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Letters to the Editor
disappearance of the thrombus on TTE without thrombotic events or bleeding complications. We further confirmed thrombus resolution with transesophageal echocardiography more 6 months later (Fig. 1C). Finally, we speculate that thrombophilia by longterm dialysis was severe enough to cause left atrial thrombus without any other thrombogenic abnormalities. We advise clinicians to consider regular echocardiographic assessment (3) and anticoagulant therapy on a patient-by-patient basis in dialysisdependent patients during a proper period (4). Conflict of interest: none declared. Financial support: none.
Kyosuke Takeshita,1,2 Tadashi Matsushita,2 and Toyoaki Murohara1 1 Department of Cardiology, Nagoya University Graduate School of Medicine, 2Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan Email: [email protected]
REFERENCES 1. Lo DS, Rabbat CG, Clase CM. Thromboembolism and anticoagulant management in hemodialysis patients: a practical guide to clinical management. Thromb Res 2006;118:385–95. 2. Eleftheriadis T, Antoniadi G, Akritidou A et al. A case report of recurrent vascular access thrombosis in a hemodialysis patient reveals combined acquired and inherited thrombophilia. Ther Apher Dial 2008;12:190–2. 3. Green D, Roberts PR, New DI, Kalra PA. Sudden cardiac death in hemodialysis patients: an in-depth review. Am J Kidney Dis 2011;57:921–9. 4. Marinigh R, Lane DA, Lip GY. Severe renal impairment and stroke prevention in atrial fibrillation: implications for thromboprophylaxis and bleeding risk. J Am Coll Cardiol 2011; 57:1339–48.
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Movie clip SA. Transthoracic echocardiography (TTE). Parasternal long-axis view showing the mass shown in Figure 1A.
Ther Apher Dial, Vol. 19, No. 1, 2015
Three Cases of Emphysematous Cystitis in End-Stage Renal Disease Patients Undergoing Hemodialysis and Continuous Ambulatory Peritoneal Dialysis Dear Editor, Emphysematous cystitis (EC) is an infection of the bladder with the formation of gas in the bladder wall and lumen. Here, we present three dialysis patients affected with EC. CASE 1 A 68-year-old woman on continuous ambulatory peritoneal dialysis (CAPD) was admitted with complete urinary retention, macrohematuria and lower abdominal pain. A computed tomography (CT) scan showed the presence of gas on and inside the wall of the urinary bladder. Corynebacterium genitalium was identified in urine cultures and she was diagnosed with EC. Meropenem hydrate was admninistered and her symptoms gradually improved. Since the residual urine volume was relatively high, the urinary catheter was left in place for fear of recurrence. CASE 2 A 47-year-old man on hemodialysis was admitted with a 3-day history of intermittent abdominal pain with high fever and constipation. A CT scan revealed diffuse air formation inside the bladder wall. Marked pyuria was seen and Escherichia coli was identified in urine cultures. He was diagnosed with EC, and doripenem hydrate and immunoglobulin were administered intravenously. The outcome was favorable after 6 days of treatment. Since a relatively high volume of residual urine was recognized, intermittent catheterization was performed by the patient after that. CASE 3 An 81-year-old woman on hemodialysis was admitted with lower abdominal pain, incomplete urinary retention, and macrohematuria. A tender tympanitic bladder was palpated in the suprapubic region. A CT scan revealed the bladder to be distended and containing residual urine, clotted blood, and gas. Cystoscopy revealed the bladder mucosa to be inflamed and hemorrhagic. Escherichia coli was © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
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Letters to the Editor TABLE 1. Case Age/Sex Dialysis method Dialysis vintage (years) Underlying condition HbA1c (%) Anticoagulants Antiplatelet agent Symptoms WBC (cells/μL) Segmented neutrophils (%) CRP (mg/dL) Urine volume (mL/day) Responsible bacteria Figure
95
Patients’ clinical characteristics and data
1 68/Female CAPD 2 DM, sarcoidosis 6.2 Warfarin Urinary retention, abdominal pain, macrohematuria 16 160 84.0 6.8 1400 Corynebacterium genialium
2
3
47/Male HD 8 DM, ASO 9.2
81/Female HD 8 DM, AS, LCS 6.0
Ticlopidine, aspirin, sarpogrelate Urinary retention, abdominal pain, pyuria, fever 12 750 84.9 25.0 400 Escherichia coli
Aspirin Urinary retention, abdominal pain, macrohematuria 12 770 78.1 Not examined 300 Escherichia coli
AS, aortic stenosis; ASO, arteriosclerosis obliterans; CRP, C-reactive protein; DM, diabetes mellitus; LCS, lumbar canal stenosis; WBC, white blood cell.
