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Article: Thrombocytopenia: A Diagnostic Dilemma and Incidental Detection of Systemic Lupus Erythematosus in a Middle-Aged Asian Male.

Maitra, Somnath / Roy, Sasmit / Mukherjee, Aveek / Naramala, Srikanth / Bose, Subhasish

2020 Volume 12, Issue 9, Page(s) e10375

Abstract: Systemic lupus erythematosus is a multisystem disorder much more common in females than males due to the effect of the hormone estrogen. There are also specific differences in clinical presentation in men and women. We present a unique case of a 54-year- ... ...

Abstract	Systemic lupus erythematosus is a multisystem disorder much more common in females than males due to the effect of the hormone estrogen. There are also specific differences in clinical presentation in men and women. We present a unique case of a 54-year-old middle-aged Asian male presenting with only generalized weakness without other systemic features and with only incidental finding of thrombocytopenia. Notable laboratory values were positive for antinuclear antibody (ANA) and anti-double-stranded DNA (dsDNA), low complement 3 level with normal complement 4 levels, along with severe thrombocytopenia and mild anemia. The patient was eventually diagnosed with systemic lupus erythematosus based on these parameters. Bone marrow biopsy revealed an increased number of megakaryocytes without hypocellular or hypercellular marrow and no dysplasia of cell lines. He was initiated on oral prednisone, and his symptoms recovered remarkably with normalization of lab values upon discharge. The case's importance lies in the fact that the diagnosis of lupus can be missed in male patients with nonspecific clinical features due to certain differences in presentation from females. This diagnosis should be included in the workup of any thrombocytopenia.
Language	English
Publishing date	2020-09-11
Publishing country	United States
Document type	Case Reports
ZDB-ID	2747273-5
ISSN	2168-8184
ISSN	2168-8184
DOI	10.7759/cureus.10375
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Article ; Online: Seizures, renal failure and acute respiratory failure: not your typical case of Henoch-Schonlein purpura.

Bose, Subhasish / Pathireddy, Samata / Baradhi, Krishna M / Aeddula, Narothama Reddy

BMJ case reports

2019 Volume 12, Issue 7

Abstract: A 30-year-old Caucasian woman with no prior medical history presented with pedal oedema, arthralgias and abdominal pain with diarrhoea, following a respiratory infection. She had mild abdominal tenderness along with a purpuric rash on the extremities and ...

Abstract	A 30-year-old Caucasian woman with no prior medical history presented with pedal oedema, arthralgias and abdominal pain with diarrhoea, following a respiratory infection. She had mild abdominal tenderness along with a purpuric rash on the extremities and was anaemic. Following initial workup for anaemia and rash, her condition deteriorated with renal impairment, respiratory failure and seizures necessitating ventilatory support, dialysis and steroids. Serologies were negative, and skin biopsy showed leucocytoclastic vasculitis without vascular IgA deposition, and renal biopsy showed subendothelial, mesangial deposits of IgA with C3 indicative of Henoch-Schonlein purpura (HSP). She was treated with steroids, haemodialysis and on 6-month follow-up recovered renal function. We present the case to illustrate that HSP, though rare in adults, can present with multiorgan failure, with renal, pulmonary and central nervous system involvement, and the need for early diagnosis and prompt treatment for rapid clinical recovery.
MeSH term(s)	Acute Kidney Injury/diagnosis ; Acute Kidney Injury/etiology ; Acute Kidney Injury/pathology ; Acute Kidney Injury/therapy ; Adrenal Cortex Hormones/therapeutic use ; Adult ; Anticonvulsants/therapeutic use ; Biopsy ; Electroencephalography ; Female ; Glomerulonephritis/etiology ; Glomerulonephritis/pathology ; Glomerulonephritis/therapy ; Humans ; Magnetic Resonance Imaging ; Purpura, Schoenlein-Henoch/complications ; Purpura, Schoenlein-Henoch/diagnosis ; Purpura, Schoenlein-Henoch/pathology ; Purpura, Schoenlein-Henoch/therapy ; Renal Dialysis ; Respiration, Artificial ; Respiratory Distress Syndrome/etiology ; Respiratory Distress Syndrome/therapy ; Seizures/diagnosis ; Seizures/drug therapy ; Seizures/etiology
Chemical Substances	Adrenal Cortex Hormones ; Anticonvulsants
Language	English
Publishing date	2019-07-17
Publishing country	England
Document type	Case Reports ; Journal Article
ISSN	1757-790X
ISSN (online)	1757-790X
DOI	10.1136/bcr-2019-229939
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Article ; Online: Alport's syndrome and intracranial aneurysm: mere coincidence or undiscovered causal relationship.

