M G R 경희의료원 신장내과 R2 조창현

탁 O 근 M/37 admission : C.C. ) Right chest pain ( onset: 4 일전 ) C.C. ) Right chest pain ( onset: 4 일전 ) P.I. ) 남자 37 세 4 년전 HTN 진단받았으나 특별한 치료하지않고 지내던 자로 내원 10 일전부터 소변에 거품이 많아지고 몸이 약간 붓는 느낌들었으나 관찰 하며 지내왔다. 내원 4 일전 우측 가슴이 답답하고 숨쉴때 마다 통증이 발생하 여 상계백병원 응급실 방문하였으나 이상소견 발견되지 않아 귀가 조치하였 다. 통증 심해져 내원 당일 본원 응급실 방문하였으며 ECG, chest PA 상 이 상소견 발견되지 않아 외래 진료 권유 받고 신장 내과 외래 진료 후 further evaluation 위해 입원하였다. P.I. ) 남자 37 세 4 년전 HTN 진단받았으나 특별한 치료하지않고 지내던 자로 내원 10 일전부터 소변에 거품이 많아지고 몸이 약간 붓는 느낌들었으나 관찰 하며 지내왔다. 내원 4 일전 우측 가슴이 답답하고 숨쉴때 마다 통증이 발생하 여 상계백병원 응급실 방문하였으나 이상소견 발견되지 않아 귀가 조치하였 다. 통증 심해져 내원 당일 본원 응급실 방문하였으며 ECG, chest PA 상 이 상소견 발견되지 않아 외래 진료 권유 받고 신장 내과 외래 진료 후 further evaluation 위해 입원하였다. PMHx : DM /HTN/ TB / Hepatitis ( - / + / - / - ) Op Hx (-) PMHx : DM /HTN/ TB / Hepatitis ( - / + / - / - ) Op Hx (-) Personal Hx Personal Hx Alcohol : 주 1 회 소주 1~2 병 Smoking : 20 pack years

Review of system General fever(-) chill(-) edema (+), Wt. gain(+) ; 5kg / 1 month General fever(-) chill(-) edema (+), Wt. gain(+) ; 5kg / 1 month Skin itching(-) rash(-) Skin itching(-) rash(-) Head & Neck headache(-) stiffness(-) Head & Neck headache(-) stiffness(-) E & ENT visual disturbance(-) sore throat(-) E & ENT visual disturbance(-) sore throat(-) Respiratory cough(-) sputum(-) rhinorhea(-) hemoptysis(-) dyspnea(-) Respiratory cough(-) sputum(-) rhinorhea(-) hemoptysis(-) dyspnea(-) Cardiac chest pain(+; Right, pleuritic pain) Cardiac chest pain(+; Right, pleuritic pain) palpitation (-) exertional dyspnea(-) palpitation (-) exertional dyspnea(-) G-I A/N/V/D/C (-/-/-/-/-) abdominal pain(-) melena(-) G-I A/N/V/D/C (-/-/-/-/-) abdominal pain(-) melena(-) Renal oligurina(-) dysuria (-) hematuria (-) polyuria(-) flank pain(-) Renal oligurina(-) dysuria (-) hematuria (-) polyuria(-) flank pain(-) Others arthhralgia(-) myalgia(-) syncope(-) Dizziness(-) Others arthhralgia(-) myalgia(-) syncope(-) Dizziness(-) calf pain (-) calf pain (-)

Physical examination General alert consciousness General alert consciousness Skin no rash, No pigmentation Skin no rash, No pigmentation Head & neck no Neck vein engorgement, no palpable neck mass Head & neck no Neck vein engorgement, no palpable neck mass E / ENT oral ulcer(-) Pinkish conjunctivae, Clear sclera E / ENT oral ulcer(-) Pinkish conjunctivae, Clear sclera Chest clear Breathing Sound without rale & crackle Chest clear Breathing Sound without rale & crackle regular heart beat without murmur regular heart beat without murmur chest wall tenderness ( - ) chest wall tenderness ( - ) Abdomen soft and flat abdomen Abdomen soft and flat abdomen no tenderness or rebound tenderness no tenderness or rebound tenderness normoactive bowel sound normoactive bowel sound Back/extremity CVA tenderness(-/-), knee swelling(-) Back/extremity CVA tenderness(-/-), knee swelling(-) pretibial pitting edema (+/+) pretibial pitting edema (+/+) 140/90mmHg–80/min–18/min–36.7 ℃ Bwt 90kg, Height 175cm

