Case 78
With discussion
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CASE 78 (August 2012)

Clinical information

The patient is a 42-year-old with a history of non-insulin dependent diabetes mellitus for 11 years. He presented edema and erythema in his left leg three weeks ago, was treated with antibiotics with partial response. These lesions have been repeated for several years. For the past 3 days has generalized edema and dyspnea.

In addition, his medical history is relevant for obesity, hypertension and dyslipidemia for several years. Poorly controlled diabetes, hypertension and dyslipidemia because he is a patient with poor adherence to treatment.

On physical examination: BP: 160/90, respiratory frequence: 16, withoutr dyspnea. decreased breath sounds in both lung bases. Desquamative area on leg and left heel, with erythematous background. Edema in face, legs and scrotum, mild ascites.

Laboratory tests: Hb 10.2, Hct 32, platelets 380,000, WBC: 13,000, neutrophils: 70%, lymphocytes: 20%, coagulation and liver tests: normal. Creatinine 3.1, BUN 86. Virus: negative ANA: negative, C3: 20 (90-180), C4 37 (10-40). Urinalysis: proteinuria 1,000 mg/dL, erythrocytes: 15/hpf, leukocytes: 5/hpf, granular casts. Proteinuria: 12.3 g/24 h. ASLO not increased

A renal biopsy was undertaken. See the images.

Figure 1. H&E, X200.

Figure 2. H&E, X400.

Figure 3. H&E, X400.

Figure 4. H&E, X400.

Figure 5. Masson's trichrome stain, X400.

Figure 6. Methenamine-silver stain, X400.

Figure 7. PAS, X400.

Figure 8. H&E, X400.

Figure 9. Immunofluorscence for IgG, X400.

Figure 10. Immunofluorscence for C3, X400.

Figure 11. Immunofluorscence for C3, X400.

Direct immunofluorescence for IgA, IgG, IgM, C1q, kappa, and lambda: Negative.

What is your diagnosis?

See diagnosis and discussion