SEVELAMER CRYSTALS: WREAKING HAVOC IN THE COLON
A CASE OF A SPLENIC ABSCESS THAT LIKELY SEEDED FROM A GASTROCNEMIUS ABSCESS B. Hubble; V. Soegaard; V. Tati Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge Introduction: Splenic abscesses are rare, occurring at a rate of 0.14-0.7%. Risks include immunosuppression, malignancy, trauma, diabetes and hematogenous spread from infective endocarditis. Typical presentation consists of fever and abdominal pain. This is a patient that had a rather unusual presentation of an unusual condition. Case: A 48 year-old woman presented with one month of left leg swelling and pain. After two negative DVT workups in the outpatient setting, a non-contrast CT showed a large lobulated splenic mass/ cyst and she was sent to the hospital for further workup. Upon swollen, erythematous, and tender. She was found to be septic and initiated on Vancomycin and Zosyn. She underwent abdominal MRI, upper endoscopy and endoscopic ultrasound, which were non-revealing. Antibiotics were stopped, at which point her leg became more erythematous and she had difficulty walking. This prompted CT of the leg which revealed an abscess throughout most of the gastrocnemius muscle. Vancomycin was restarted and patient underwent surgical drainage of the leg with subsequent washouts prior to closing. CT guided aspiration of splenic lesion revealed purulent material consistent with abscess. Due to concern of continued hematogenous seeding, she underwent robotic splenectomy. Intraoperative cultures from both sites demonstrated MRSA, despite persistently negative blood cultures. She was initially discharged on Linezolid but returned for fever so she was restarted on Vancomycin to complete a 6week course for suspected transient bacteremia despite negative cultures. exam, leg was Discussion: This was a rare case of a splenic abscess as the source had likely seeded from the abscess in her gastrocnemius. Initially, the thought was that the patient had cellulitis in her leg,
myeloma. Management of myeloma- related AKI includes holding nephrotoxic agents, providing IV hydration, correcting electrolyte and pH abnormalities, and treating the underlying MM with bortezomib-based therapy and corticosteroids. Plasmapheresis may be considered for free LC removal, which has been shown to expedite renal recovery. Hospitalists should consider LC cast nephropathy as a possible cause for AKI that does not improve with supportive care. The importance of a timely and multifaceted approach lies in the prevention of progressive renal disease and other complications.
E. Clements; K. Sulaiman Department of Internal Medicine, LSU Health Sciences Center – Shreveport Sevelamer is a cationic polymer which works to bind intestinal phosphate, thereby lowering serum phosphate levels in patients with chronic kidney disease or end stage renal disease (ESRD). Hyperphosphatemia is a well- known complication of advanced kidney disease, necessitating dietary restriction of phosphorus and administration of binders to control phosphorous levels. Not only is hyperphosphatemia an independent risk factor for cardiovascular disease, but mortality rates are increased with prolonged hyperphosphatemia compared to those with well-controlled phosphate levels. This makes phosphate binders an integral part of evidence-based practice in ESRD patients. Here we present a case of sevelamer crystal-induced cecal inflammation and ulceration causing superimposed abscess formation. Initially a concern for malignancy, biopsies were taken during a colonoscopy following an incidental finding of cecal mass on Computed Tomography (CT) scan of the abdomen and pelvis. This scan was performed to rule out covert source of infection as this patient had persistent gram-positive bacteremia. An important element of this case was the co-morbid condition of severe chronic constipation. We also review other cases described of sevelamer crystal involvement in colon mucosal inflammation. Hematochezia and stricture formation have been described in these other cases, however this is the first documented case of abscess or mass formation.
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30 J LA MED SOC | VOL 171 | NO. 1
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