Bose, Subhasish / Pathireddy, Samata / Baradhi, Krishna M / Aeddula, Narothama Reddy

BMJ case reports

2019 Volume 12, Issue 1

Abstract: A 44-year-old Caucasian man with a history of deceased donor renal transplant for end-stage renal disease from Alport's syndrome (AS), presented with a spontaneous subarachnoid haemorrhage and hydrocephalus. Following an external ventricular drain for ... ...

Abstract	A 44-year-old Caucasian man with a history of deceased donor renal transplant for end-stage renal disease from Alport's syndrome (AS), presented with a spontaneous subarachnoid haemorrhage and hydrocephalus. Following an external ventricular drain for the hydrocephalus, a CT angiography revealed a dissection of the left vertebral artery extending into vertebro-basilar junction necessitating a bypass between left occipital artery to left posterior inferior cerebellar artery. He had a posterior fossa Craniectomy, C1 laminectomy and coiling off, of the left vertebral artery. Postprocedure course was prolonged but uneventful with complete recovery and normal renal function 18 months postpresentation. AS, a disease caused by abnormalities in the synthesis of type IV collagen, can cause aneurysms with severe and permanent neurological sequalae. We present a case of AS with intracranial arterial dissection with potential life-threatening consequences and discuss the genetic and molecular basis of AS along with review of the relevant literature.
MeSH term(s)	Adult ; Diagnosis, Differential ; Humans ; Intracranial Aneurysm/complications ; Intracranial Aneurysm/diagnostic imaging ; Intracranial Aneurysm/surgery ; Male ; Nephritis, Hereditary/complications ; Nephritis, Hereditary/physiopathology ; Tomography, X-Ray Computed
Language	English
Publishing date	2019-01-29
Publishing country	England
Document type	Case Reports ; Journal Article
ISSN	1757-790X
ISSN (online)	1757-790X
DOI	10.1136/bcr-2018-228175
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Article ; Online: Methamphetamine (

Baradhi, Krishna M / Pathireddy, Samata / Bose, Subhasish / Aeddula, Narothama Reddy

BMJ case reports

2019 Volume 12, Issue 9

Abstract: A 26-year-old Caucasian man with no medical history, except years of oral and intravenous drug abuse, presented with fatigue, shortness of breath, epistaxis and uncontrolled hypertension. He was pale with skin ecchymosis over his thighs and was anaemic, ... ...

Abstract	A 26-year-old Caucasian man with no medical history, except years of oral and intravenous drug abuse, presented with fatigue, shortness of breath, epistaxis and uncontrolled hypertension. He was pale with skin ecchymosis over his thighs and was anaemic, with severe renal failure and metabolic acidosis. Following initial clinical stabilisation of the patient, a renal biopsy was obtained, which showed vascular and glomerular changes consistent with thrombotic microangiopathic injury and advanced glomerulosclerosis. He was treated with antihypertensives and required haemodialysis. He admitted using 'crystal meth' regularly for many years, which is likely responsible for his renal failure. We present the case to illustrate methamphetamine-induced renal disease leading to end-stage renal disease and to bring awareness among practising clinicians, ancillary healthcare workers and public health professionals of this often undervalued cause of renal failure, which can be prevented.
MeSH term(s)	Acidosis/complications ; Adult ; Disease Progression ; Humans ; Hypertension/complications ; Kidney Failure, Chronic/chemically induced ; Kidney Failure, Chronic/pathology ; Male ; Methamphetamine/adverse effects ; Substance Abuse, Intravenous ; Substance Abuse, Oral
Chemical Substances	Methamphetamine (44RAL3456C)
Language	English
Publishing date	2019-09-19
Publishing country	England
Document type	Case Reports
ISSN	1757-790X
ISSN (online)	1757-790X
DOI	10.1136/bcr-2019-230288
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Article ; Online: Guillain-Barre syndrome with concurrent posterior reversible encephalopathy syndrome and hyponatraemia: mere coincidence or rare coexistence.

Drye, Carley / Bose, Subhasish / Pathireddy, Samata / Aeddula, Narothama Reddy

BMJ case reports

2019 Volume 12, Issue 7

Abstract: A 61-year-old Caucasian woman with a history of hypertension presented with a week's history of confusion falls and back pain was found to have hyponatraemia from secretion of antidiuretic hormone and treated appropriately. Given her persistent symptoms, ...

