BK virus interstitial nephritis (BKVIN) isBKVIN caused irreversible deterioration of graft function in all patients but renal function stabilized after antiviral treatment (creatinine clearance: 51.8-32 mL/min; p = 0.001) and no graft loss occurred in cidofovir-treated recipients during 24.8 (8-41) months follow-up. Peak serum cidofovir concentrations were dose-dependent and attained approximately onetenth of the in vitro EC 50 for cidofovir against BK-virus, while pre-treatment with probenecid did not alter peak serum concentrations nor affected the incidence of nephrotoxicity. In fact, no cidofovir-related renal toxicity occurred; few patients had minor transient side effects (nausea, skin rash). In contrast, 9 of 13 patient who received no adjuvant cidofovir therapy lost their graft after median 8 (4-40) months.In this selected group of recipients with BKVIN, the use of adjuvant low-dose cidofovir therapy resulted in prolonged graft survival and stabilized graft function.

Diarrhoea and weight loss are frequently reported adverse events in rheumatoid arthritis (RA) patients receiving the disease-modifying antirheumatic drug (DMARD) leflunomide. According to the available literature these side effects occur mostly during the first 6 months of treatment, are rather mild and rarely lead to treatment withdrawal. In this report, we describe the clinical, endoscopic and histologic findings in two RA patients with severe diarrhoea and important weight loss more than 12 months after starting treatment with leflunomide. In both cases the symptoms were caused by colitis, but one had ulcerative and the other microscopic colitis. Despite treatment with budesonide the complaints only improved after withdrawal of leflunomide, making a causal relationship between this drug and the pathogenesis of colitis probable. The heterogeneous histopathological findings in these two patients, however, do not allow us to draw any definitive conclusions about the mechanism by which leflunomide causes diarrhoea and weight loss in RA patients. We conclude that persistent diarrhoea or weight loss in patients taking leflunomide can be more serious than what is previously reported in the literature. In such cases leflunomide treatment should be stopped and an endoscopic examination of the colon is recommended. Given the long half-life of this drug a washout procedure with cholestyramine should be considered whenever the problem is severe or persistent.

Alkaline encrusted pyelitis is an infectious disease characterised by encrustations in the wall of the upper urinary tract, surrounded by severe inflammation. Destruction of native kidneys and kidney grafts may occur, resulting in end stage renal failure. Corynebacterium group D2, an urea splitting microorganism, is nearly exclusively associated with this disease. The most important predisposing factors are previous urological procedures and an immunosuppressed state. In a suggestive clinical context, diagnosis should be made with unenhanced computed tomography findings and bacteriologic isolation of the responsible microorganism. The treatment is threefold: appropriate antibiotic therapy, by preference with glycopeptides, acidification of urine and chemolysis, and if needed, surgical removal of encrustations. We report the case of a patient who was diagnosed with this rare condition and could escape maintenance dialysis after correct diagnosis was made and conservative treatment was started using antibiotics and combined oral and local acidification.

The clinical presentation of lead intoxication may vary widely and in the absence of a high clinical index of suspicion, the diagnosis may be missed. The effects of lead on mitochondrial oxidative phosphorylation and its interaction with calcium-mediated processes explain the heterogenous presentation. In this case report, the diagnosis was finally made when bilateral wrist drop developed on top of abdominal cramps and anemia. Before, ascites raised the suspicion of a tumor. Therefore, each element of the triad of unexplained anemia, abdominal cramps, and bilateral wrist (or foot) drop should lead any physician to consider the diagnosis of lead intoxication. This case also illustrates the importance of a careful and meticulous social history in patient management.

The clinical presentation of lead intoxication may vary widely and in the absence of a high clinical index of suspicion, the diagnosis may be missed. The effects of lead on mitochondrial oxidative phosphorylation and its interaction with calcium-mediated processes explain the heterogenous presentation. In this case report, the diagnosis was finally made when bilateral wrist drop developed on top of abdominal cramps and anemia. Before, ascites raised the suspicion of a tumor. Therefore, each element of the triad of unexplained anemia, abdominal cramps and bilateral wrist (or foot) drop should lead any physician to consider the diagnosis of lead intoxication. This case also illustrates the importance of a careful and meticulous social history in patient management.A 32-year-old man was elbowed in the chest while fighting for a rebound in a recreational basketball game. He fell to the ground and his chest ached from the blow. Four days later he developed more severe chest pressure with dyspnea and came to the hospital. His chest wall was tender and his pulse slow, but the remainder of his physical examination was normal. Electrocardiogram showed sinus bradycardia, first-degree atrioventricular (AV) block, and occasional isorhythmic AV dissociation, but no ischemic ST-T changes. Cardiac troponin I rose to 1.74 ng/mL (normal o0.50). The patient therefore underwent coronary angiography, showing spiral dissection of the right coronary artery with extensive thrombus filling the distal portion of the vessel. Stenting was unsuccessful in restoring flow. This case highlights the potential dangers of blunt chest trauma in recreational sports and shows how angiography can distinguish myocardial contusion from coronary artery dissection.KEY WORDS: coronary artery dissection; coronary artery injury; blunt chest trauma; blunt cardiac trauma.