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Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @Dilushiwijay @myadla
@acssjr @dra_miliflores

Diagnoses in nephrology at different junctures

Few at admission
Few in the history
Few in the sequence
Few in the investigations
Few in the biopsy
And a few in the recovery

2

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin.@myadla. @Dilushiwijay
@dra_miliflore @acssjr

Similar presentation in Post Tx Pt

But ..why is it so rare ?
Why dont we see it often despite high use ?

Thoughts ?

1 2

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

pubmed.ncbi.nlm.nih....
pubmed.ncbi.nlm.nih....

☄️ More than few reported cases exist

2 4

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

When you suspect MMF-hyperinflammation
dont forget to exclude these
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores
@acssjr.bsky.social

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

⚠️ Few warnings exist already

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

Proposed mechanism of hyperinflammation due to MMF
#ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores
@acssjr.bsky.social

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

💥 Could this be MAS in SLE? We are seeing it more often,

🗝️ - Clues in clinical practice
Fever
Pancytopenia
Organomegaly
⬇️ ESR with disease activity

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

2 6

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

Differentiating fever from flare in lupus
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores @acssjr

NLR
CRP/ESR ratio <2/2-15/>15 : <2 s/o infection

2 5

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

💣. Predisposition - Yes

Not enough for diagnosis
❌ No organism identified
❌ No focus of infection

4

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

ℹ️Turns out patient has hypogammaglobulinemia
❓MMF related/disease related
Ig A - 134 mg/dl ( 70-400)
⬇️Ig G - 669 mg/dL (700-1600)
⬇️⬇️Ig M - 38 mg/dL (40-230)

😏Does it explain all?

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

2 4

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph

Do you agree ?

Post your final diagnosis ....

Is it to do with IST ?

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph

see the time line of admissions for febrile episodes
Class switch
High inflammatory markers
Infection clues negative
3 episodes in 2-3 months

Where should this lead to ?

1 1 5

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

🦠 When do you think fever is of infection in origin?

⁉️ Can we rule out all infections all the times? Say some hidden TB or a very timid virus. We need more markers.

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr
@dra_miliflores

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph
yet another admission ..in a weeks time
premature discharge vs recurrence of infection /appearance of flare

High inflammatory markers favour infection
or is it non infectious inflammation

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

⚓️ What features would suggest SLE activity for you?

⚖️ Do you weigh on global assessment?

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph
Rx with antibiotics
Restarted on IST after fever subsidence

What next ?
Evaluation being negative for all infections : Bacteria /virus ..
How to go further ?

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

🔂 3 admissions with acute febrile illnesses within
2-month span
🩺 No focal signs/symptoms
☢️ Routine imaging -negative -No organ-specific
illness
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @myadla @ISNkidneycare
@Dilushiwijay @acssjr @dra_miliflores

ESR:CRP <2
S/O infection than flare
Lupus. 2018 Jun;27(7):1123-1129

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

How to differentiate between flare /Infection in SLE
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores @acssjr.bsky.social

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

🗣️Fever in SLE - An enigma wrapped in mystery.

Interested in hearing your phrases of fever and also how do you define it in routine practice?

🧈 Just basics
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph @brammahin @myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores

Does the evaluation suggest flare ?
All atypical infections ruled out
Malignancy ??????
What else ?
PET-CT ?

Brammah R Thangarajah @kidneying.bsky.social · Jul 31

#ECNeph