From Telemedicine to the ICU—Fever and Rash in a 9-Year-Old Girl

A 9-year-old girl presented to her primary care pediatrician via telemedicine during the initial months of the coronavirus disease 2019 pandemic because of 4 days of warmth perceived by her mother, decreased energy, and a new rash on her upper extremities. After 10 additional days of documented fever >38°C, worsening fatigue, and 1 day of nausea, vomiting, and diarrhea, she was allowed to schedule an in-person visit with her pediatrician after testing negative for severe acute respiratory syndrome coronavirus 2. She appeared ill on arrival to clinic, and her pediatrician recommended evaluation in an emergency department. Her initial laboratory testing revealed nonspecific elevation in several inflammatory markers and leukopenia, and she responded well to intravenous hydration. Over the next 2 weeks, her fever persisted, constitutional symptoms worsened, and she developed progressively painful cervical lymphadenopathy and pancytopenia. She was evaluated in clinic by several specialists and eventually was urged to present to the emergency department again, at which time she was admitted to the PICU. After consulting additional specialists and waiting for laboratory results, the team reached a definitive diagnosis and initiated therapy; however, she experienced rapid clinical decline shortly thereafter. The specialists who assisted with identification of the underlying etiology of her symptoms were able to work together to manage the subsequent complications.

Use of the extracorporeal detoxification methods for methotrexate elimination

The article considers a clinical case of a 12-year-old child with osteosarcoma of the left tibia, T1N0M0G3, treated with high-dose methotrexate 12 g/m2. As a result of delayed elimination of methotrexate, the patient developed acute liver failure. The ALT level increased to 4790 U/L, AST — to 4320 U/L, which indicates life-threatening acute liver damage. There was no coagulopathy, significant increase in bilirubin, and hepatic encephalopathy. The timely use of efferent therapy allowed avoiding the complete course of acute liver failure. The patient received intravenous hydration therapy and urine alkalinization with 3000 ml/m2/day of 5% glucose in combination with 20 μmol NaHCO3/L and 20 μmol KCl/L. The urine output was more than 600 ml/m2/6 hours. Additionally, antidote therapy with calcium folinate was administered. In this case, we used continuous venous-venous hemodiafiltration using Prismaflex. After the first session, which lasted for 78 hours, there was a re-increase in serum methotrexate concentration and ALT, AST levels, which indicates a large volume of distribution of methotrexate and the need for long-term extracorporeal therapy. Therefore, the second session of continuous venous-venous hemodiafiltration was provided. After the second session, there was no re-increase in methotrexate level in the blood and the transaminases and total bilirubin returned to normal levels. Additionally, the patient was tested for homocysteine levels for hyperhomocysteinemia, as well as 4 genes that also determine the predisposition to hyperhomocysteinemia — methylenetetrahydrofolate reductase gene MTHFR C677T, A1298C, methionine synthase MTRR, and MTR. The presence of elevated levels of homocysteine, as well as heterozygosity of these genes, indicate a slow excretion of methotrexate or a complete delay in its excretion. Our patient presented the negative results of these tests. Conclusions. This clinical case indicates the effectiveness of continuous venous-venous hemodiafiltration in combination with intravenous hydration, urine alkalinization, and antidote therapy in the treatment of hepatotoxicity of high-dose methotrexate on the background of delayed excretion.

