Case 27
With discussion
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CASE 27 (May 2008)

Clinical information

A 68-year-old Afro-American man was evaluated in our hospital by malaise and edema. He had P. falciparum malaria three months previous to medical attention. He does not complaint fever. Urinary volume diminished. No other symptoms. Blood pressure: 150/90, heart rate: 84 X', rhythmic. Legs edema. No skin lesions. No respiratory alterations.

Personal antecedents: No diabetes mellitus, blood hypertension treated with captopril, no other antecedents. There are not related family antecedents.

Hemoglobin: 10.4, hematocrit: 31%, leukocytes: 8,200/mL, platelets 270,000/ul. Serum creatinine: initially 14.0 mg/dL, several days after hospitalization diminished to 2.2 mg/dL. Proteinuria: 19.39 g/24h, urine erythrocytes: 40 HPF, glucosuria, Bence-Jones protein positive; granular casts. Serum proteins electrophoresis: normal. No hypercholesterolemia. Total serum proteins: 5.7 g/L (6.4 - 8.2), albumin: 2.94 g/L (3.9 - 4.6). ANAs negative; ANCAs: negative; VDRL: no reactive; complement levels: normal.

Renal ultrasound: Diminished corticomedullary differentiation, mild size bilateral increase.

What is your clinical diagnosis?

See the images of the biopsy.

Figure 1. Endocapillary hypercellularity in some segments (segmental) of some glomeruli (focal). H&E, x400.

Figure 2. Glomerular capillary lumina preserved in some segments but missed in others. Methenamine-silver stain, X400.

Figure 3. A peripheral segment of a glomeruli without tuft lesions, but with podocyte hypertrophy. Masson's trichrome stain, X400.

Figure 4. Interstitial fibrosis and tubular acute changes. H&E, X400.

Figure 5. Direct immunofluorescence using antiserum to IgA, x400. The tuft is negative. There is positive droplets in podocytes (protein reabsortion).

Figure 6. Direct immunofluorescence using antiserum to IgM, x400. Focal and segmental deposition of IgM.

Figure 7. Direct immunofluorescence using antiserum to C3, x400. Focal and segmental deposition of C3.

Direct immunofluorescence for IgG and C1q: Negative.

What is your diagnosis?

See diagnosis and discussion