Initial laboratory finding CBC/DC CBC/DC 7070/mm3-16.1g/dL–49.9%-287X10 3 / ㎣ (Seg 65.7 %) 7070/mm3-16.1g/dL–49.9%-287X10 3 / ㎣ (Seg 65.7 %) aPTT 36.1sec /34, PT 11.5sec/13.3 ( INR : 0.89 ) aPTT 36.1sec /34, PT 11.5sec/13.3 ( INR : 0.89 ) Chemistry Chemistry T/ D-bilirubin 0.40/0.05mg/dL( mg/dL) T/ D-bilirubin 0.40/0.05mg/dL( mg/dL) AST/ALT 32/28 U/L (<40/<40 U/L) AST/ALT 32/28 U/L (<40/<40 U/L) ALP/rGT 82/23 U/L (39-117/<50 U/L) Glucose 111mg/dl ALP/rGT 82/23 U/L (39-117/<50 U/L) Glucose 111mg/dl Prot/ALB 4.0/1.2g/dL( / g/dL) TG 188 mg/dL Prot/ALB 4.0/1.2g/dL( / g/dL) TG 188 mg/dL T-cholesterol 314mg/dL(<200) LDL-cholesterol 220,HDL-cholesterol 35 T-cholesterol 314mg/dL(<200) LDL-cholesterol 220,HDL-cholesterol 35 BUN/Cr 9/0.8 mg/dL (8-23/ mg/dL) BUN/Cr 9/0.8 mg/dL (8-23/ mg/dL) Na/K/Cl 140/4.1/106 ( / / mmol/L) Na/K/Cl 140/4.1/106 ( / / mmol/L) Ca/P 7.2 /4.1 mg/dL(8.4~10.2/2.5~5.5 mg/dl) Mg 2.5mg/dl(1.9~2.5 mg/dl) CRP 1.1 mg /dl Mg 2.5mg/dl(1.9~2.5 mg/dl) CRP 1.1 mg /dl

Cardiac marker Cardiac marker CK 86 U/L (38~160), CK-MB <1.0 ng/ml, TnI <0.05 CK 86 U/L (38~160), CK-MB <1.0 ng/ml, TnI <0.05 ABGA ABGA SaO2 96% SaO2 96% Urinalysis Urinalysis Occult Blood 2+, Bilir -, Urobilinogen 0.1, Keton – Protein >=300 mg/dl, Nitrate -, Glucose -, pH 5.5 Specific Gravity 1.020, Leucocytes +- RBC 2~4, WBC 0~1/HPF RBC 2~4, WBC 0~1/HPF

Chest PA (4-2)

KUB

ECG HR = 82 회 / min

Initial assessment #1. Acute chest pain Pleuritis / pneumonia R/O Pulmonary embolism R/O Costochondritis, rib fracture R/O Herpes zoster R/O Pericarditis #2. Nephrotic syndrome

Diagnosis plan #1. Acute chest pain Chest CT, sputum exam Chest CT, sputum exam Rib series, bone scan Rib series, bone scan Echo cardiography Echo cardiography #2. Nephrotic syndrome 24 hour urine protein excretion, abdominal ultrasonography urine RBC morphology serology for GN (ASO,RF,Cryglobulin, Ig G-A-M-E, ANA, ANCA) renal Biopsy

Chest CT

Chest CT (2)

Lung perfusion scan

Extremity vascular doppler

Renal vascular doppler

Abdominal ultrasonography

24hr urine collection Protein 7462 mg/day (40~ 150 mg/day ) Urine Creatinine 1667 mg/day ( 800 ~ 1800 mg/day ) CrCl mL/min ( 70 ~ 157 ml/min ) Serum Cr 0.8 mg/dL Urine Cr 63.4 mg/dL Urine volume 2630 mL/day Urine RBC Morphology < 5% ( dysmorphic RBC )

Serologic markers IgG mg/dL IgA mg/dL IgG mg/dL IgA mg/dL IgM g/dL IgE mg/dL IgM g/dL IgE mg/dL C mg/dL C mg/dL C mg/dL C mg/dL C-ANCA Negative P-ANCA Negative C-ANCA Negative P-ANCA Negative ANA Non-reactive ANA Non-reactive RF <9.50 IU/mL RF <9.50 IU/mL ASO <51.30 IU/Ml (< 200) Cyoglobulin NEG ASO <51.30 IU/Ml (< 200) Cyoglobulin NEG HBsAg / anti-HBc Ab /anti-HBs Ab ( -/ -/ - ) anti-HIV (-) Anti-HCV (-) VDRL non-reactive

Laboratory evaluation of thrombophilic states D-dimer : 2.36 ug/ml ( < 0.5 ) fibrinogen : 687 mg/dl ( 200~400 ) AT III : 0.21 – 70% (0.19 ~ 0.31 ) Prot C : 127 % ( 70 ~130 ) Prot S : 90 % ( 70 ~143 )

