Case 57
With discussion
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CASE 57 (November 2010)

Clinical information

A 12-year-old girl presented with edema, which had developed over the previous month. In other Hospital was diagnosed as nephrotic syndrome and began treatment with prednisone: 60 mg/m2/d. Edema and other symptoms continued despite three months of treatment. She had, in addition, fatigue, weakness and drowsiness.

On physical examination: Good general condition, hydrated, facial and legs edema, blood pressure 150/98 mm Hg. Height 149 cm, weight: 35 kg.

Laboratory: Serum creatinine: 0.37 mg/dL, BUN: 7 mg/dL, K: 3.9 Meq/L, Na: 141 Meq/L. Blood cells count: normal. Total cholesterol: 519 mg/dL, triglycerides: 545 mg/dL, serum albumin, 1.9 g/L. Urinalysis: density 1,020, proteins 500 mg/dL, RBC: 2 per high power field, no casts. Proteinuria: 105 mg/m2/h. VDRL: nonreactive; virus B and C: negative. C3: 181 mg/dL (90-190), C4: 30 mg/dL (10-40), anti-DNA and ANA: negative.

With a clinical diagnosis of steroid-resistant nephrotic syndrome a renal biopsy was made. See the images.

Figure 1. H&E, X100.

Figure 2. H&E, X200.

Figure 3. H&E, X400.

Figure 4. Masson's trichrome stain, X400.

Figure 5. Methenamine-silver stain, X400

Figure 6. Direct immunofluorescence using antiserum to IgM, X400.

Figure 7. Direct immunofluorescence using antiserum to IgM, X400.

Immunofluorescence staining for IgM was similar in the 5 glomeruli found in the tissue sections.
Direct immunofluorescence for IgA, IgG, C3 and C1q: Negative.

What is your diagnosis?

See diagnosis and discussion