Thank you, Lily for presenting a case this morning of a middle-aged woman from Mexico being treated for a metastatic GI malignancy p/w flank pain, AKI and palpable purpura found to have obstructive nephropathy and candiduria .
- Classic approach to AKI: pre-, intrinsic-, post-renal hold-up even when the patient becomes more complicated. Always remember to consider carefully a patient’s volume status and run the med list.
- The DDx for purpura can be broken down first by whether or not the lesions are palpable. If NOT palpable, we call these petechiae or ecchymoses based on the size (<3mm = petechiae). This should prompt consideration of the coagulation cascade, platelets, uremia. If palpable, this suggests inflammation and a possible vasculitis. See an approach to palpable purpura below.
- Yeast in urine is usually a colonizer and not a pathogen. However, treatment for funguria is indicated in patients with renal transplant and immunosuppression. See link for more info http://www.sjkdt.org/article.asp?issn=1319-
|Candiduria: A Review of Clinical Significance and Management – Zakeya Abdulbaqi Bukhary|
- Treatment of Candida can be guided by in vitro susceptibility testing (although all labs do not send these).
- Fluconazole gains high concentrations of active drug in the urine, is better tolerated and is less likely to be associated with the emergence of resistance during therapy.
- The greatest concern for fluconazole resistance is related to C. glabrata and C. krusei isolates which require maximal doses of amphotericin B.
- As HH mentioned – Echinocandin anti fungal agents (caspofungin, micafungin, and anidulafungin) can be used although low sub-therapeutic levels are achieved in the urine because the drug has poor glomerular filtration with subsequent diminished tubular secretion.
More Info at: http://www.sjkdt.org/article.asp?issn=1319-
Causes of Non-Palpable Purpura based on size of lesion
- Remember these lesions are macular and are typically NOT inflammatory
- Petechiae (small lesions < 3 mm)
- Abnormal palatele function
- Increased intravascular pressures
- DIC and infection
- Ecchymoses (larger lesions > 5 mm)
- Coagulation defects
- DIC and infection (purpura fulminas)
- External trauma
- Hypergammaglobulinemic purpura
See the following link for more information in a case based ppt from the American Academy of Dermatology Titled “Petechiae, Purpura and Vasculitis.”
Break down Vasculitis based on vessel size