Abstract	A 61-year-old Caucasian woman with a history of hypertension presented with a week's history of confusion falls and back pain was found to have hyponatraemia from secretion of antidiuretic hormone and treated appropriately. Given her persistent symptoms, despite a normal CT head on presentation, an MRI head was obtained, showing vasogenic oedema in line with posterior reversible encephalopathy syndrome (PRES). Despite aggressive antihypertensives and supportive measures, unfortunately, her condition deteriorated, with increased confusion, new left-sided flaccid paresis, paraesthesias and worsening of the back pain. Following further testing including a cerebrospinal fluid analysis, finally diagnosed with an atypical presentation of Guillain-Barre syndrome (GBS), and prompt management with intravenous immunoglobulins was initiated. She recovered clinically and returned to near-normal function on follow-up. We use this case to suggest the importance of dysautonomia in GBS and various clinical manifestations it can present with, including PRES and hyponatraemia.
MeSH term(s)	Accidental Falls ; Confusion/etiology ; Female ; Guillain-Barre Syndrome/diagnosis ; Guillain-Barre Syndrome/drug therapy ; Guillain-Barre Syndrome/physiopathology ; Humans ; Hyponatremia/drug therapy ; Hyponatremia/physiopathology ; Immunoglobulins, Intravenous/therapeutic use ; Immunologic Factors/therapeutic use ; Magnetic Resonance Imaging ; Middle Aged ; Posterior Leukoencephalopathy Syndrome/drug therapy ; Posterior Leukoencephalopathy Syndrome/physiopathology ; Treatment Outcome
Chemical Substances	Immunoglobulins, Intravenous ; Immunologic Factors
Language	English
Publishing date	2019-07-11
Publishing country	England
Document type	Case Reports ; Journal Article
ISSN	1757-790X
ISSN (online)	1757-790X
DOI	10.1136/bcr-2019-229749
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Article: Acute Pancreatitis Due to Disseminated Varicella Zoster Infection in an Individual with Newly Diagnosed Human Immunodeficiency Virus.

Roy, Sasmit / Bose, Subhasish / Pandey, Ramesh K / Naramala, Srikanth / Hossain, Muhammad Rajib

Cureus

2020 Volume 12, Issue 2, Page(s) e7027

Abstract: Varicella-zoster virus (VZV) infection is generally considered as a benign and self-limiting disease. However, individuals with VZV infection can have disseminated to various organs leading to serious complications, particularly in adults. This pattern ... ...

Abstract	Varicella-zoster virus (VZV) infection is generally considered as a benign and self-limiting disease. However, individuals with VZV infection can have disseminated to various organs leading to serious complications, particularly in adults. This pattern is more prevalent in immunosuppressed individuals. Disseminated varicella is historically known to involve the central nervous system (CNS), liver, and lungs. However, dissemination of varicella to the pancreas and subsequently causing acute pancreatitis has been rarely reported. We present a case of disseminated varicella infection in a newly diagnosed human immunodeficiency virus (HIV) patient causing acute pancreatitis at initial disease presentation and subsequently leading to multi organ dysfunction. A 42-year-old African American female who was initially being treated for Pneumocystis carinii pneumonia (PCP) at an inner-city hospital developed severe epigastric pain radiating to back along with nausea on day 2 of admission. Physical findings revealed tachycardia, epigastric tenderness and newly formed vesicular rash involving the neck and face classical of varicella infection. Skin biopsy and serum sample confirmed varicella infection by VZV polymerase chain reaction (PCR) test. Labs revealed elevated lipase, amylase at a level diagnostic of acute pancreatitis. The patient had no other risk factors for pancreatitis. She was started on intravenous Acyclovir and intravenous hydration with isotonic normal saline. She was managed conservatively for other systemic complications. Pancreatitis resolved after five days of clinical presentation. She completed two weeks of Acyclovir, her condition steadily improved and she was successfully discharged home with no further recurrence. Acute pancreatitis is a rare infectious association of disseminated varicella infection. Clinicians should always be mindful of this infectious etiology as one of the rare differentials for acute pancreatitis as this is a treatable cause and could prevent morbidity, mortality associated with this condition if treated timely.
Language	English
Publishing date	2020-02-18
Publishing country	United States
Document type	Case Reports
ZDB-ID	2747273-5
ISSN	2168-8184
ISSN	2168-8184
DOI	10.7759/cureus.7027
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Article: Cocaine and Alcohol Co-Ingestion-Induced Severe Rhabdomyolysis With Acute Kidney Injury Culminating in Hemodialysis-Dependent End-Stage Renal Disease: A Case Report and Literature Review.

