Morning Report Unknown

1
Morning ReportUnknown 73
2

• You evaluate a 35 year old woman with leg pain
  and swelling. She states she noticed progressive
  painless, bilateral leg swelling over the past
  2-3 months, but just last night, noted
  significant pain and increase in size of her left
  leg. Prior to two months ago, she had always
  been in good health.
• PMH none
• G1 P1
• Medications none
• No significant Family History, no drugs or
  alcohol, no tobacco, no allergies.
• ROS is entirely negative.

3

• Physical Exam
• Appears healthy
• bp 114/68 p 70 r 12 t 37.0 C
• PEERLA, EOMI, some puffiness around her eyes
  noted
• No thyromegaly or adenopathy
• No increased JV pressure
• Heart regular, no murmur
• Lungs clear
• Abdomen soft, bowel sounds present, no mass
• No clubbing or cyanosis
• Right leg 2 edema to the level of the knee, no
  tenderness
• Left leg 3 edema to the level of the knee,
  significant tenderness over the calf and with
  dorsiflexion

4

• A lower extremity doppler study shows normal flow
  in the right leg, but a large deep venous
  thrombosis in the left popliteal vein extending
  from below to above the knee
• Labs
• AST 30 ALT 32 Alk Phos 70 Alb 1.8
  TP 4.8 PT 11.2 PTT 23.8
• UA 1.012 2 RBCs 0 WBCs 0 bacteria 3
  protein nitrite negative glucose negative
• ANA 180, speckled

12.9
138
102
11
5.5
277
88
38
3.9
27
0.8
5

• You plan to begin anticoagulation with IV
  unfractionated heparin, but are able to obtain a
  renal biopsy before anticoagulation. Results of
  the biopsy are shown below

6
What is this patients most likely diagnosis?

• A) Systemic lupus with rapidly progressive
  glomerulonephritis
• B) Lupus anticoagulant type antiphospholipid
  antibody syndrome with renal vein thrombosis
• C) Membranous glomerulopathy with
  hypercoagulability
• D) IgA nephropathy
• E) Idiopathic focal glomerulosclerosis

7
What is this patients most likely diagnosis?

• A) Systemic lupus with rapidly progressive
  glomerulonephritis
• B) Lupus anticoagulant type antiphospholipid
  antibody syndrome with renal vein thrombosis
• C) Membranous glomerulopathy with
  hypercoagulability
• D) IgA nephropathy
• E) Idiopathic focal glomerulosclerosis

8
Nephrotic syndrome
9
Membranous glomerulopathy

• Causes
• 1 idiopathic
• Malignancy
• SLE
• Drugs
• Hepatitis (BC)
• NSAIDs
• DM
• Other
• Syphilis
• Transplant rejection
• Sarcoid
• Sjogrens
• Schistosomiasis

• Presentation
• Edema
• Hyperlipidemia
• Proteinuria
• Hypoalbuminemia
• Lipiduria
• Usually bland sediment
• Complications
• Hypercoagulability
• Renal vein thrombosis

10
Membranous glomerulopathy

• Histology
• Light microscopy diffuse GBM thickening
• Immunofluorescence diffuse, granular IgG
  deposition along the capillary walls
• EM electron dense deposits in the subepithelial
  space across the GBM

OBJECTIVE recognize the clinical presentation
and renal biopsy findings in a patient with
membranous glomerulonephritis