Biopsy ( HE ) X 40

Biopsy ( HE )

Biopsy ( MT )

Biopsy ( Silver )

Final diagnosis and Plan #1. Pulmonary thromboembolism anticoagulation ( heparin and warfarin ) anticoagulation ( heparin and warfarin ) stop smoking, HTN control stop smoking, HTN control #2. Nephrotic syndrome ( Membranous glomerulopathy ) Low salt (1~2g / day ) diet Low salt (1~2g / day ) diet Angiotensin receptor blocker Diuretics ( Lasix + thiazide ) HMG CoA reductase inhibitors Immunosuppressive agents ( steroid + cyclosporin )

Case 2

윤 O 두 M/44 admission : C.C. ) Right leg numbness ( onset: 7 일전 ) C.C. ) Right leg numbness ( onset: 7 일전 ) P.I. ) 특이 병력 없던 44 세 남자로 내원 7 일전 Right leg numbness 발생하여 본원 한방병원 입원하였다. 내원 2 개월 전부터 소변에서 거품뇨가 자주 관찰 되었으나 evaluation 하지 않고 지내왔으며 한방병원에서 입원 치료 도중 단 백뇨 발견되어 further evaluation 위해 신장내과 신장내과 전원되었다. P.I. ) 특이 병력 없던 44 세 남자로 내원 7 일전 Right leg numbness 발생하여 본원 한방병원 입원하였다. 내원 2 개월 전부터 소변에서 거품뇨가 자주 관찰 되었으나 evaluation 하지 않고 지내왔으며 한방병원에서 입원 치료 도중 단 백뇨 발견되어 further evaluation 위해 신장내과 신장내과 전원되었다. PMHx : DM /HTN/ TB / Hepatitis ( - / - / - / - ) PMHx : DM /HTN/ TB / Hepatitis ( - / - / - / - ) heart disease (-), acute cerebral infart (+) heart disease (-), acute cerebral infart (+) Op Hx (-) Op Hx (-) Personal Hx Personal Hx Alcohol : none Smoking : none

Review of system General fever(-) chill(-) fatigue(-), Weight gain : 6kg / 1week General fever(-) chill(-) fatigue(-), Weight gain : 6kg / 1week Skin itching(-) rash(-) Skin itching(-) rash(-) Head & Neck headache(-) stiffness(-) Head & Neck headache(-) stiffness(-) E & ENT visual disturbance(-) sore throat(-) E & ENT visual disturbance(-) sore throat(-) Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-) Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-) Cardiac chest pain ( - ) Cardiac chest pain ( - ) palpitation (-) exertional dyspnea(-) palpitation (-) exertional dyspnea(-) G-I A/N/V/D/C (-/-/-/-/-) abdominal pain(-) melena(-) G-I A/N/V/D/C (-/-/-/-/-) abdominal pain(-) melena(-) Renal oligurina(-) dysuria (-) hematuria (-) polyuria(-) flank pain(-) generalized edema (+) Renal oligurina(-) dysuria (-) hematuria (-) polyuria(-) flank pain(-) generalized edema (+) Others arthhralgia(-) myalgia(-) syncope(-) dizziness(-) Others arthhralgia(-) myalgia(-) syncope(-) dizziness(-) right lower extremity numbness(+), weakeness(-) right lower extremity numbness(+), weakeness(-)

Physical examination General alert consciousness General alert consciousness Skin no rash, no pigmentation Skin no rash, no pigmentation Head & neck no neck vein engorgement,no palpable neck mass Head & neck no neck vein engorgement,no palpable neck mass E / ENT oral ulcer(-) pinkish conjunctivae, clear sclera E / ENT oral ulcer(-) pinkish conjunctivae, clear sclera Chest clear breathing sound without rale & crackle Chest clear breathing sound without rale & crackle regular heart beat without murmur regular heart beat without murmur Abdomen soft and flat abdomen Abdomen soft and flat abdomen no tenderness or rebound tenderness no tenderness or rebound tenderness normoactive bowel sound normoactive bowel sound Back/extremity CVA tenderness(-/-), knee swelling(-) Back/extremity CVA tenderness(-/-), knee swelling(-) pretibial pitting edema ( ++ / ++ ) pretibial pitting edema ( ++ / ++ ) Neurologic exam motor power V/V, sensory 80% /100% Neurologic exam motor power V/V, sensory 80% /100% DTR ( ++/ ++ ), babinski sign (-/-) DTR ( ++/ ++ ), babinski sign (-/-) 110/70mmHg–72/min–18/min–36.7 ℃ Bwt 60kg, Height 170cm