Roy, Sasmit / Konala, Venu Madhav / Adapa, Sreedhar / Naramala, Srikanth / Bose, Subhasish

Cureus

2020 Volume 12, Issue 6, Page(s) e8595

Abstract: Cocaine toxicity is associated with several organ dysfunctions, including acute kidney injury (AKI). Rhabdomyolysis is the most likely mechanism that mediates AKI, and associated alcohol co-ingestion can amplify the situation. AKI, if severe, can result ... ...

Abstract	Cocaine toxicity is associated with several organ dysfunctions, including acute kidney injury (AKI). Rhabdomyolysis is the most likely mechanism that mediates AKI, and associated alcohol co-ingestion can amplify the situation. AKI, if severe, can result in end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). All patients with cocaine intoxication should be screened for rhabdomyolysis and AKI along with testing for other drug toxicity, including alcohol. Aggressive measures should be taken to treat the underlying cause that contributes to AKI, and the patients need to be educated about this severe condition. Our patient is a unique case where cocaine and alcohol co-ingestion led to severe rhabdomyolysis, AKI, and subsequently developed ESRD requiring ongoing hemodialysis (HD). He was on daily cocaine and alcohol co-ingestion for seven days and subsequently developed AKI with oliguria from rhabdomyolysis. His creatine kinase (CK) was significantly elevated to 141974 IU/L, and his serum creatinine was 11 mg/dl. Despite aggressive intravenous hydration, his kidney function did not improve, and he ended up needing HD for more than one year despite abstaining from cocaine.
Language	English
Publishing date	2020-06-13
Publishing country	United States
Document type	Case Reports
ZDB-ID	2747273-5
ISSN	2168-8184
ISSN	2168-8184
DOI	10.7759/cureus.8595
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Article: Transition of Renal Patients Using AlloSure Into Community Kidney Care (TRACK): Protocol for Long-Term Allograft Surveillance in Renal Transplant Recipients.

Dale, Bethany L / Bose, Subhasish / Kuo, Sheng / Burns, Alana / Daou, Pierre / Short, Jenna / Miles, Jake

JMIR research protocols

2021 Volume 10, Issue 3, Page(s) e25941

Abstract: Background: Patients with end-stage kidney disease require complex and expensive medical management. Kidney transplantation remains the treatment of choice for end-stage kidney disease and is considered superior to all other modalities of renal ... ...

Abstract	Background: Patients with end-stage kidney disease require complex and expensive medical management. Kidney transplantation remains the treatment of choice for end-stage kidney disease and is considered superior to all other modalities of renal replacement therapy or dialysis. However, access to kidney transplant is limited by critical supply and demand, making it extremely important to ensure longevity of transplanted kidneys. This is prevented through lifelong immunosuppression, with caution not to overly suppress the immune system, resulting in toxicity and harm. Transition of care to community nephrologists after initial kidney transplantation and monitoring at a transplant center is an important process to ensure delivery of effective and patient-centric care closer to home. Once transplanted, laborious surveillance of the immune system and monitoring for potential rejection and injury are undertaken through an armamentarium of screening modalities. Posttransplant surveillance for kidney function and injury remains key to follow-up care. While kidney function, quantified by estimated glomerular filtration rate and serum creatinine, and kidney injury, measured by proteinuria and hematuria, are standard biomarkers used to monitor injury and rejection posttransplant, they have recently been demonstrated to be inferior in performance to that of AlloSure (CareDx Inc, Brisbane, CA) circulating donor-derived, cell-free DNA (dd-cfDNA). Objective: The outcomes and methods of monitoring renal transplant recipients posttransplant have remained stagnant over the past 15 years. The aim of this study is to consider intensive surveillance using AlloSure dd-cfDNA in an actively managed protocol, assessing whether it increases long-term allograft survival in kidney transplant recipients compared with current standard clinical care in community nephrology. Methods: The study protocol will acquire data from a phase IV observational trial to assess a cohort of renal transplant patients managed using AlloSure dd-cfDNA and patient care managers versus 1000 propensity-matched historic controls using United Network for Organ Sharing U.S. Scientific Registry of Transplant Recipients data. Data will be managed in a centralized electronic data server. The primary outcome will be superior allograft survival, as a composite of return to dialysis, retransplant, death due to allograft failure, and death with a functional graft (infection, malignancy, and cardiovascular death). The secondary endpoints will assess improved kidney function through decline in estimated glomerular filtration rate and immune activity through development of donor-specific antibodies. Results: The total sample is anticipated to be 3500 (2500 patients managed with AlloSure dd-cfDNA and 1000 propensity-matched controls). Active enrollment began in November 2020. Conclusions: Based on a significant literature base, we believe implementing the surveillance of dd-cfDNA in the kidney transplant population will have a positive impact on graft survival. Through early identification of rejection and facilitating timely intervention, prolongation of allograft survival versus those not managed by dd-cfDNA surveillance protocol should be superior. International registered report identifier (irrid): PRR1-10.2196/25941.
Language	English
Publishing date	2021-03-15
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2719222-2
ISSN	1929-0748
ISSN	1929-0748
DOI	10.2196/25941
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Article: An Elderly Man with Syncope, Hypoxia, and Confusion: A Case Report and Review of Literature.

