagnosis. The following causes were found: micro-angiopathy, pericardial blood causing tamponade, and myocarditis. CONCLUSION We were able to document only 19 cases of childhood hemolytic-uremic syndrome complicated by a direct cardiac compromise. Nonetheless, we speculate that a direct cardiac compromise accounts for many cases of childhood hemolytic-uremic syndrome complicated by sudden death during the initial hospitalization. Hence, we propose to always measure troponin in children with hemolytic-uremic syndrome to detect a latent myocardial damage. What is Known: • Overhydration, hypertension, anemia, or dyselectrolytemias sometimes cause cardiovascular impairment in childhood hemolytic-uremic syndrome. What is New: • This study documents 19 cases of childhood hemolytic-uremic syndrome complicated by a direct cardiac compromise ≤ 25 days after diagnosis. • The Following causes were found: micro-angiopathy, pericardial blood causing tamponade, and myocarditis.
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Affiliation(s)
- Davide Rigamonti
- Pediatric Department of Southern Switzerland, Via Ospedale, CH-6500, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Pediatric Department of Southern Switzerland, Via Ospedale, CH-6500, Bellinzona, Switzerland. .,Division of Pediatric Nephrology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland.
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10
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Thiongane A, Ndongo AA, Ba ID, Boiro D, Faye PM, Keita Y, Ba A, Cissé DF, Basse I, Thiam L, Ly ID, Niang B, Ba A, Fall AL, Diouf S, Ndiaye O, Ba M, Sarr M. [ Hemolytic-uremic syndrome (HUS) in children at the University Hospital Center in Dakar: about four cases]. Pan Afr Med J 2016; 24:138. [PMID: 27642476 PMCID: PMC5012731 DOI: 10.11604/pamj.2016.24.138.8822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/17/2016] [Indexed: 12/02/2022] Open
Abstract
Le syndrome hémolytique et urémique (SHU) est une cause fréquente d'insuffisance rénale aiguë (IRA) organique chez l'enfant. C'est une complication évolutive des gastroentérites aiguës (GEA) en particulier à Escherichia coli de l'enfant. Notre objectif était de décrire les aspects cliniques, thérapeutiques et évolutifs de cette affection chez quatre enfants. Nous avions colligé quatre cas de SHU. L’âge moyen était de 10,5 mois (5-15mois) exclusivement des garçons. L'examen clinique retrouvait une anémie de type hémolytique (pâleur et ictére), un syndrome oedémateux avec oligo-anurie (2 cas), une hypertension artérielle (1 patient), une GEA avec déshydratation sévère et choc hypovolémique (2 patients), des troubles de conscience. L'IRA était notée chez tous les patients de même que la thrombopénie et les schizocytes au frottis. Le Coombs direct était négatif. Il y avait une hyperkaliémie (3patients) dont 1 patient supérieure à 9,2 mmol/l, une hyponatrémie à 129mmol/l(1 patient) et une hypernatrémie à 153mmol/l (1 patient). Le shu était secondaire à une pneumonie à pneumocoque (1 patient), une GEA à E. coli (1 patient). Le traitement était essentiellement symptomatique et comprenait la restriction hydrique, la transfusion de concentrés érythrocytaires, les diurétiques, la dialyse péritonéale et l'hémodialyse. L’évolution était marquée par la survenue d'une insuffisance rénale chronique (1 patient) après 6 mois de suivi et la guérison (1 cas). Nous avions noté 3décés. Le SHU est la cause la plus fréquente d'IRA organique du nourrisson. Le diagnostic est essentiellement biologique, le traitement est surtout symptomatique.
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Affiliation(s)
- Aliou Thiongane
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | | | - Idrissa Demba Ba
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Djibril Boiro
- Service de Pédiatrie de l'Hôpital Abass Ndao, Dakar, Sénégal
| | - Papa Moctar Faye
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Younoussa Keita
- Service de Pédiatrie de l'Hôpital Aristide Le Dantec, Dakar, Sénégal
| | - Aïssatou Ba
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | | | | | - Lamine Thiam
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Indou Déme Ly
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Babacar Niang
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Abou Ba
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | | | - Saliou Diouf
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Ousmane Ndiaye
- Service de Pédiatrie de l'Hôpital Abass Ndao, Dakar, Sénégal
| | - Mamadou Ba
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
| | - Mamadou Sarr
- Centre Hospitalier National d'Enfants Albert Royer, Dakar, Sénégal
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11
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Flam B, Sackey P, Berge A, Zachau AC, Brink B, Lundberg S. Diarrhea-associated hemolytic uremic syndrome with severe neurological manifestations treated with IgG depletion through immunoadsorption. J Nephrol 2016; 29:711-4. [PMID: 26995001 DOI: 10.1007/s40620-016-0294-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Diarrhea-associated hemolytic uremic syndrome (HUS) is characterized by acute kidney injury with microangiopathic hemolytic anemia and thrombocytopenia with a diarrhea prodrome, typically caused by Shiga-like toxin-producing Escherichia coli. Supportive management is generally recommended. CASE REPORT A 58-year-old female with diarrhea-associated HUS developed delayed-onset severe neurological manifestations including coma, status epilepticus, and subcortical magnetic resonance imaging signal alterations. Rescue treatment with immunoglobulin (Ig)G depletion through immunoadsorption was followed by significant improvement in neurological and renal function. The patient recovered with only minimal sequelae. CONCLUSION Delayed-onset neurological abnormalities may occur in diarrhea-associated HUS. Novel specific treatment options include IgG depletion through immunoadsorption. Severe clinical and imaging findings do not preclude a good outcome.
