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Pathology Conference

Pathology Conference. 2011/9/28 Nephro CR 侯羿州 Commentary: 薛綏醫師. Case 1. 316557X 39 y/o Male 工人 Travel Hx: China. Chief Complaint. Bilateral lower leg edema for more than 1 week. Present Illness. History of hypertension, renal stones and hyperuricemia without regular medication.

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Pathology Conference

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  1. Pathology Conference • 2011/9/28 • Nephro CR 侯羿州 • Commentary: 薛綏醫師

  2. Case 1 • 316557X • 39 y/o • Male • 工人 • Travel Hx: China

  3. Chief Complaint • Bilateral lower leg edema for more than 1 week.

  4. Present Illness • History of hypertension, renal stones and hyperuricemia without regular medication. • Dizziness, productive cough 3 days after arriving 上海. Leg edema, dizziness and general weakness occurred. So he used Herb(? 白加黑) after URI S/S occurs. • After treatment no obvious improvement was noted.

  5. Present Illness • Pneumonia was impressed in China. Therefore he received antibiotics, including Vancomycin and levofloxacin. • Acute kidney injury was noted. H/D was performed since 6/22. • His U/O was around 1000cc/d. • The patient denied other S/S such as fever, conscious disturbance, chest pain, etc.

  6. Past History • Hypertension, under treatment? • Hyperuricemia. • Left renal stone.

  7. Physical Examination • BT: 36.6/ HR: 109/min/ RR: 17/min/ BP: 181/139mmHg • BW: 74.56kg/ 182cm • Consciousness: clear • HEENT: anicteric sclera; non-pale conjunctiva • Heart and chest: Bilateral crackle breathing sound. • Extremities: no pitting edema

  8. Impression • Acute kidney injury, RIFLE-F, complicated withe azotemia, suspect due to RPGN, pneumonia • Bilateral lung pneumonia. • Hypertension • Hyperurecemia Hx.

  9. Kidney Echo on 7/7 • Left: 13.0cm; right: 12.4cm • Bilateral large kidneys with parenchymal renal disease.

  10. Serology workup • C3: 135; C4: 22.20 • ANA: negative; anti-DsDNA: <40.5 • ASLO: <52.80; RPR:nonreactive • Anti-Basement membrane Ab: negative. • HBV, anti-HCV, HIV: all negative. • ANCA: p-ANCA and c-PANCA are both negative.

  11. Admission course • Azotemia progressed with faire U/O. • U/O: 1400/1140/1050/8700/500/700(since 7/8) • Clindamycin since 7/7~8/4Rocephin since 7/7~7/27Vancomycin since 7/12 after pneumonia delay resolution.

  12. Admission course • H/D was arranged since 7/11 due to azotemia and decrease urine output. • HRCT done 7/12 under suggestion of Chest due to pneumonitis workup. • Bronchoscopy was done on 7/14.

  13. HRCT on 7/11 • Favor pulmonary vasculitis. Other DDx of similar finding include SLE vasculitis, Goodpasture disease, Wegener’s granulomatosis, hypersensitivity pneumonitis or atypical pneumonia.

  14. Bronchoscopy • Heterogenous hypoechopic with air -bronchogram echogenecity in istal LB6.

  15. BAL finding • CMV 4顆/slide • Lung Bx: mild chronic inflammation. • TB PCR: negative.

  16. Admission course • Give gancyclovir for CMV pneumonitis since 7/18 • Biopsy was arranged for impression of RPGN.

  17. Pathology • KIDNEY NEEDLE BIOPSY: ACCERATED HYPERTENSION.

  18. Case 2 • 898481X • Female • Married • 29 y/o • G4P0A3, GA 26+5 wks(6/22)

  19. Chief complaint • Uvula swelling and short of breath on 2011/6/22.

  20. Present Illness • Type I DM for 10 years under Novomix 24/20, NPH 10U bid, Regular HM 10UT qd • HTN, under labetalol 1pc bid and furosemide 1pc qd after pregnancy • Irbesartan use til 2011/2 • Chronic kidney disease , baseline Cr 1.78 on 2010/3

  21. Present Illness • Leg edema on and off after proteinuria(4+) noted since 2008. • Progressive short of breath in 2011/6. • Uvula swelling progressed with bilateral lower leg edema. • No blood show was noted. Denied other S/such as abdominal pain, fever, chills, abdominal pain, etc.

  22. Present Illness • Progressive azotemia was told at OPD. • Persistent tachypnea. • F/S 47, BP 220/110 • Fetal distress with bradycardia occurred twice on 2011/6. • Emergent C/S was done on 6/22. • Transfer to ICU after C/S.

  23. Physical Examination • BT: 36.2/ HR: 85/min/ RR: 18/min/ BP: 210/130mmHg • BW: 58kg • Consciousness: clear • HEENT: anicteric sclera; non-pale conjunctiva • Heart and chest: Tachypnea, bilateral crackle breathing sound. • Extremities: pitting edema 1+

  24. Admission course • 6/22: emergent C/S. Alive baby 597gm, 3->6 • Ponstan 1pc qid after 6/22Methyldopa for hypertension • Dyspnea on 6/27. • U/O: 1750-2850-2300-2050 (6/27-6/28-6/29 -6/30

  25. 7/2 Serologic workup • HBV : negative; anti-HCV: negative • C3: 126; C4: 30.60 • ANA: negative; anti-DsDNA: <40.5 • ASLO: <52.80; RPR:nonreactive • IgA: 193; IgM: 174; IgE: <16.9 • 24hr Urine protein: 19.6g/d • 24hr CCr: 8.2ml/min

  26. Kidney Echo on 7/7 • Left: 11.2cm; right: 10.6cm • Right pelviectasis • Parenchymal renal disease.

  27. Impression • Acute kidney injury, RIFLE-F, complicated withe azotemia, metabolic acidosis, suspect due to preclampsia or RPGN • Type I diabetes mellitus with nephropathy • Nephrotic syndrome, suspect due to DM nephropathy • Hypertension

  28. Pathology on 7/15 • Kidney biopsy: DIABETIC NODULAR GLOMERULOSCLEROSIS, TUBULO-INTESTITIAL NEPHRITIS

  29. After discharge 9/7 • BUN 33.2 • Cr 4.2 • K 4.1

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