Konala, Venu Madhav / Naramala, Srikanth / Adapa, Sreedhar / Aeddula, Narothama Reddy / Bose, Subhasish

Cureus

2019 Volume 11, Issue 9, Page(s) e5567

Abstract: Controversies exist regarding the treatment of acute massive pulmonary embolism (PE) with anticoagulation alone or with thrombolytic therapy. Paradoxical embolism in the presence of a patent foramen ovale (PFO) is a rare but well-known entity and should ... ...

Abstract	Controversies exist regarding the treatment of acute massive pulmonary embolism (PE) with anticoagulation alone or with thrombolytic therapy. Paradoxical embolism in the presence of a patent foramen ovale (PFO) is a rare but well-known entity and should always be looked for in case of a PE associated with systemic thromboembolism. We report a case of acute sub-massive PE treated with thrombolytic therapy in an elderly gentleman who had a paradoxical embolism and ischemic stroke as a result of a clot traversing through a PFO. We discussed diagnostic modalities, treatment of choice, and associated controversies in management.
Language	English
Publishing date	2019-09-04
Publishing country	United States
Document type	Case Reports
ZDB-ID	2747273-5
ISSN	2168-8184
ISSN	2168-8184
DOI	10.7759/cureus.5567
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Article ; Online: An Overlapping Case of IgG4-Related Disease and Systemic Lupus Erythematosus.

Naramala, Srikanth / Biswas, Sharmi / Adapa, Sreedhar / Gayam, Vijay / Konala, Venu Madhav / Bose, Subhasish

Journal of investigative medicine high impact case reports

2019 Volume 7, Page(s) 2324709619862297

Abstract: We are reporting a case of a 63-year-old Chinese female who presented to the rheumatology clinic with positive antinuclear antibody and unintentional weight loss along with lymphadenopathy. Further workup revealed eosinophilia, elevated anti-double ... ...

Abstract	We are reporting a case of a 63-year-old Chinese female who presented to the rheumatology clinic with positive antinuclear antibody and unintentional weight loss along with lymphadenopathy. Further workup revealed eosinophilia, elevated anti-double stranded DNA, serum protein, and serum IgG4 (immunoglobulin G4). The patient was diagnosed with systemic lupus erythematosus. Due to the raised IgG4 level along with eosinophilia and diffuse lymphadenopathy, IgG4-related systemic disease was suspected. It was confirmed with IgG4 staining on lymph node biopsy. Our case is presenting the fact that systemic lupus erythematosus and IgG4-related disease can be present in the same patient with multiple overlapping features making accurate diagnosis challenging.
MeSH term(s)	Autoantibodies/immunology ; Biopsy ; Female ; Humans ; Immunoglobulin G4-Related Disease/complications ; Immunoglobulin G4-Related Disease/diagnosis ; Immunoglobulin G4-Related Disease/pathology ; Lupus Erythematosus, Systemic/complications ; Lupus Erythematosus, Systemic/diagnosis ; Lupus Erythematosus, Systemic/pathology ; Lymph Nodes/pathology ; Middle Aged
Chemical Substances	Autoantibodies
Language	English
Publishing date	2019-07-17
Publishing country	United States
Document type	Case Reports ; Journal Article
ZDB-ID	2710326-2
ISSN	2324-7096 ; 2324-7096
ISSN (online)	2324-7096
ISSN	2324-7096
DOI	10.1177/2324709619862297
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