NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand Rounds Clinical Vignette

• Martin Tabaksblat MD, PGY-2
• October 7, 2009

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Chief Complaint
The patient is a 75-year-old man who presents to
an outpatient clinic complaining of persistent
lower extremity edema for 6 months.
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History of Present Illness

• The patient was in his usual state of good
  health until 6 months prior to presentation when
  his primary physician noted he was hypertensive
  (165/90) and had bilateral lower extremity edema.
  
• The patient was started on an antihypertensive
  medication regimen. His lower extremity edema
  persisted.
• The patient was otherwise asymptomatic.

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Additional History

• Past Medical History
• Type-2 Diabetes Mellitus
• Diagnosed 12 years prior
• Hypertension
• Hyperlipidemia
• Prostate Cancer

• Past Surgical History
• Prostatectomy
• Family History
• Non-contributory
• Social History
• Remote smoking history
• Rare social alcohol use
• Denies illicit drug use

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Medications
Hydrochlorothiazide 25mg daily Metoprolol 50mg
every morning evening Irbesartan 300mg
daily Glyburide 1.25 mg daily Simvastatin 10mg
daily Aspirin 81mg daily
Allergies No known drug allergies
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Physical Examination
General Comfortable appearing elderly man,
appears his stated age, and is alert and oriented
x3. Vital Signs T 97.8, BP 136/60, HR 70, RR
16 O2 sat 100 on room air, Weight 190
lbs. Extremities 2 lower extremity edema
bilaterally. The remainder of the physical exam
was normal.
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Laboratory Findings

• CBC within normal limits
• Basic Metabolic Panel
• BUN 38 mg/dL
• Creatinine 1.7mg/dL
• The remainder of the basic metabolic was within
  normal limits
• Hepatic Panel
• Albumin 2.9 g/dL
• The remainder of the hepatic panel was within
  normal limits
• Hemoglobin A1C 6.8 (lt6.5)

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Laboratory Findings

• Lipid Panel
• Total cholesterol 163mg/dL (lt200mg/dL)
• LDL cholesterol 87mg/dL (lt100mg/dL)
• HDL cholesterol 43mg/dL (gt/ 40mg/dL)
• Triglycerides 165mg/dL (lt150mg/dL)
• Urinalysis
• 4 protein (negative)
• No red blood cells
• The remainder of the urinalysis was within
  normal limits
• 24 hour Urine
• Protein 5573 mg (30-150mg)
• Creatinine 1397mg (1000-2000mg)

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Other Studies

• Renal Ultrasound
• Kidneys are normal in size
• Small (1.5cm) left renal cyst
• No stones or hydronephrosis appreciated

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Differential Diagnosis

• Nephrotic Syndrome
• Diabetic Nephropathy
• Focal Glomerulosclerosis
• Membranous Nephropathy
• Minimal Change Disease
• Amyloidosis

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Additional Laboratory Studies

• ANA negative
• pANCA cANCA negative
• Cryoglobulins negative
• Complement levels (C3,4) within normal limits
• Urine Protein Electrophoresis albumin and other
  
• plasma proteins present.
• Serum Immunofixation no monoclonal spike present

• Hepatitis C Ab negative
• Hepatitis BsAg negative

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Diagnostic Work-Up

• An ophthalmologist evaluated the patient for
  retinopathy to help assess the likelihood of
  diabetic nephropathy.
• There was no evidence of diabetic retinopathy.
• The diagnostic work-up therefore proceeded with a
  percutaneous renal biopsy.

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Renal Biopsy Results

• Glomeruli demonstrating thickened peripheral
  capillary walls with silver positive spike
  formation.
• Mesangial matrix appears slightly increased but
  clear-cut nodule formation is not seen and there
  is no appreciable hypercellularity.

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Final Diagnosis

• Primary Membranous Glomerulopathy
• (with additional features likely reflecting
  diabetic injury)