CASE 76 (June 2012)
The patient is a 24-year-old woman with a history of multiple hospitalizations for hypertensive emergencies and convulsive episodes, focal epilepsy secondary to vascular process (thrombosis). Hypertension difficult to control, about 8 years of evolution. Diagnosis of antiphospholipid syndrome (possibly primary) three years ago.
Anticardiolipins (IgA and IgM): positive, lupus anticoagulant "definitely positive" (I don't know the titles). Hematocrit: 42%, Hb: 13.3 mg/dL, platelets: 90.000/mm3. TTP: 163.9, INR: 1.24. No schistocytes in peripheral blood. ANA and anti-DNA: negative. C3: 92 (90-180), C4: 19.6 (10-40). Creatinine: 1.3 mg/dL, creatinine clearance: 53 mL/min, proteinuria: 226 mg/24 h, without hematuria. Renal ultrasound: "normal", without stenosis in arteries.
Due to impaired renal function and mild proteinuria, a renal biopsy was undertaken.
Figure 1. H&E, X100.
Figure 2. Methenamine-silver stain, X200.
Figure 3. Masson's trichrome stain, X200.
Figure 4. H&E, X400.
Figure 5. Masson's trichrome stain, X400.
Figure 6. H&E, X400.
Figure 7. H&E, X400.
Figure 8. Masson's trichrome stain, X400.
Figure 9. Methenamine-silver stain, X400.
Figure 10. Methenamine-silver stain, X400.
Figure 11. Masson's trichrome stain, X400.
Direct immunofluorescence for IgA, IgG, C3, C1q, kappa, and lambda: Negative; mesangial traces for IgM.
What is your diagnosis?