CASE 199 (September 2022)

Clinical information

The patient is a 41-year-old woman with dry symptoms in the oral mucosa and conjunctiva, of approximately 1 year of evolution, managed empirically with oral moisturizing and self-medicated ophthalmic "drops". Evaluated by internal medicine, oral and ophthalmic dryness is corroborated and paraclinical tests are ordered. Normal blood count. ESR: 30mm/hr. Serum creatinine: 1.78 mg/dL, BUN: 28 mg/dL. ANAs: 1:320 fine speckled, anti-Ro: 88.8 IU/mL (normal: <14 IU/mL), anti-La: 34 IU/mL (normal: <14 IU/mL); C3 and C4 normal. negative ANCAs; Anti-DNA: negative. Urinalysis: Proteins: 150 mg/dL (1.5 g/24 hours), 6-8 erythrocytes/hpf, leukocytes: 5-6/hpf, without casts. A diagnosis of Sjögren's syndrome is made and treatment is started.

Due to impaired renal function, proteinuria, microhematuria, and leukocyturia, a renal biopsy is ordered:

Figure 1. H&E, X100.

Figure 2. H&E, X100. Marked tubulointerstitial inflammation.

Figure 3. H&E, X400. There is tubulitis.

Figure 4. H&E, X400. There are scattered eosinophils.

Figure 5. H&E, X400.

Figure 6. H&E, X400. Normal glomeruli.

Figure 7. Masson's trichrome stain, X200. There are areas with chronic changes.

Figure 8. Masson's trichrome stain, X400.

Figure 9. Metenamine-silver stain, X400. The glomerular capillary walls are unaltered.

Figure 10. PAS, X200.

Figure 11. EM, original magnification, X2,100. Normal podocyte processes, glomerular basement membranes, and endothelium.

Figure 12. EM, original magnification, X2,100. Normal glomerular capillary walls.

Figure 13. EM, original magnification, X2,100.

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

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