identified in urine culture. She was diagnosed with EC and bladder tamponade with hemorrhagic cystitis. Continuous bladder irrigation was started and cefepime dihydrochloride hydrate was administered. The inflammatory and hemorrhagic findings were improved and the patient was discharged on day 11. But one month later, she was readmitted with complete urinary retention. A CT scan revealed a high volume of residual urine and bilateral hydronephrosis. Neurogenic bladder caused by lumbar canal stenosis was suspected as the cause of the urinary retention. A permanent indwelling bladder catheter was inserted. Underlying diabetes mellitus is a well-known risk factor of EC. All of our three patients had diabetes mellitus. Maintaining urine volume might explain the occurrence of EC (1). Our patients also retained urine, in amounts ranging from 300 to 1400 mL (Table 1). All three patients had neurogenic bladder and needed an indwelling bladder catheter or intermittent self-catheterization. Checking the urinary volume or voiding symptoms of dialysis patients may help physicians recognize the risk of EC. Dialysis patients are highly associated with cardiovascular disease and frequently receive antiplatelet medication. These medications might lead to the prolongation of bleeding from the bladder mucosa and might be associated with disease progression of EC. Dysuria, macrohematuria, and abdominal pain are common symptoms of EC. However, these are © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
relatively non-specific symptoms and an asymptomatic case has been reported (2); in order to diagnose EC timely and correctly, physicians need to suspect this disease. Seiko Takanohashi, Satoko Uyama, and Akashi Togawa Department of Nephrology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan Email: [email protected] REFERENCES 1. Yokoo T, Awai T, Yamazaki H et al. Emphysematous cystitis complication in a patient undergoing hemodialysis. Clin Exp Nephrol 2007;11:247–50. 2. Lin C-J, Chen H-H, Chen Y-C et al. Emphysematous cystitis in a asymptomatic hemodialysis patient. Nephrology (Carlton) 2008;13:178–9.
Plasma Exchange Treatment in a Case of Colchicine Intoxication Dear Editor Colchicine has a narrow therapeutic index and poisoning is dose dependent. The major toxicity with 10% mortality after ingestions of 0.5 to 0.8 mg/kg of colchicine, and 100% mortality after ingestions of
Ther Apher Dial, Vol. 19, No. 1, 2015
94
Letters to the Editor
disappearance of the thrombus on TTE without thrombotic events or bleeding complications. We further confirmed thrombus resolution with transesophageal echocardiography more 6 months later (Fig. 1C). Finally, we speculate that thrombophilia by longterm dialysis was severe enough to cause left atrial thrombus without any other thrombogenic abnormalities. We advise clinicians to consider regular echocardiographic assessment (3) and anticoagulant therapy on a patient-by-patient basis in dialysisdependent patients during a proper period (4). Conflict of interest: none declared. Financial support: none.
Kyosuke Takeshita,1,2 Tadashi Matsushita,2 and Toyoaki Murohara1 1 Department of Cardiology, Nagoya University Graduate School of Medicine, 2Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan Email: [email protected]
REFERENCES 1. Lo DS, Rabbat CG, Clase CM. Thromboembolism and anticoagulant management in hemodialysis patients: a practical guide to clinical management. Thromb Res 2006;118:385–95. 2. Eleftheriadis T, Antoniadi G, Akritidou A et al. A case report of recurrent vascular access thrombosis in a hemodialysis patient reveals combined acquired and inherited thrombophilia. Ther Apher Dial 2008;12:190–2. 3. Green D, Roberts PR, New DI, Kalra PA. Sudden cardiac death in hemodialysis patients: an in-depth review. Am J Kidney Dis 2011;57:921–9. 4. Marinigh R, Lane DA, Lip GY. Severe renal impairment and stroke prevention in atrial fibrillation: implications for thromboprophylaxis and bleeding risk. J Am Coll Cardiol 2011; 57:1339–48.
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Movie clip SA. Transthoracic echocardiography (TTE). Parasternal long-axis view showing the mass shown in Figure 1A.