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Affiliation(s)
- Benjamin Flam
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Peter Sackey
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Berge
- Department of Infectious Disease, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Anne C Zachau
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo Brink
- Department of Nephrology, Karolinska University Hospital, Stockholm, Sweden
| | - Sigrid Lundberg
- Department of Nephrology, Karolinska University Hospital, Stockholm, Sweden.,Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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12
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Woo DE, Lee JM, Kim YK, Park YH. Recombinant Human Erythropoietin Therapy for a Jehovah's Witness Child With Severe Anemia due to Hemolytic-Uremic Syndrome. Korean J Pediatr 2016; 59:100-3. [PMID: 26958070 PMCID: PMC4781730 DOI: 10.3345/kjp.2016.59.2.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/02/2014] [Accepted: 10/20/2014] [Indexed: 11/27/2022]
Abstract
Patients with hemolytic-uremic syndrome (HUS) can rapidly develop profound anemia as the disease progresses, as a consequence of red blood cell (RBC) hemolysis and inadequate erythropoietin synthesis. Therefore, RBC transfusion should be considered in HUS patients with severe anemia to avoid cardiac or pulmonary complications. Most patients who are Jehovah's Witnesses refuse blood transfusion, even in the face of life-threatening medical conditions due to their religious convictions. These patients require management alternatives to blood transfusions. Erythropoietin is a glycopeptide that enhances endogenous erythropoiesis in the bone marrow. With the availability of recombinant human erythropoietin (rHuEPO), several authors have reported its successful use in patients refusing blood transfusion. However, the optimal dose and duration of treatment with rHuEPO are not established. We report a case of a 2-year-old boy with diarrhea-associated HUS whose family members are Jehovah's Witnesses. He had severe anemia with acute kidney injury. His lowest hemoglobin level was 3.6 g/dL, but his parents refused treatment with packed RBC transfusion due to their religious beliefs. Therefore, we treated him with high-dose rHuEPO (300 IU/kg/day) as well as folic acid, vitamin B12, and intravenous iron. The hemoglobin level increased steadily to 7.4 g/dL after 10 days of treatment and his renal function improved without any complications. To our knowledge, this is the first case of successful rHuEPO treatment in a Jehovah's Witness child with severe anemia due to HUS.
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Affiliation(s)
- Da Eun Woo
- Department of Pediatrics, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Yu Kyung Kim
- Department of Laboratory Medicine, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Yong Hoon Park
- Department of Pediatrics, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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13
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Ito M, Shiozaki A, Shimizu M, Saito S. Hemolytic-uremic syndrome with acute encephalopathy in a pregnant woman infected with epidemic enterohemorrhagic Escherichia coli: characteristic brain images and cytokine profiles. Int J Infect Dis 2015; 34:119-21. [PMID: 25841635 DOI: 10.1016/j.ijid.2015.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 03/27/2015] [Accepted: 03/30/2015] [Indexed: 11/15/2022] Open
Abstract
A food-poisoning outbreak due to enterohemorrhagic Escherichia coli (EHEC) occurred in Toyama, Japan. The case of a 26-year-old pregnant woman with hemolytic-uremic syndrome who developed acute encephalopathy due to EHEC infection after eating raw meat is presented herein. On day 2 following admission, a cesarean section was performed because of a non-reassuring fetal status. Fecal bacterial culture confirmed an O111/O157 superinfection. Intensive care therapies including continuous hemodiafiltration and plasma exchange were performed. After the operation, the patient developed encephalopathy for which steroid pulse therapy was added. Her condition improved gradually and she was discharged 55 days after delivery.
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Affiliation(s)
- M Ito
- Department of Obstetrics and Gynecology, University of Toyama, Toyama-shi, Toyama 930-0194, Japan
| | - A Shiozaki
- Department of Obstetrics and Gynecology, University of Toyama, Toyama-shi, Toyama 930-0194, Japan
| | - M Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - S Saito
- Department of Obstetrics and Gynecology, University of Toyama, Toyama-shi, Toyama 930-0194, Japan.
