Case 22
With discussion
Versión en Español

CASE 22 (December 2007)

Clinical information

The patient is a 54-year-old woman with history of hypothyroidism, with positive antimicrosomal antibodies, in treatment with thyroid hormonal replacement, and who had received steroids, without clinical response of her hypothyroidism. She is now evaluated due to general unspecific symptoms and increased serum creatinine: 2.2 mg/dL. In urinalysis: proteins: 120 mg/dL, 3 erythrocytes and 5 leukocytes HPF, without casts. Hb: 12.5 mg/dL, Hto: 40%, platelets: 320,000/mm3, leukocytes 6,900, erythrosedimentation 28 mm/h, BUN: 38. ANAs: 1:80 speckled pattern, nti-DNA: negative, anti-Ro: 1:172.

On clinical examination there is not edema nor skin alterations. Blood pressure: 130/85, heart rate: 72 x min. There are not abdominal alterations. Serum cretinine increased until 4,4 mg/dL and the patient is hospitalized and a renal biopsy was undertaken (Figures 1 and 2). Althoug there is not systemic lupus erythematous (SLE) criteria, methylprednisolone boluses were suministered. There is a good response and serum creatinine falls to 1,6 mg/dL one week after steroids were started. The patient continues on ambulatory controls with prednisone. Two months after the first renal biopsy renal function is normal, urinalysis did not show anormalities, and there was not other alterations. Prednisone is discontinued. One month later the patient newly present with general malaise, she now relates legs edema, and serum creatinine is 7,3 mg/dL. Viral tests are negative. There are not alterations in liver function tests. Proteinuria: 850 mg/24h; ANAs 1:320 speckled pattern, anti-Ro is now negative, ENAs negative, anti-DNA negative, lupus anticoagulant negative, C3 120, C4 44.7 (no diminished). Renal ultrasound: no alterations. Blood cells count without changes, there is not anemia. Erythrosedimentation: 57 mm/h. TSH: 34 (0.5–4.7 mU/L - notoriously increased - hypothyroidism). Blood pressure is not increased and there are not skin lesions.

A second renal biopsy is undertaken (Figures 3, 4, 5, and 6)

What is your clinical diagnosis?

See the images.

Figure 1. First renal biopsy. H&E, left X100, right X200.

Figure 2. First renal biopsy. Left, methenamine-silver stain X100, right, Masson's trichrome stain, X200.

Figure 3. Second renal biopsy. H&E, left X100, right X200.

Figure 4. Second renal biopsy. H&E, left and right X400.

Figure 5. Second renal biopsy. Methenamine-silver stain, left X100, right X400.

Figure 6. Second renal biopsy. Masson's trichrome stain, left X100, right X200.

Immunofluorescence for IgA, IgG, IgM, C3, and C1q were negative.

What is your diagnosis?

See diagnosis and discussion