Case 14
With discussion
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Clinical information

A 22-years-old Hispanic female, 30 weeks into a her third pregnancy, presented with chronic arterial hypertension, and at 25 weeks with preeclampsia; she had in addition chronic renal disease. Her first pregnancy was normal and there was not obstetric complications. Her second pregnancy was complicated due to severe and early preeclampsia with fetal death at 28 weeks; when finishing the second pregnancy the patient continued with proteinuria (3.5 to 8.9 mg/dL) and hematuria.

Other rigurous studies were nor done because economic, educational, and social conditions of the patient were not ideal. Again she becomes pregnant eight months after the unfortunated second pregnancy. She had chronic hypertension that worsened from 16 week into pregnancy, intrauterine growth retardation, and proteinuria: 15 g/24h. On examination there was marked pedal and pre-tibial oedema.

Other laboratory data included serum creatinine 2.2 mg/dL; normal liver function tests and normal platelet count. Anti-hypertensive therapy was with calcium channel blocker and magnesium but it could not be controlled. Oval fat bodies and fatty casts in the urine and 1+ hematuria with no RBC casts; albumin 2.3; glucose 81; negative ANAs; C3: 90 (80-160), C4: 15 (17-40); Hb: 9.5 mg%, Hto 31%, no schistocytes; some days after she presented mildly elevated liver function tests; lupus anticoagulant, anti-cardiolipin antibodies, and hepatitis virus tests were negative. Anti-DNA, ASLO, and ANCA were all negative; there was no monoclonal spike on serum electrophoresis.

Her pregnancy was finished by caesarean. Seven days after the childbirth a renal biopsy was performed. See the images.

Figure 1. H&E, X400.

Figure 2. H&E, X400.

Figure 3. Masson's trichrome stain, X400.

Figure 4. Masson's trichrome stain, X400.

Figure 5. Methenamine silver stain, X400.

Figure 6. Methenamine silver stain, X400.

Figure 7. Immunofluorescence using antiserum to IgG, x400. Staining was diffuse.

Figure 8. Immunofluorescence using antiserum to C3, x400. Staining was diffuse.

Figure 9. Immunofluorescence using antiserum to IgM, X400. Staining was segmental.

Immunofluorescence for IgA and C1q were negative.

Epithelial crescents in 2 of 8 glomeruli.

What is your diagnosis?

See diagnosis and discussion