PP162 Use Of The RenalGuard® System To Prevent Contrast-Induced Nephropathy

IntroductionContrast-induced nephropathy (CIN) is a common cause of hospital-acquired acute kidney injury (AKI) following the administration of contrast media for coronary interventions or procedures such as diagnostic coronary angiography. The optimal way of preventing CIN remains uncertain. However, preliminary intravenous hydration, minimizing the volume of contrast media, and avoiding the use of nephrotoxic drugs are recommended in current management guidelines. The aim of this analysis was to compare the RenalGuard® system with standard care.MethodsA comprehensive literature search was conducted in PubMed and Google Scholar to identify evidence on the clinical and economic effectiveness of forced diuresis with matched hydration using the RenalGuard system for preventing CIN. Multiple criteria decision analysis (MCDA) was used to assess the performance of the method in hospital settings, compared with alternative options.ResultsSeveral systematic reviews with meta-analyses demonstrated that forced diuresis with matched hydration using the RenalGuard system was associated with a significantly lower relative risk of CIN among high-risk patients with chronic kidney disease. However, the evidence supporting the advantage of the proposed method over current forced diuresis techniques with manual calculation of the volumes for matched hydration in the hospital setting was limited.ConclusionsAlthough the effectiveness of the RenalGuard system has been demonstrated in meta-analyses, its clinical advantage over forced diuresis with manual hydration calculation is uncertain. It is also worth noting the lack of evidence to date on this technology, the fact that it is still at the research stage in some countries, and that it is not included in CIN management guidelines.

Recurrent Takotsubo syndrome complicated with ischemic enteritis successfully treated by hydration: a case report

Background Takotsubo syndrome is a sudden and an acute form of transient cardiac dysfunction, triggered by mental and physical stress. The treatment for Takotsubo syndrome is not well understood and is incompletely established. Takotsubo syndrome is partly thought to be caused by coronary ischemia under sympathetic nerve activation. Case presentation We report the case of an 80-year-old Japanese woman with recurrent Takotsubo syndrome complicated with ischemic enteritis. In this case, abdominal pain and dehydration due to ischemic enteritis is thought to have triggered Takotsubo syndrome. Her life was saved with rapid, adequate intravenous hydration. She was diagnosed with coronary vasospastic angina using coronary angiography on her second admission. This case highlights the potential of adequate intravenous hydration in increasing coronary blood flow. In our case, it should be noted that pulmonary congestion was mild and may have improved Takotsubo syndrome without the use of diuretics. Conclusion Adequate hydration must be considered for prompt improvement of cardiac function in Takotsubo syndrome. Replenishment of fluid to increase coronary blood flow, improvement of heart load without exacerbating heart failure, and stabilization of circulation dynamics can help treat patients with Takotsubo syndrome without using diuretics.

Chronic Milk-Dependent Food Protein-Induced Enterocolitis Syndrome in Children from West Pomerania Region

Characteristics of chronic milk-dependent food protein-induced enterocolitis syndrome (FPIES) in children from the region of Western Pomerania were studied. Prospectively, 55 children were diagnosed at a median of 2.2 months. The open food challenges (OFC), morphologies, milk-specific IgE (sIgE) (FEIA method, CAP system), and skin prick tests (SPTs) were examined. Vomiting and diarrhea escalated gradually but quickly led to growth retardation. Of the infants, 49% had BMI < 10 c, 20% BMI < 3 c; 25% had anemia, and 15% had hypoalbuminemia. During the OFCs we observed acute symptoms that appeared after 2–3 h: vomiting diarrhea and pallor. A total of 42% children required intravenous hydration. Casein hydrolysates or amino acids formulae (20%) were used in treatment. In 25% of children, SPT and milk sIgE were found, in 18%—other food SPTs, and in 14% allergy to other foods. A transition to IgE-dependent milk allergy was seen in 3 children. In the twelfth month of life, 62% of children had tolerance to milk, and in the twenty-fifth month—87%. Conclusions. Chronic milk-dependent FPIES resolves in most children. By the age of 2 children are at risk of multiple food sensitization, and those who have milk sIgE are at risk to transition to IgE-mediated milk allergy. Every OFC needs to be supervised due to possible severe reactions.

