CASE 68 (October 2011)
A previously healthy 25-year-old man presented with a 8-day history of jaundice, malaise, nausea and vomiting: 3-4 times a day. Diarrhea with mucus, 4 episodes a day. Generalized jaundice for a week. Subjective fever, chills and headache. No urinary symptoms. The patient reported having ingested a "purge" from a "naturist" store, approximately 5 days before the onset of symptoms; it is unknown components of this product and they do not appear on the container. Habitual use of liquor every weekend, usually until drunkenness. Denies smoking and psychoactive substances.
Physical examination: Good general appearance, BP: 110/68, HR: 88 x min., RR: 17 x min. Generalized jaundice. Cardiopulmonary: normal. Abdominal pain on deep palpation in the right hypochondrium. Liver palpable 4 cm below the costal margin. Rest of physical exam normal.
Laboratory: Hb: 15.8 mg/dL, Hto: 48%; WBC: 5,080, lymphocytes: 20%, neutrophils: 76%: eosinophils: 1%; platelets: 176,000. Coagulation tests: normal. Serum creatinine at admission: 1.2mg/dL, BUN: 14 mg/dL, but them increased until 6.5 mg/dL and 83 mg/dL, respectively, at 9th day of hospitalization, requiring hemodialysis. Total bilirubin: 12 mg/dL, direct bilirubin: 9.4 mg/dL; alkaline phosphatase: 204 U/L (30-120); AST: 70 U/L (0-35); ALT: 50 U/L (0-35). Urinalysis: density: 1,025, proteins 75 mg/dL, erithrocytes: 60/hpf, leukocytes: 50/hpf, granular and leokocytaire casts.
Tests for viral hepatitis were negative. Testing for Leptospira, syphilis, HIV, CMV, Epstein-Barr virus were negative. ANAs positive: 1:40, speckled, anti-DNA: negative, C3: 191 mg/dL (90-180), C4: 57 mg/dL (10-40). Protein electrophoresis normal. Abdominal ultrasound: kidneys with normal size, echogenicity and corticomedullary differentiation; hepatomegaly, without nodules or masses. Normal chest radiograph. Upper gastrointestinal endoscopy: mild antral gastritis.
A renal biopsy was undertaken. See the images.
Figure 1. H&E, X100.
Figure 2. H&E, X200.
Figure 3. H&E, X200.
Figure 4. H&E, X400.
Figure 5. H&E, X400.
Figure 6. Masson's trichrome stain, X400.
Figure 7. Methenamine-silver stain, X400.
Immunofluorescence staining for IgA, IgG, IgM, C3, C1q, kappa, and lambda: Negative.
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