Brammah R Thangarajah
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kidneying.bsky.social
Brammah R Thangarajah
@kidneying.bsky.social
16 followers 23 following 38 posts
Aspiring Educator, Nephrologist, and Lecturer in Medicine. Live in the northernmost part of the beautiful island of Sri Lanka. #NSMC Intern 2023 #Glomcon fellow 2024
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kidneying.bsky.social
Thanks a lot for the opportunity and, more importantly, an impetus to keep moving.
Hope you all stayed engaged and entertained
See you in other
@ECNeph
discussions.

#ECNeph
a man in a suit and tie is standing in front of a door and says `` thank you '' .
ALT: a man in a suit and tie is standing in front of a door and says `` thank you '' .
media.tenor.com
July 31, 2025 at 1:00 PM
kidneying.bsky.social
#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
July 31, 2025 at 12:58 PM
kidneying.bsky.social
#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 ?
July 31, 2025 at 12:57 PM
kidneying.bsky.social
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

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

☄️ More than few reported cases exist

July 31, 2025 at 12:55 PM
kidneying.bsky.social
When you suspect MMF-hyperinflammation
dont forget to exclude these
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores
@acssjr.bsky.social
July 31, 2025 at 12:54 PM
kidneying.bsky.social
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

⚠️ Few warnings exist already
July 31, 2025 at 12:54 PM
kidneying.bsky.social
Proposed mechanism of hyperinflammation due to MMF
#ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores
@acssjr.bsky.social
July 31, 2025 at 12:53 PM
kidneying.bsky.social
💥 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

July 31, 2025 at 12:52 PM
kidneying.bsky.social
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
July 31, 2025 at 12:51 PM
kidneying.bsky.social
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

💣. Predisposition - Yes

Not enough for diagnosis
❌ No organism identified
❌ No focus of infection
July 31, 2025 at 12:50 PM
kidneying.bsky.social
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
July 31, 2025 at 12:48 PM
kidneying.bsky.social
#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph

Do you agree ?

Post your final diagnosis ....

Is it to do with IST ?
July 31, 2025 at 12:47 PM
kidneying.bsky.social
#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 ?
July 31, 2025 at 12:45 PM
kidneying.bsky.social
🦠 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

July 31, 2025 at 12:45 PM
kidneying.bsky.social
#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
July 31, 2025 at 12:44 PM
kidneying.bsky.social
⚓️ What features would suggest SLE activity for you?

⚖️ Do you weigh on global assessment?

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

July 31, 2025 at 12:43 PM
kidneying.bsky.social
#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 ?
July 31, 2025 at 12:43 PM
kidneying.bsky.social
🔂 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

July 31, 2025 at 12:42 PM
kidneying.bsky.social
#ECNeph @brammahin @myadla @ISNkidneycare
@Dilushiwijay @acssjr @dra_miliflores

ESR:CRP <2
S/O infection than flare
Lupus. 2018 Jun;27(7):1123-1129
July 31, 2025 at 12:41 PM
kidneying.bsky.social
How to differentiate between flare /Infection in SLE
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores @acssjr.bsky.social
July 31, 2025 at 12:40 PM
kidneying.bsky.social
🗣️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
July 31, 2025 at 12:40 PM
kidneying.bsky.social
#ECNeph @brammahin @myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores

Does the evaluation suggest flare ?
All atypical infections ruled out
Malignancy ??????
What else ?
PET-CT ?
July 31, 2025 at 12:39 PM
kidneying.bsky.social
#ECNeph
July 31, 2025 at 12:36 PM
kidneying.bsky.social
#ECNeph@brammahin@myadla @ISNkidneycare @Dilushiwijay
@acssjr @dra_miliflores

How to differentiate flare /infection in SLE
Infection versus disease activity in systemic lupus erythematosus patients with fever. BMC Rheumatol. 2024 Aug 14;8(1):34
July 31, 2025 at 12:36 PM
kidneying.bsky.social
#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr @dra_miliflores

Admitted in a weeks time with fever , polyarthralgia
Is it relapse /recurrence of infection
High inflammatory markers : is it SLE flare ?
July 31, 2025 at 12:35 PM