Case 86
With discussion
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CASE 86 (April 2013)

Clinical information

The patient is a 8 year old girl with nephrotic syndrome, with edema that began a month earlier. Steroid treatment was started but no response after the first 4 weeks. Now with raised serum creatinine: 2.1 mg / dL, microscopic hematuria: 9-10 erythrocytes per high power field (HPF) and hypertension: BP: 140/90.

Other paraclinical: Hb: 13 mg/dL, Ht. 39%, normal white blood cell count and platelets; albumin: 1.7 g/dL, BUN 41 mg/dL, total cholesterol 410 mg/dL, triglycerides: 388 mg/dL. Tests for viruses: negative, ANA: negative; C3: 93 (90-180), C4: 27 (10-40). Urinalysis: granular casts, proteinuria 500 mg/dL. Proteinuria in 24 h: 12 g. Renal ultrasound: normal size, good corticomedullary differentiation.

See the images of the renal biopsy.

Figure 1. H&E, X100.

Figure 2. H&E, X200.

Figure 3. Masson's trichrome stain, X400.

Figure 4. Masson's trichrome stain, X400.

Figure 5. Masson's trichrome stain, X400.

Figure 6. PAS, X400.

Figure 7. Methenamine-silver stain, X400.

Figure 8. Methenamine-silver stain, X400.

Figure 9. Masson's trichrome stain, X400.

Immunofluorescence for IgA, IgG, C3, and C1q: Negative; IgM: unspecific mild focal and segmental immunostaining.

What is your diagnosis?

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