Multiple myeloma is a blood dyscrasias that accounts of almost 10% of all hematological malignancy. The presentation of myeloma kidney is highly variable and it often presents as renal insufficiency, renal tubular dysfunction and proteinuria of various types. In Malaysia the true incidence of myeloma kidney is unknown. Often the diagnosis of myeloma kidney was missed out despite the patient has sought medical treatment early. A high index of suspicion is required when the middle to elderly age patients present with unexplained renal impairment and enlarged kidneys. We present here the presentation of a rare subtype of myeloma in a relatively young patient whereby the patient presented with nephrotic syndrome and azotemia.

Enterobacter gergoviae is a gram negative rod-shaped opportunistic organism reported to cause urinary and respiratory tract infections, but peritonitis caused by this organism is unknown. We report a case of 50-year-old patient on peritoneal dialysis (PD) presented with Enterobacter gergoviae peritonitis with septic shock. Despite Intraperitoneal (IP) cloxacillin 250mg qid and IP ceftazidime 1gram q24h and subsequent escalation with IP amikacin 2mg/kg q24h and IP vancomycin 15mg/kg q24h within the next 48 hours, his peritonitis remained refractory and required catheter removal. Although Enterobacter gergoviae is naturally sensitive to aminoglycosides, carbapenems and quinolones, it reacts differently to the beta lactam antibiotics. Their resistance to third-generation cephalosporins is fast emerging and treatment with third-generation cephalosporins may cause AmpC-overproducing mutants. The majority of Enterobacteriaceae, including Extended-spectrum beta-lactamases producers, remain susceptible to carbapenems. Our report provides an unfavourable course of E. gergoviae peritonitis likely due to acquired secondary drug resistance during the therapy period.

Ochrobactrum anthropi is a rare nosocomial pathogen that is manifesting itself mostly in immunocompromised patients and those with indwelling catheters. Identification of the microorganism is challenging and the ability to survive in aquatic surroundings have made it a clinically significant pathogen. Furthermore, the clinical picture of O. anthropi infection, is not well described. It may manifest in any form of clinical infections though bacteremia is the most common mode of presentation reported in the limited literature. We report here two cases of O. anthropi bacteremia presenting in an immunocompetent and an immunocompromised host respectively with different clinical manifestation and response. In view of the highly variable presentation of O.anthropi, a high index of suspicion must be given to at risks patients to ensure the timely diagnosis and optimal clinical outcome.

Diabetic ketoacidosis (DKA) is a medical emergency which requires prompt management to prevent mortality. Treatment is complicated in end stage renal failure (ESRF) patients due to their altered physiology in sugar metabolism and fluid haemodynamics. To date, there are only a few case reports illustrating the presentation and management of DKA in ESRF patients and a definite guideline on treatment of DKA in ESRF is seriously lacking. We report here a case of an ESRF patient on maintenance haemodialysis, who develops DKA due to missed insulin, and outline our successful treatment plan. We hope our reported case report research can further contribute to the knowledge of DKA management in ESRF.

Leptospirosis has a wide range of presentation which ranges from mild flu-like symptoms, to severe form including renal failure, liver failure, and hemorrhage. Pulmonary involvement can progress from subtle clinical features to life threatening pulmonary hemorrhage and acute respiratory distress syndrome. Although benefits of corticosteroids in adult respiratory distress syndrome have been proven and accepted, evidence for use of corticosteroids in pulmonary leptospirosis is still limited. Given the vasculitic nature of severe leptospirosis, it has been proposed that addition of intravenous corticosteroid therapy, particularly in cases of pulmonary involvement is beneficial. We report a case of leptospirosis with suspected pulmonary hemorrhage which deteriorates after a few days of admission in our tertiary hospital. We have demonstrated that the prescription of a lower dose of corticosteroid than what was widely reported in the literature can equally led to a satisfactory recovery of the pulmonary hemorrhage.

Factor XII deficiency, also known as the Hageman factor, is a rare disorder that has not been associated with any adverse outcomes. It is an interesting blood disorder whereby in the state of deficiency, it causes prolongation activated partial thromboplastin time (aPTT) which is correctable with mixing test. Although there have been case reports that have mentioned events of thrombosis and bleeding, however, no clear causal relationship has been established. Evidence for adverse events occurring in patients with Factor XII deficiency is sparse. We report here a case of a lady with a history of miscarriages who was incidentally found to have Factor XII deficiency during a routine workup for prolonged aPTT.

Streptoccoccus plurianimalium is a rare pathogen that has recently made a crossover from its common host, animals to humans. As reports start to emerge from this pathogen, it has come to light that it can cause clinically significant infections in a broad spectrum of systems. However, the mode of transmission of this pathogen has not yet been fully established. We report here a case of Streptoccoccus plurianimalium peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis in our centre. To the best of our knowledge, this is the first case report of a Streptoccoccus plurianimalium peritonitis in an end-stage kidney disease patient.

Introduction: Mass COVID-19 vaccination has been pivotal in the fight against this pandemic. The occurrence of glomerular disease following COVID-19 vaccinations particularly mRNA vaccine has been reported. The reported cases in the region are limited and number of cases reported are low in contrast to the total number of vaccine doses given worldwide, the healthcare providers should be alerted about such issues to provide swift and proper management. Case Series: Here, we report 3 cases of Focal segmental glomerulosclerosis (FSGS) following COVID-19 vaccination and their outcomes. Two of the patients received BNT162b2 vaccination and one received CoronaVac vaccination. The mean age of the patients was 33+/-7 years old. The mean duration onset of FSGS was 23+/-19 days post vaccinations. Two of the patients (BNT162b2 vaccination and CoronaVac vaccination) achieved complete remission after corticosteroid therapy. This is the first reported case of De Novo FSGS following CoronaVac vaccination in the literature. The third patient, who received BNT162b2 vaccination and presented late (42 days post vaccination) was not in remission despite three months of immunosuppressive treatment. Conclusion: The treating physician needs to be aware of the possibility of the development of FSGS associated with COVID-19 vaccination and how to proceed with vaccination schedule in these populations. Overall, the advantage of COVID-19 vaccination far outweighs the possibility of COVID-19 vaccine-associated glomerular disease.