CASE 23 (December 2007)
A 65-year-old withe male presented with three months of generalized edema. His history was relevant for severe dyslipemia and peripheral arterial occlusive disease that required lower extremity amputation several years ago. The patient did not relate other symptoms.
The patient was cigarette smoker from 20-year-old until 5 years ago; he ocassionally drinks liquor, and he works in a jeweller's from 20 years ago (he handles mercury).
His family history does not have other pathologic antecedents than blood systemic hypertension and coronary disease.
On physical examination, blood pressure 160/100, heart rate: 84, body mass index: 27,5; edema in legs and face, and ascitis. There are not neurological alterations nor skin lesions.
Laboratory tests: Hb 12,8 mg/dL, Hto: 38%; normal leukocytes; liver function tests: normal; serum creatinine: 1,1 mg/dL; C3 y C4: normal values; ANAs, ANCAs, hepatotropic viruses, and HIV: negative. Total cholesterol: 360 mg/dL; triglycerides: 418 mg/dL; serum albumin: 2,6 g/dL; total proteins: 4,1 g/L. Serum protein electrophoresis: without monoclonal spike. Chest X-rays without lesions; abdominal ultrasound: without alterations, kidneys with normal size and corticomedullary differentiation conserved.
Urinalysis: Proteinuria: 23,0 g/24h, 6 erythrocytes HPF, there are not casts nor Bence-Jones protein.
What is your clinical diagnosis?
A renal biopsy was performed.
See the images.
Figure 1. H&E, X400.
Figure 2. PAS stain, X400.
Figure 3. Masson's trichrome stain, X400.
Figure 4. Methenamine silver stain, X400.
Figure 5. Methenamine silver stain, X400.
Figure 6. Immunofluorescence using antiserum to IgG, x400. Staining was diffuse.
Figure 7. Immunofluorescence using antiserum to C3, x400. Staining was diffuse.
Immunofluorescence for IgA, IgM, and C1q were negative.
What is your diagnosis?