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14
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Park SH, Kim GS. Anesthetic management of living donor liver transplantation for complement factor H deficiency hemolytic uremic syndrome: a case report. Korean J Anesthesiol 2014; 66:481-5. [PMID: 25006375 PMCID: PMC4085272 DOI: 10.4097/kjae.2014.66.6.481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 05/07/2013] [Accepted: 05/09/2013] [Indexed: 11/10/2022] Open
Abstract
We experienced a living donor liver transplantation for a 26-month-old girl with complement factor H deficiency. Complement factor H is a plasma protein that regulates the activity of the complement pathway. Complement overactivity induced by complement factor H deficiency is associated with atypical hemolytic uremic syndrome. Liver transplantation can be the proper treatment for this condition. During the liver transplantation of these patients, prevention of the complement overactivation is necessary. Minimizing complement activation, through the use of modalities such as plasma exchange before the surgery and transfusion of fresh frozen plasma throughout the entire perioperative period, may be the key for successful liver transplantation in these patients.
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Affiliation(s)
- Suk-Hee Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab-Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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15
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Lee HW, Chung MJ, Kang H, Choi H, Choi YJ, Lee KJ, Lee SW, Han SH, Kim JS, Song SY. Gemcitabine-induced hemolytic uremic syndrome in pancreatic cancer: a case report and review of the literature. Gut Liver 2014; 8:109-12. [PMID: 24516709 PMCID: PMC3916680 DOI: 10.5009/gnl.2014.8.1.109] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 06/24/2013] [Accepted: 06/26/2013] [Indexed: 01/18/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is a rare thrombotic complication characterized by a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS may be caused by several different conditions, including infection, malignancy, and chemotherapeutic agents, such as mitomycin, cisplatin, and most recently, gemcitabine. The outcome of gemcitabine-induced HUS is poor, and the disease has a high mortality rate. This study reports a case of gemcitabine-induced HUS in a patient with pancreatic cancer in Korea.
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Affiliation(s)
- Hye Won Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Huapyong Kang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Heun Choi
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Youn Jeong Choi
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Joo Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyuk Han
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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16
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Shimizu M, Kuroda M, Inoue N, Konishi M, Igarashi N, Taneichi H, Kanegane H, Ito M, Saito S, Yachie A. Extensive serum biomarker analysis in patients with enterohemorrhagic Escherichia coli O111-induced hemolytic-uremic syndrome. Cytokine 2013; 66:1-6. [PMID: 24548418 DOI: 10.1016/j.cyto.2013.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/14/2013] [Accepted: 12/09/2013] [Indexed: 01/22/2023]
Abstract
Proinflammatory cytokines are related to the pathogenesis of enterohemorrhagic Escherichia coli infection and hemolytic-uremic syndrome (HUS). We employed an antibody array that simultaneously detects 174 serum cytokines. We identified five serum biomarkers, namely insulin growth factor-binding protein-2, angiopoietin-2, soluble interleukin-6 receptor, soluble tumor necrosis factor receptor type II, and matrix metalloprotease protein-3 whose levels increased with the development of HUS. Furthermore, the levels of these cytokines were significantly increased in severe HUS compared with mild HUS. These cytokines might play an important role in the pathogenesis of HUS and may also be used to predict the severity of HUS.
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Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan.
| | - Mondo Kuroda
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan
| | - Natsumi Inoue
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan
| | - Michio Konishi
- Department of Pediatrics, Tonami General Hospital, Japan
| | - Noboru Igarashi
- Department of Pediatrics, Toyama Prefectural Central Hospital, Japan
| | - Hiromichi Taneichi
- Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Hirokazu Kanegane
- Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Mika Ito
- Department of Obstetrics and Gynaecology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynaecology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Akihiro Yachie
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan
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17
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Kute VB, Trivedi HL, Vanikar AV, Shah PR, Gumber MR, Kanodia KV. Collapsing glomerulopathy and hemolytic uremic syndrome associated with falciparum malaria: completely reversible acute kidney injury. J Parasit Dis 2012; 37:286-90. [PMID: 24431586 DOI: 10.1007/s12639-012-0164-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 08/11/2012] [Indexed: 11/26/2022] Open
Abstract
Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. Herein, we report a case of spontaneous resolution of AKI due to collapsing glomerulopathy (CG) and hemolytic-uremic syndrome (HUS) associated with P. falciparum malaria. Our case report highlights the fact that early intervention on the triggering cause of CG without a long course of steroids may obtain a remission of this severe subset of CG and may obtain a remission of HUS without therapeutic plasmapheresis The etiologic treatment of CG and HUS may avoid progression to end-stage renal disease.
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Affiliation(s)
- Vivek Balkrishna Kute
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS], Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Hargovind L Trivedi
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS], Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Aruna V Vanikar
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, IKDRC-ITS, Ahmedabad, India
| | - Pankaj R Shah
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS], Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Manoj R Gumber
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS], Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Kamal V Kanodia
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, IKDRC-ITS, Ahmedabad, India
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