Ther Apher Dial, Vol. 19, No. 1, 2015
Three Cases of Emphysematous Cystitis in End-Stage Renal Disease Patients Undergoing Hemodialysis and Continuous Ambulatory Peritoneal Dialysis Dear Editor, Emphysematous cystitis (EC) is an infection of the bladder with the formation of gas in the bladder wall and lumen. Here, we present three dialysis patients affected with EC. CASE 1 A 68-year-old woman on continuous ambulatory peritoneal dialysis (CAPD) was admitted with complete urinary retention, macrohematuria and lower abdominal pain. A computed tomography (CT) scan showed the presence of gas on and inside the wall of the urinary bladder. Corynebacterium genitalium was identified in urine cultures and she was diagnosed with EC. Meropenem hydrate was admninistered and her symptoms gradually improved. Since the residual urine volume was relatively high, the urinary catheter was left in place for fear of recurrence. CASE 2 A 47-year-old man on hemodialysis was admitted with a 3-day history of intermittent abdominal pain with high fever and constipation. A CT scan revealed diffuse air formation inside the bladder wall. Marked pyuria was seen and Escherichia coli was identified in urine cultures. He was diagnosed with EC, and doripenem hydrate and immunoglobulin were administered intravenously. The outcome was favorable after 6 days of treatment. Since a relatively high volume of residual urine was recognized, intermittent catheterization was performed by the patient after that. CASE 3 An 81-year-old woman on hemodialysis was admitted with lower abdominal pain, incomplete urinary retention, and macrohematuria. A tender tympanitic bladder was palpated in the suprapubic region. A CT scan revealed the bladder to be distended and containing residual urine, clotted blood, and gas. Cystoscopy revealed the bladder mucosa to be inflamed and hemorrhagic. Escherichia coli was © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
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Letters to the Editor TABLE 1. Case Age/Sex Dialysis method Dialysis vintage (years) Underlying condition HbA1c (%) Anticoagulants Antiplatelet agent Symptoms WBC (cells/μL) Segmented neutrophils (%) CRP (mg/dL) Urine volume (mL/day) Responsible bacteria Figure
95
Patients’ clinical characteristics and data
1 68/Female CAPD 2 DM, sarcoidosis 6.2 Warfarin Urinary retention, abdominal pain, macrohematuria 16 160 84.0 6.8 1400 Corynebacterium genialium
2
3
47/Male HD 8 DM, ASO 9.2
81/Female HD 8 DM, AS, LCS 6.0
Ticlopidine, aspirin, sarpogrelate Urinary retention, abdominal pain, pyuria, fever 12 750 84.9 25.0 400 Escherichia coli
Aspirin Urinary retention, abdominal pain, macrohematuria 12 770 78.1 Not examined 300 Escherichia coli
AS, aortic stenosis; ASO, arteriosclerosis obliterans; CRP, C-reactive protein; DM, diabetes mellitus; LCS, lumbar canal stenosis; WBC, white blood cell.
identified in urine culture. She was diagnosed with EC and bladder tamponade with hemorrhagic cystitis. Continuous bladder irrigation was started and cefepime dihydrochloride hydrate was administered. The inflammatory and hemorrhagic findings were improved and the patient was discharged on day 11. But one month later, she was readmitted with complete urinary retention. A CT scan revealed a high volume of residual urine and bilateral hydronephrosis. Neurogenic bladder caused by lumbar canal stenosis was suspected as the cause of the urinary retention. A permanent indwelling bladder catheter was inserted. Underlying diabetes mellitus is a well-known risk factor of EC. All of our three patients had diabetes mellitus. Maintaining urine volume might explain the occurrence of EC (1). Our patients also retained urine, in amounts ranging from 300 to 1400 mL (Table 1). All three patients had neurogenic bladder and needed an indwelling bladder catheter or intermittent self-catheterization. Checking the urinary volume or voiding symptoms of dialysis patients may help physicians recognize the risk of EC. Dialysis patients are highly associated with cardiovascular disease and frequently receive antiplatelet medication. These medications might lead to the prolongation of bleeding from the bladder mucosa and might be associated with disease progression of EC. Dysuria, macrohematuria, and abdominal pain are common symptoms of EC. However, these are © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
relatively non-specific symptoms and an asymptomatic case has been reported (2); in order to diagnose EC timely and correctly, physicians need to suspect this disease. Seiko Takanohashi, Satoko Uyama, and Akashi Togawa Department of Nephrology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan Email: [email protected] REFERENCES 1. Yokoo T, Awai T, Yamazaki H et al. Emphysematous cystitis complication in a patient undergoing hemodialysis. Clin Exp Nephrol 2007;11:247–50. 2. Lin C-J, Chen H-H, Chen Y-C et al. Emphysematous cystitis in a asymptomatic hemodialysis patient. Nephrology (Carlton) 2008;13:178–9.
Plasma Exchange Treatment in a Case of Colchicine Intoxication Dear Editor Colchicine has a narrow therapeutic index and poisoning is dose dependent. The major toxicity with 10% mortality after ingestions of 0.5 to 0.8 mg/kg of colchicine, and 100% mortality after ingestions of
Ther Apher Dial, Vol. 19, No. 1, 2015
