CASE 175 (September 2020)

Clinical information

The patient is a 41-year-old woman with a diagnosis of systemic lupus erythematosus for 7 years. She has had multiple cutaneous, hematological and joint manifestations. No prior renal involvement has been documented. Now she is evaluated for presenting generalized edema, documenting nephrotic syndrome. Proteinuria 5.8 g/day. Serum creatinine: 0.9 mg/dL, BUN: 12 mg/dL. In the urinalysis there are 5 red blood cells/hpf, leukocytes: 2/hpf, without casts. C3: 84 mg/dL, C4: 10 mg/dL. ANAs: 1:320, anti-DNA: 1:20. Normal hemoleukogram. There are no cutaneous alterations at the time of the biopsy. She reports arthralgia, without arthritis. The patient is being treated with oral steroids and hydroxychloroquine.

Kidney biopsy is done. Look at the photomicrographs.

Figure 1. Masson's trichrome stain, X100.

Figure 2. H&E, X200. No chronic changes; sparse lymphocytes in the interstritium.

Figure 3. H&E, X400. Mild mesangial cells number increase, without other alterations.

Figure 4. Masson's trichrome stain, X400. There are not fuschinophilic deposits.

Figure 5. Masson's trichrome stain, X400.

Figure 6. Methenamine-silver stain, X400. Smooth capillary walls, without double contours or spikes.

Figure 7. Methenamine-silver stain, X400.

Figure 8. EM, original magnification, X1,500.

Figure 9. EM, original magnification, X2,100. Note the diffuse loss of podocyte processes, with normal-appearing basement membranes and endothelium.

Figure 10. EM, original magnification, X1,500.

Figure 11. EM, original magnification, X2,100.

Figure 12. EM, original magnification, X2,100.

Direct immunofluorescence for IgA, IgG, IgM, C3, C1q, kappa, and lambda: Negative.

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