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A South African man with renal failure and pulmonary shadowing

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2789 (Published 11 June 2012) Cite this as: BMJ 2012;344:e2789
  1. Neil Chanchlani, medical student1,
  2. Elizabeth Neale, medical student1,
  3. Paul B Rylance, consultant physician and nephrologist2
  1. 1University of Birmingham, Birmingham B29 7PU, UK
  2. 2Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, UK
  1. Correspondence to: N Chanchlani nxc651{at}bham.ac.uk

A 37 year old black South African man, who had been in the United Kingdom for about eight years, presented to the emergency department with a grand mal seizure that lasted 15 minutes. He had a one week history of feeling non-specifically unwell, a non-productive cough, and breathlessness, but no history of headaches, previous seizures, myalgia, arthralgia, adenopathy, or rashes. On examination, he had hypertension (177/108 mm Hg), tachycardia (102 beats/min), and a normal temperature (37.0°C). A chest examination was normal, as was the rest of the examination, and he was not dehydrated. Initial investigations showed raised creatinine (1949 µmol/L), urea (43 mmol/L), potassium (6 mmol/L), and C reactive protein (60 mg/L) concentrations. He was anaemic, with a haemoglobin of 93 g/L. Urinalysis showed proteinuria (3+) and haematuria (2+). In addition, arterial blood gases on air showed a metabolic acidosis (pH 7.29, partial pressure of oxygen 10.5 kPa, partial pressure of carbon dioxide 3.99 kPa, and base excess −11.2 mmol/L).

Chest radiography was performed (fig 1). He was started on intravenous antibiotics for his respiratory symptoms. According to local hospital guidelines, combination treatment with piperacillin and tazobactam (Tazocin), clarithromycin, and co-trimoxazole was given to cover bacterial, atypical, and opportunistic organisms.

In view of the seizure, we performed computed tomography of the head and a lumbar puncture. Both were normal, and the patient’s uraemic state was thought to be the most likely the cause of his seizure.

The raised urea, acidosis, and borderline hyperkalaemia were considered grounds for immediate haemodialysis and fluid removal.

Questions

  • 1 What does the chest radiograph show?

  • 2 What differential diagnoses should be considered?

  • 3 How would you confirm the diagnosis?

  • 4 What further investigations are needed in view of the renal failure?

  • 5 What long term management needs to be started once the diagnosis is confirmed? …

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