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CASE 50 (April 2010)
Clinical information
The patient is a 42-year-old, housewife,
who lives in a rural area. She has no history of disease. She consults
due to abdominal pain, localized in right upper quadrant radiating to
back, accompanied by nausea, malaise and headache. Generalized edema.
She describes dyspnea. The patient reports dysphagia and catarrhal symptoms
until two weeks ago.
On physical examination: regular general
condition. Blood pressure: 169/86 mm Hg., heart rate: 56 bpm, respiratory
frequency: 16. There is no fever. Bipalpebral edema. There are not lymphadenopathy
or organomegaly. Normal cardiopulmonary auscultation. There are not skin
lesions. On abdominal palpation there is pain in right upper quadrant.
Edema in lower limbs. Presumptive diagnosis on admission: cholelithiasis,
cholecystitis, hypertension.
Laboratory tests: complete blood count
and coagulation tests: normal. Serum creatinine: 0.9 mg/dL; BUN: 12 mg/dL;
creatinine clearance: 75.62 mL/min. Total cholesterol: 204 mg/dL; LDL:
133 mg/dL; triglycerides: 129 mg/dL. Glycemia: 67 mg/dL. Serum albumin:
3.0 g/dL. C3: 36 (90-180), C4: 12.6 (10-40), ANAs and ANCAs: negative;
anti-DNA: negative. Viruses B y C: negative. HIV: negative. Urinalysis:
Proteins: 500 mg/dL, pH: 6.5; 5-6 leukocytes: 5-6 hpf, erythrocytes: 8-12
hpf, granular casts: 1-2 hpf, nitrites: negative. Proteinuria: 1.98 g/24h,
volume: 3,330 mL.
Chest Rx: loss of costophrenic angles.
Abdominal ultrasound: without cholecystitis, normal-appearing kidneys.
Echocardiography: ejection fraction: normal, signs of hypertensive heart
disease, moderate mitral regurgitation, no vegetations.
On diagnostic thoracentesis the pleural
fluid is exudate type, with few lymphocytes and ADA negative.
A renal biopsy is undertaken. See the
images.
Figure 1.
H&E, X100.
Figure 2.
H&E, X400.
Figure 3.
H&E,
X400.
Figure 4.
H&E, X400.
Figure 5.
Methenamine-silver
stain, X400.
Figure 6.
Masson's
trichrome stain, X400.
Figure 7.
PAS, X400.
Figure 8.
Direct immunofluorescence using antiserum
to IgG, X400.
Figure 9.
Direct immunofluorescence using antiserum
to C3, X400.
Direct immunofluorescence for IgA, IgM,
and C1q: Negative.
What is your diagnosis?
See
diagnosis and discussion
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