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Case Studies

Case Study 1

In the presented clinical case, the main clinical manifestations in Mr. J.R. is severe toxigenic secretory diarrhea, as well as nausea with vomiting, which lasted for 48 hours. These symptoms were the cause of severe dehydration, which manifests itself clinically as weakness and dizziness, and an increase in body temperature is a consequence of the immune response (release of cytokines) in response to an infectious agent. Therefore, Mr. J.R. there was a prerenal type of acute kidney injury, which occurs in the event of a significant decrease in the volume of circulating blood. The glomeruli of the kidney do not receive sufficient perfusion, resulting in ischemia of the renal cortex and a reduction in glomerular filtration rate (Yu & Bonventre, 2018). At the same time, it is essential to note that one of the probable causative agents of this type of diarrhea is Shiga toxin-producing E. Coli, which can cause direct damage to these organs (instinct injury type of acute kidney injury) as a result of massive hemolysis of erythrocytes, which is designated as vital a threatening condition such as hemolytic-uremic syndrome (Bruyand et al., 2018). Therefore, a mixed variant of acute kidney damage in Mr. J.R. in the presented clinical case, taking into account the clinical symptoms, and such an alarming sign as a metallic taste in the mouth is associated with Pepto-Bismol. It is unlikely to be related to acute heavy metal poisoning.

Acute kidney injury does not occur in every patient with severe diarrhea, but Mr. J.R. had several important risk factors that increase the likelihood of such a complication. Firstly, old age (the physiological reserve of functioning nephrons is reduced in such patients). Second, severe dehydration (vomiting and diarrhea) without adequate replacement of lost fluid, which was both a provoking factor and a risk factor for the resulting complication (Bruyand et al., 2018). Thirdly, concomitant diseases of both the cardiovascular and the endocrine and urinary systems are possible in such patients, which also significantly increases the risks in the category of elderly patients.

In patients with chronic kidney disease, especially in the latter stages of the disease, hematological complications occur, which are associated with the loss of several essential functions of a normally functioning kidney. A particularly common manifestation is anemia, the main reason for which is the lack of production of such a biologically active substance as erythropoietin, which is one of the primary regulators of the maturation process of mature red blood cells from progenitor cells in the red bone marrow (erythropoiesis). Therefore, patients often have severe chronic anemia and require replacement therapy, which fortunately exists and is highly effective, for example, recombinant exogenous erythropoietin (Yamamoto et al., 2017). The second group of hematological problems is coagulopathy, which can be expressed to varying degrees depending on the etiology of chronic kidney disease and consist of both a decrease and an increase in the procoagulant state (Yu & Bonventre, 2018). For example, in the case of nephrotic syndrome and systemic lupus erythematosus, thrombosis occurs especially often as a result of the retention of abundant proteins (such as fibrinogen) against the background of the loss of small fractions, mainly albumin and the concentration of coagulation factors is increased. Also, in the case of uremia in the late stages of the disease, platelet activity often increases, which also increases procoagulant activity.

Case Study 2

Definitely, in this clinical case, Ms. P.C. has both clinical signs and little objective evidence of a sexually transmitted infection such as gonorrhea. Firstly, past medical history indicates the presence of unprotected intercourse six days before the onset of the first clinical manifestations. In comparison, the incubation period for this infection is concise (on average, two to seven days), which suggests this etiology (Dickson, Arnason, Friedman, Metz, & Grimshaw, 2017). Besides, the sexual partner probably had an asymptomatic form of the disease or was also in the incubation period of infection, since he was able to contaminate and infect the mucous membranes of the vagina of this patient during the last intercourse. Second, the nature of the vaginal discharge can often provide valuable information and preliminary conclusions about the possible causative agent, and the greenish-yellow and fetid life of this secretion are characteristic of a disorder such as gonorrhea (Lovett & Duncan, 2019). Thirdly, microscopic examination revealed the presence of gram-negative intracellular diplococci, as well as a high content of white blood cells (an inflammatory reaction to the introduction of this pathogen), which is also characteristic of this disease. Therefore, the most likely microorganism that fits this description and causes such vaginal discharge is Neisseria gonorrhoeae (Fifer, Saunders, Soni, Sadiq, & FitzGerald, 2020). Another name for these bacteria is Gonococci, which has target cells such as the epithelium of the mucous membranes of the genitourinary system and has an upward spread of infection, causing urethritis, vaginitis, endometritis and even peritonitis in women. Besides, damage to other extragenital mucous membranes (rectum, conjunctiva) is possible. Still, in this case, this did not occur due to the lack of contact of the infected sexual organ of the sexual partner with these potential entrance gates.

Often, Neisseria gonorrhoeae infections have an erased or low-symptom course, and such cases require screening and outpatient antibiotic treatment (Dickson et al., 2017). At the same time, Ms. P.C. There are alarming clinical signs that require clinicians to consider the need for hospitalization and treatment of this patient in a hospital setting under the supervision of medical personnel. This is due to the possibility of widespread inflammation of the pelvic organs (uterus, fallopian tubes, and ovaries) and the peritoneum covering them. This condition is referred to as pelvic peritonitis. It can cause severe acute complications, including sepsis and even death of the patient, without mentioning chronic problems such as the formation of synechiae and adhesions and the risk of future infertility (Fifer et al., 2020). Severe pain in the projection of the pelvic organs, as well as intoxication (nausea, emesis), can be considered as determining factors for hospitalization and adequate treatment of Ms. P.C. in a hospital setting.

References 

Bruyand, M., Mariani-Kurkdjian, P., Gouali, M., de Valk, H., King, L. A., Le Hello, S., & Loirat, C. (2018). Hemolytic uremic syndrome due to Shiga toxin-producing Escherichia coli infection. Medecine et Maladies Infectieuses, 48(3), 167-174.

Dickson, C., Arnason, T., Friedman, D. S., Metz, G., & Grimshaw, J. M. (2017). A systematic review and appraisal of the quality of practice guidelines for the management of Neisseria gonorrhoeae infections. Sexually Transmitted Infections, 93(7), 487-492.

Fifer, H., Saunders, J., Soni, S., Sadiq, S. T., & FitzGerald, M. (2020). UK national guideline for the management of infection with Neisseria gonorrhoeae. International Journal of STD & AIDS, 31(1), 4-15.

Lovett, A., & Duncan, J. A. (2019). Human immune responses and the natural history of Neisseria gonorrhoeae infection. Frontiers in Immunology, 9(4), 3187-3191.

Yamamoto, H., Nishi, S., Tomo, T., Masakane, I., Saito, K., Nangaku, M., & Ito, Y. (2017). Japanese Society for Dialysis Therapy: Guidelines for renal anemia in chronic kidney disease. Renal Replacement Therapy, 3(1), 36-42.

Yu, S. M. & Bonventre, J. V. (2018). Acute kidney injury and the progression of diabetic kidney disease. Advances in Chronic Kidney Disease, 25(2), 166-180.