Initial laboratory finding CBC/DC CBC/DC 4000/mm3-11.1g/dL–33.9%-124X10 3 / ㎣ (Seg 65.7 %) 4000/mm3-11.1g/dL–33.9%-124X10 3 / ㎣ (Seg 65.7 %) aPTT 36.1sec /33, PT 13.4sec/13.3 ( INR : 1.02 ) aPTT 36.1sec /33, PT 13.4sec/13.3 ( INR : 1.02 ) Chemistry Chemistry T/ D-bilirubin 0.60/0.05mg/dL( mg/dL) T/ D-bilirubin 0.60/0.05mg/dL( mg/dL) AST/ALT 22/13 U/L (<40/<40 U/L) AST/ALT 22/13 U/L (<40/<40 U/L) ALP/rGT 56/26 U/L (39-117/<50 U/L) Glucose 111mg/dl ALP/rGT 56/26 U/L (39-117/<50 U/L) Glucose 111mg/dl Prot/ALB 3.4/0.9g/dL( / g/dL) TG 126 mg/dl Prot/ALB 3.4/0.9g/dL( / g/dL) TG 126 mg/dl T-cholesterol 226mg/dL(<200) LDL-cholesterol 145,HDL-cholesterol 22 T-cholesterol 226mg/dL(<200) LDL-cholesterol 145,HDL-cholesterol 22 BUN/Cr 14/1.0 mg/dL (8-23/ mg/dL) BUN/Cr 14/1.0 mg/dL (8-23/ mg/dL) Na/K/Cl 145/4.2/111 ( / / mmol/L) Na/K/Cl 145/4.2/111 ( / / mmol/L) Ca/P 6.2 /2.5 mg/dL(8.4~10.2/2.5~5.5 mg/dl) Mg 1.8mg/dl(1.9~2.5 mg/dl) CRP 0.5 mg /dl Mg 1.8mg/dl(1.9~2.5 mg/dl) CRP 0.5 mg /dl

Urinalysis Urinalysis Occult Blood 3+, Bilir -, Urobilinogen 0.1, Keton – Protein >=300 mg/dl, Nitrate -, Glucose -, pH 6.0 Specific Gravity 1.020, Leucocytes - RBC 2~4, WBC 0~1/HPF RBC 2~4, WBC 0~1/HPF

Chest PA (4-2)

ECG HR = 88 회 / min

Brain MRI

Initial assessment & plan #1. Left parietal lobe infarction aspirin anticoagulation ( heparin and warfarin ) #2. Nephrotic syndrome 24 hour urine protein excretion, abdominal ultrasonography urine RBC morphology serology for GN ( ASO,RF,Cryglobulin, Ig G-A-M-E, ANA, ANCA) renal Biopsy

Abdominal ultrasonography

Renal vascular doppler

Echocardiography

24hr urine collection Protein 7258 mg/day (40~ 150 mg/day ) Urine Creatinine 1361 mg/day ( 800 ~ 1800 mg/day ) CrCl 78.7 mL/min ( 70 ~ 157 ml/min ) Serum Cr 1.1 mg/dL Urine Cr 63.4 mg/dL Urine volume 2150 mL/day

Serologic markers IgG 1010 mg/dL IgA mg/dL IgG 1010 mg/dL IgA mg/dL IgM 84.0 g/dL IgE mg/dL IgM 84.0 g/dL IgE mg/dL C3 80.4mg/dL C mg/dL C3 80.4mg/dL C mg/dL C-ANCA negative P-ANCA negative C-ANCA negative P-ANCA negative ANA negtive RF <9.50 IU/mL ANA negtive RF <9.50 IU/mL ASO <99.0 IU/Ml (< 200) Cyoglobulin negative ASO <99.0 IU/Ml (< 200) Cyoglobulin negative HBsAg / anti-HBc Ab /anti-HBs Ab ( -/ -/ - ) anti-HIV (-), Anti-HCV (-) VDRL non-reactive

Laboratory evaluation of thrombophilic states D-dimer : 5.05 ug/ml ( < 0.5 ) fibrinogen : 429 mg/dl ( 200~400 ) AT III : – 66% (0.19 ~ 0.31 ) Prot C : 121 % ( 70 ~130 ) Prot S : 88 % ( 70 ~143 )

Renal Biopsy

Biopsy ( HE ) X 40

Biopsy ( HE )

Biopsy (MT)

Biopsy ( Silver )

Biopsy ( IF) Ig G C1q C3

Biopsy ( EM )

Final diagnosis and Plan #1. Acute cerebral infarction aspirin anticoagulation ( heparin and warfarin ) #2. Nephrotic syndrome ( Membranous glomerulopathy ) Low salt (1~2g / day ) diet Low salt (1~2g / day ) dietARB Diuretics ( Lasix ) HMG CoA reductase inhibitors Immunosuppressive agents ( steroid + cyclophosphamide )