The Riddle Of The Piddle
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This document discusses four case studies: 1) A 34-year-old man unconscious after heroin injection presenting with swollen muscles. 2) A 47-year-old man with cough and dark urine diagnosed with paroxysmal nocturnal hemoglobinuria. 3) A 42-year-old man who self-immolated with severe burns and low blood pH. 4) A 45-year-old man in a motorbike accident brought to the hospital with an injured shoulder. The document also discusses kidney anatomy in different species and historical references.
The Riddle Of The Piddle
- 1. “ THE RIDDLE OF THE PIDDLE ” Linas Dziukas 22nd April 2016
- 2. Atlas & Epitome of Human Histology & Microscopic Anatomy Johannes Sobotta 1903 Rauber’s Lehrbuch der Anatomie des Menschen Volume 4 1914
- 3. Atlas & Epitome of Human Histology & Microscopic Anatomy Johannes Sobotta 1903 Atlas of Human Histology Arnold Brass 1897
- 4. Rauber’s Lehrbuch der Anatomie des Menschen Volume 4 1914 Atlas & Epitome of Human Histology & Microscopic Anatomy Johannes Sobotta 1903
- 5. University of Birmingham 2012
- 6. Rauber’s Lehrbuch der Anatomie des Menschen Volume 4 1914 Textbook of Histology & Microscopic Anatomy of the Human Body Szymonowicz 1902
- 7. Brenner & Rector’s The Kidney 8e 2008 Human Microscopic Anatomy Krstic 1991
- 8. Case 1 34 year old man who was unconscious for a unknown time in a car after an intravenous injection of heroin Presents with GCS of 13 Swollen right deltoid muscle Swollen right gluteal muscles
- 9. Case 1
- 10. Case 2 This 47 year old man came to the Emergency Department with a history of a cough with small volumes of yellowish sputum. This developed three days ago. There was no fever nor any upper respiratory tract symptoms. He took cough tablets that contained pseudoephedrine, an antihistamine and paracetamol. His respiratory symptoms improved, but the day before presentation urine was darker. On the day of presentation his urine was a dark brown colour, and he became short of breath.
- 11. Case 2 His first clinical presentation was at the age of 24 years, when he had a laparotomy because of ischaemic small bowel due to thrombosis of mesenteric veins. Since then he has had multiple haemolytic episodes that were usually precipitated by respiratory infections.
- 12. Case 2 He has also had episodes when his urine is dark brown in the morning, but returns to a normal colour during the day
- 13. Case 2 Heart rate was 110 beats per minute, blood pressure was 130/80 mm Hg, respiratory rate was 15 beats per minute, and SaO2 was 98% on room air. The jugular venous pulse was not visible, auscultation of the heart was normal apart from a soft systolic ejection murmur, and examination of the lungs was normal. Abdominal examination was normal. Urine analysis was positive for blood.
- 14. Case 2 Normal Range Sodium 137 135–145 mmol/L Potassium 3.5 3.5–5.2 mmol/L Bicarbonate 19 22-32 mmol/L Urea 4.7 3.0-8.0 mmol/L eGFR > 90 Lactic dehydrogenase (LD) 2660 120–250 U/L Haptoglobin < 0.08 0.3-2.0 g/L
- 15. Total protein 75 60–80 g/L Albumin 38 32-45 g/L Bilirubin 77 < 20 µmol/L ALT 63 < 35 U/L GGT 62 < 50 U/L ALP 82 30–110 U/L Case 2 Liver Function Tests
- 16. Case 2 Hb 52 > 130 g/L MCV 128 80-100 fL WBC 3.31 4.5-13.5 x 109/L Platelets 121 150-400 x 109/L Reticulocytes 218.2 30-140 x 109/L Reticulocytes % 17.22 0.7-3.2% INR 1 0.8-1.2 PT 13.4 12–13 seconds APTT 39.3 30 - 50 seconds
- 17. Diagnosis Case 1: Myoglobinuria secondary to rhabdomyolysis Case 2: Paroxysmal nocturnal hemoglobinuria Prevalence: 1.3 per 1,000,000 population
- 18. PNH Close integration between the complement cascade (grey) and the coagulation cascade (green). Anita Hill et al. Blood 2013;121:4985-4996 Methemoglobin Acute renal failure Renal hemosiderosis Hemoglobinuria
- 19. Haemosiderin Haemosiderin Intra-tubular haemosiderin Nephrol Dial Transplant (2011) 0: 1–4 doi: 10.1093/ndt/gfr391
- 20. Erythrophagocytosis - neutrophil Erythrophagocytosis - monocyte Erythrophagocytosis in Paroxysmal Cold Hemoglobinuria American Journal of Hematology 74:196–197 (2003)
- 23. Case 3 42 year old man who immolated himself inside a house Patient intubated Had arterial pH of 6.5
- 26. Preston and Northcote Communuty Hospital 1982
- 28. Preston and Northcote Communuty Hospital 1982
- 30. Case 4 A 45 year old man was brought in by ambulance after a motorbike accident. He landed heavily on his shoulder.
- 33. Rat
- 34. Lamb Kidney
- 35. Pig Kidney
- 36. 4 year old human Ox Kidney
- 37. A B CRat
- 38. and pyelotubular reflux Campbell’s Urology 8e 2002
- 39. Primate - Crest Kidney
- 40. Primate - Pyelotubular Reflux
- 41. Cunningham’s Anatomy - 1912 Netter - 2002 Human Kidney
- 42. Human Kidney Atlas D’Anatomie Descriptive C Bonamy & Paul Broca 1860’s
- 43. Pig Kidney - Intra-renal Reflux
- 44. Scarring in a pig model of sterile high pressure reflux CJ Hodson 1972
- 45. Right “lobar nephronia” in pig model of R sidedVUR and bladder neck obstruction Yale 1980
- 46. “If the doors of perception were cleansed every thing would appear to man as it is, Infinite. For man has closed himself up, till he sees all things thro' narrow chinks of his cavern.” The Marriage of Heaven and Hell William Blake 1793 Atlas D’Anatomie Descriptive C Bonamy & Paul Broca 1860’s