Post colonoscopy colonic perforation with parietal abscess: a rare case report

Colonoscopy is a common method of diagnosing colon and rectum illnesses. Complications from colonoscopy are rare. However, perforation is one of the most common problems observed. The incidence is 0.005-0.085 percent. Extraperitoneal and mixed postcolonoscopy colonic perforations are classified as intraperitoneal, extraperitoneal and both combined. Extraperitoneal perforation is rare and frequently accompanied with subcutaneous emphysema and retroperitoneal abscess. Contrast CT scan is the most effective diagnostic and therapy tool. A parietal abscess after colonoscopy is quite rare. Only one incidence of post-colonoscopy retroperitoneal colonic perforation with parietal abscess has been reported. An unusual case of colonic perforation after diagnostic colonoscopy was presented with a parietal abscess on the left iliac area. The patient, a 63-year-old diabetic male, had a diagnostic colonoscopy for intestinal irregularity. Afternoon severe ache over left iliac region brought patient to doctor. Nothing notable was discovered. So, they prescribed symptomatic drugs. Symptomatic medications were prescribed but without any relief. An abdominal contrast CT was recommended to him by his doctor after a few days. This retro muscular accumulation in the left transverses abdominis muscle communicated with the sigmoid colon. No signs of peritonitis or septicemia. Patient was stable. The aspirated fluid was sent for culture and sensitivity testing, and intravenous hydration and antibiotics were commenced. Patient tolerated conservative care. The subject was discharged in 2 weeks. Diagnosis and treatment of perforation are critical to recovery.

Silicone Induced Severe Hypercalcemia

Background: Silicone injections are becoming increasingly prevalent for cosmetic enhancement in the transgender population. We report a case of silicone-induced hypercalcemia to highlight the process of extra-renal production of 1,25-hydroxy (OH) vitamin D (calcitriol) and discuss the approaches in managing this rare entity. Clinical Case: A 51-year-old African American transgender female with a past medical history of human immunodeficiency virus (HIV) on antiretroviral therapy with undetectable viral load presented with right flank pain, nausea, and vomiting for one day. On examination, nodules were palpated in both breasts, left lateral hip, and the gluteal area had hyperpigmentation from silicone injections ten years ago. Calcium was elevated at 15.2 mg/dL (8.5–10.5) with albumin 3.8 g/dL (3.5–5), ionized calcium 7.4 mg/dL (4.64–5.28), phosphate 4.5 mg/dL (2.5–4.8) and creatinine of 3.2 mg/dL (0.4–1.4). Imaging revealed right ureteral calculi with hydronephrosis requiring stent placement. PTH was suppressed &lt;5 pg/ml (12–72) and PTHrP were negative. Vitamin D 25 (OH) of 28 ng/mL (30–100) with elevated 1, 25 OH2 D3 144 pg/ml (19–79) and ACE 141 units/L (12–60) were suggestive of a granulomatous process. CT chest and abdomen without contrast did not show any hilar, mediastinal, or abdominal lymphadenopathy to suggest sarcoidosis or lymphoma, but numerous bilateral calcified masses were noted within the breasts consistent with silicone injections. Serum and urine electrophoresis were consistent with monoclonal gammopathy of undetermined significance. Patient deferred further evaluation (PET-CT and skin biopsy for granulomatous changes) as an outpatient. Calcium improved in 4 days to 10.5 mg/dL with intravenous hydration, calcitonin 260 units, IV furosemide 20 mg, and pamidronate of 60 mg. Despite a repeat dose of Pamidronate 60 mg a week later her calcium was rising again to 11.1 mg/dL. Plastic surgery evaluation concluded that due to extensive implants, surgery would be very disfiguring and challenging. She was reluctant to start prednisone as it may affect healing after surgery and the need for antibiotic prophylaxis for HIV, but she later agreed. Prednisone 20 mg daily was started for granulomatous disease and Calcium improved to 10.3 mg/dL. Conclusion/Clinical Lesson: Silicone Induced hypercalcemia is a rare entity with diagnostic and treatment dilemmas. Based on the few reported cases, silicone induced severe hypercalcemia is managed with IV hydration, denosumab, or zoledronic acid. However, glucocorticoids may maintain normocalcemia like in other granulomatous diseases. Removal of silicone implants may improve hypercalcemia, but it is challenging given the extent of implants, disfigurement, and possible disseminated disease and may not be curative. These aspects need to be considered in evaluating and management.