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& 2013 International Society of Nephrology Kidney International (2013) 84, 1055; doi:10.1038/ki.2013.155
Unusual presentation of a common disease in an ESRD patient Gayathri Ganesh1, Divya Shankaranarayanan1, Ashish Verma1, Kanchanamala Thirumurthi2, Milly Mathew1 and Georgi Abraham1 1
Department of Nephrology, Madras Medical Mission Hospital, Chennai, India and 2Department of Pathology, Madras Medical Mission Hospital, Chennai, India Correspondence: Georgi Abraham, Department of Nephrology, Madras Medical Mission Hospital, 4-A, Dr. JJ Nagar, Mogappair, Chennai 600037, Tamil Nadu, India. E-mail: [email protected]
Figure 1 | Chest computed tomography showing mediastinal tumor causing mass effect over superior vena cava.
Figure 3 | Necrotizing granulomatous inflammation with inset showing Langerhans giant cells.
A 56-year-old Burmese man with diabetic end-stage renal disease (ESRD) on maintenance hemodialysis (HD) was referred for further management of superior vena cava syndrome. A diagnosis of thymoma had been previously made on the basis of magnetic resonance imaging done elsewhere showing diffuse soft-tissue lesion infiltrating the mediastinum. He was being dialyzed through a right dual lumen femoral line, as the arteriovenous fistula was Kidney International (2013) 84, 1055
Figure 2 | Three-dimensional reconstruction showing tortuous venous collaterals and abdominal veins.
inaccessible owing to extensive odema of his right arm. A computed tomography scan showed anterior mediastinal tumor abutting the thoracic aorta with mass effect over the superior vena cava, causing obstruction at the level of the azygous vein with thrombus of the right and left innominate veins and right internal jugular veins (Figure 1). Tortuous venous collaterals of the azygous, lateral thoracic, superficial thoracoabdominal, and vertebral venous plexus were noted (Figure 2). Bone marrow biopsy and aspiration was negative for lymphoma, malignancy, and granuloma. Biopsy of the mass obtained by sternotomy showed necrotizing granulomatous inflammation with pericardial fibrosis and chronic inflammation suggestive of tuberculosis (TB) (Figure 3). He was started on the appropriate antituberculosis regimen. Superior vena cava syndrome in a patient on HD is frequently caused by thrombosis or stenosis of the veins following central venous catheterization in HD patients. It can also be caused by extraluminal compression of the vein by malignancy, granulomatous diseases, goiter, and aortic aneurysms. TB may lead to unusual clinical presentations and should be considered where it is endemic. 1055
nephrology image
& 2013 International Society of Nephrology Kidney International (2013) 84, 1055; doi:10.1038/ki.2013.155
Unusual presentation of a common disease in an ESRD patient Gayathri Ganesh1, Divya Shankaranarayanan1, Ashish Verma1, Kanchanamala Thirumurthi2, Milly Mathew1 and Georgi Abraham1 1
Department of Nephrology, Madras Medical Mission Hospital, Chennai, India and 2Department of Pathology, Madras Medical Mission Hospital, Chennai, India Correspondence: Georgi Abraham, Department of Nephrology, Madras Medical Mission Hospital, 4-A, Dr. JJ Nagar, Mogappair, Chennai 600037, Tamil Nadu, India. E-mail: [email protected]
Figure 1 | Chest computed tomography showing mediastinal tumor causing mass effect over superior vena cava.
Figure 3 | Necrotizing granulomatous inflammation with inset showing Langerhans giant cells.
A 56-year-old Burmese man with diabetic end-stage renal disease (ESRD) on maintenance hemodialysis (HD) was referred for further management of superior vena cava syndrome. A diagnosis of thymoma had been previously made on the basis of magnetic resonance imaging done elsewhere showing diffuse soft-tissue lesion infiltrating the mediastinum. He was being dialyzed through a right dual lumen femoral line, as the arteriovenous fistula was Kidney International (2013) 84, 1055
Figure 2 | Three-dimensional reconstruction showing tortuous venous collaterals and abdominal veins.
inaccessible owing to extensive odema of his right arm. A computed tomography scan showed anterior mediastinal tumor abutting the thoracic aorta with mass effect over the superior vena cava, causing obstruction at the level of the azygous vein with thrombus of the right and left innominate veins and right internal jugular veins (Figure 1). Tortuous venous collaterals of the azygous, lateral thoracic, superficial thoracoabdominal, and vertebral venous plexus were noted (Figure 2). Bone marrow biopsy and aspiration was negative for lymphoma, malignancy, and granuloma. Biopsy of the mass obtained by sternotomy showed necrotizing granulomatous inflammation with pericardial fibrosis and chronic inflammation suggestive of tuberculosis (TB) (Figure 3). He was started on the appropriate antituberculosis regimen. Superior vena cava syndrome in a patient on HD is frequently caused by thrombosis or stenosis of the veins following central venous catheterization in HD patients. It can also be caused by extraluminal compression of the vein by malignancy, granulomatous diseases, goiter, and aortic aneurysms. TB may lead to unusual clinical presentations and should be considered where it is endemic. 1055
