CASE 26 (April 2008)
A 17-year-old woman was evaluated in the outpatient hospital by a history of 4 months of progressive edema. Urinary volume was decreased. She presented episodic polyarthralgia without erythema. On examination blood pressure: 160/100; limbs and facial edema.
Urinalysis: proteins: 3.18 g/24h; erythrocytes: 60 HPF; leukocytes: 15 HPF; serum creatinine: 1.17 mg/dL; creatinine clearance: 50 ml/min; BUN: 24 mg/dL; normocytic normochromic anemia. Tests for hepatitis viruses and HIV: negative. C3: 32 mg/dL (90-180); C4: 4 mg/dL (10-40).
Bilateral pleural effusion.
What is your clinical diagnosis?
See the images.
Figure 1. H&E, x100.
Figure 2. H&E, X400.
Figure 3. Masson's trichrome stain, X400.
Figure 4. Methenamine-silver stain, X400.
Figure 5. Methenamine-silver stain, X400.
Figure 6. Methenamine-silver stain, X600.
Figure 7. Left: Direct immunofluorescence using antiserum to IgA, x400. Right: Direct immunofluorescence using antiserum to IgG, x400.
Figure 8. Left: Direct immunofluorescence using antiserum to C3, x400. Right: Direct immunofluorescence using antiserum to C1q, x400.
Direct immunofluorescence for IgM: Mild positive granular immunstaining in capillary walls, similar to C1q image.
What is your diagnosis?