Hemolytic uremic syndrome (HUS) is a constellation of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury. HUS is subcategorized into primary or secondary HUS. Primary HUS is synonymous with atypical HUS (aHUS) and is attributed to genetic complement deficiency. Diffuse alveolar hemorrhage (DAH) is a serious condition complicating multiple systemic conditions. aHUS presenting as DAH is exceedingly rare. In this case, we present a 75-year-old male patient who presented with generalized weakness, malaise, and hemoptysis. He was found to have hemolytic anemia and thrombocytopenia, with elevated creatinine. Bronchoscopy confirmed DAH. He was started on plasmapheresis with a suboptimal response. aHUS was suspected and the patient was started on eculizumab with subsequent laboratory and clinical improvement. HUS and aHUS can present as DAH. It is very important to recognize both conditions as both are life threatening with high morbidity and mortality.
Renocolic fistula is a rare clinical finding that is most commonly iatrogenic after surgical intervention. Herein, we present a case of spontaneous renocolic fistula secondary to Xanthogranulomatous pyelonephritis (XGP) with a subtle presentation as anemia. Given the subtle presentation in our case, colonoscopy findings were the trigger for further investigations.: This is a 40-year-old female was asked to go to the ED by her primary care physician (PCP) for low hemoglobin on routine labs. Patient had been complaining of fatigue, nausea, diarrhea, dysuria and urinary frequency for 7 days. Labs in the Emergency departement (ED) were remarkable for a hemoglobin of 6.5 g/dL (down from 10 g/dL 3 months prior) white blood cell count (WBC) of 18x103 cmm, creatinine of 1.87 mg/dL (baseline is 1 mg/dL) with blood urea nitrogen (BUN) of 24 mg/dL. Urinalysis was remarkable for too numerous WBC, positive bacteria and nitrite. Patient received 1 Unit of packed red blood cells and was started on Ceftriaxone for a urinary tract infection. No overt source of bleeding was identified. An esophagogastroduodenoscopy (EGD) was normal while colonoscopy showed a fistula with surrounding nodularity close to the splenic flexure of the colon (figure 1), a small amount of pus was also noted coming out from the fistula. Shortly after, the patient spiked a fever of 102.7F. C-Reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) were both elevated at 17 and 140 respectively which raised the concern of inflammatory bowel disease. A CT scan of the abdomen and pelvis with contrast showed findings of acute on chronic left kidney pyelonephritis with multiple contiguous abscesses in the inferior left kidney with a staghorn calculus concerning for XGP, it also showed the fistula between the left kidney and the splenic flexure of the colon (Figure 2,3). The patient underwent exploratory laparotomy, takedown and repair of renocolic fistula, partial omentectomy and left nephrectomy by urology and general surgery teams. Patient had an uncomplicated post-operative course and was discharged home on post-operative day 6 with a stable hemoglobin of 8 g/dL.1521_B Figure 2. CT scan of the abdomen and pelvis showing a renocolic fistula and xanthogranulomatous pyelonephritis1521_C Figure 3. CT scan of the abdomen and pelvis showing a renocolic fistula and xanthogranulomatous pyelonephritisIn conclusion, XGP is a rare type of chronic pyelonephritis that is usually a result of chronic obstruction by an infected stone. Spontaneous renocolic fistulas are rare nowadays with the advancement in antibiotics and renal stones management.1521_A Figure 1. Colonoscopy showing a fistula opening with surrounding nodularity
Despite bronchoscopy's minimally invasive approach, it is not without errors and complications. When such errors do occur, patients may seek legal redress. The aim of the study was to describe the setting, contributing characteristics, and outcomes of litigation targeting bronchoscopic procedures. Westlaw (Thompson Reuters), an online legal research data set, was queried for all medical malpractice cases reported in the United States from 1983 to 2018 wherein bronchoscopy was performed. A total of 87 cases were included. Pulmonology was the most common specialty named in the cases (n=42, 48%). The most common alleged reason for litigation was procedural complication (n=25, 29%), followed by failure to diagnose (n=24, 28%) and failure to treat (n=16, 18%). A total of 49 cases (56%) were decided in favor of the defendant physician, and a settlement was reached before the trial verdict in 20 cases (23%). A verdict delivered in favor of the plaintiff occurred in 18 cases (21%). The median (interquartile range) plaintiff award and settlement payouts were $1,729,560 ($497,088 to $3,895,337) and $648,000 ($184,961 to $2,874,875), respectively. Failure to obtain complete informed consent was the only case characteristic that was significantly associated with an increased risk of payout (odds ratio: 6.67, 95% confidence interval: 1.1-84, P=0.04). Despite bronchoscopy's utility in identifying numerous pulmonary pathologies, bronchoscopy-related complications were found to be the leading cause of litigation. Identifying and addressing errors with care and proper consent may reduce the number of malpractice claims related to bronchoscopy. Level of Evidence: Level III.
Guillain-Barre syndrome (GBS) represents the most common cause of acute flaccid paralysis and is characterized by muscle weakness frequently accompanied by respiratory and bulbar paralysis which oftentimes can be life-threatening. Early recognition and intervention are essential to prevent potential complications and help hasten recovery. Herein, we report a case of a middle-aged female who presented with nonspecific gastrointestinal symptoms that were shortly followed by a unique combination of new-onset facial diplegia and asymmetric lower extremity areflexia. Treatment with intravenous immunoglobulins (IVIG) was initiated following a prompt diagnosis of GBS was made. Clinicians should always be vigilant about the possibility of GBS in the appropriate clinical setting and be aware of the essentials of management of this potentially treatable disease.
