1. Medical Grand Rounds Case Presentation 신장 내과 Prof. 임천규 /R1 변자민

2. 11790928 김 O 연 (36/F) adm. date: 2011.04.23 Adm via ED C.C) sore throato/s) 4 days ago P.I) 상기 36 세 여자환자 2010 년 12 월 IgA nephropathy 진단받고 본원 신장내과 ( 임천규 교수님 ) 추적관찰 하 던 자로 내원 4 일 전 인후통 생기면서 내원 3 일부터 열나고 혈뇨 생겨 인근 개인병원 방문, 약 처방 받았 으나 증상 호전 없었음. 그 후 미열 지속되며 오심, 구 토 발생하며 소변량 감소하는 양상보여 응급실 통해 입원함.

3. PMHx) –HTN/DM/TB/hepatitis (-/-/-/-) –IgA nephropathy (+): 2010 년 12 월 조직검사후 진 단 2005 년, 2010 년 인후편도염 후 생긴 혈뇨로 입원치료 –OP history (+): 2007 년, 2009 년 제왕절개 –Drug history (+) OPD medicationLocal clinic medication 4/204/21~23 Losartan 50mg 1T Feroba 1T Cefaclor 250mg 1T Acetaminophen 1T Varidase 1T Itopride 50mg 1C Meiact 100mg 1T Acetaminophen 1T Medirac 1C Tiropa 1T Almagate 1T

4. Review of Systems General: fever (-), chills (-), fatigue(+), weight loss (-) Skin: rash (-), itching (-), bruises (-) HEENT: headache (-), rhinorrhea (-), sore throat(+) Chest: c/s/r (+/-/-), dyspnea (-) Cardiac: chest pain (-), palpitation (-), DOE (-) GI: abdominal pain (-), A/N/V/D/C (+/+/+/-/-), hematochezia/melena (-/-) GU: dysuria(-), urgency(-), frequency (-), hematuria(+) Musculoskeletal: pain (-), edema (-), weakness (-) Nerve system: dizziness (-), sensory loss(-)

5. Physical Examinations V/S: 100/70mmHg – 72/min – 20/min – 36.4 ℃ Height: 158cm / Weight: 62kg (BMI: 24.8kg/m 2 ) General : alert, acutely ill-looking appearance Skin: rash (-), pigmentation(-), petechiae (-) HEENT: isocoric pupil with PLR (++/++) no palpable neck mass, NVE (-), LNE(-) white sclera, pinkish conjunctiva PTH (++/++), PI (+/+), whitish patch at palatine tonsil Chest: Clear breathing sound without rale / wheezing Regular heart beat without murmur Abdomen: Soft and flat abdomen Normoactive bowel sound Td / rTd (-/-) Back & Extremities: CVA Td(-/-) Pretibial pitting edema (-/-) Neurology: unremarkable

6. Initial lab finding (11.04.23) CBC/DC) 10070/mm² - 13.1 g/dl – 36.6% - 224K (seg. 73.1%) Chemistry ) TB/DB0.44/0.11 mg/dl BUN/Cr 43/6.1 mg/dl Prot/alb8.3/4.2 g/dL Na/K/Cl135/4.4/89 mg/dl AST/ALT38/8 IU/L Ca/P/Mg 7.4/6.1/2.8 mg/dL ALP/GGT56/21 IU/L Uric acid 11.2 mg/dL LD/CK576/60 U/L CRP 18.87 mg/dL ABGA7.39-36.2-84.4-21.4 96.3% U/A) RBC many/HPFWBC 5-9/HPFSG 1.023 pH 5.0 Protein (+++) 300Glucose (-)Leukocytes(-) Nitrite(-)

7. Chest X-ray (2011.04.23 )

8. ECG (2011.04.23)

9. Initial Problem List & Assessments #1. oliguria, hematuria #2. sore throat, fever, cough #3. IgA nephropathy, known  Acute renal failure r/o IgAN aggravation (RPGN, type II) r/o Post-infectious GN r/o ATN, ATIN  Acute pharyngotonsilitis #2. sore throat, fever, cough

10. Labs Specific labs Others Treatment FeNa (0.58), FeBUN (9.99), Spot urine (Prot/Cr 160/137), Urine PCR (1.16) Serology: C3, C4 ANCA, ANA, IgG/A/M/E Cryoglobulin Abdomen USG, Renal biopsy Abdomen USG, Renal biopsy Diagnostic & Therapeutic Plans 1.Hydration 2.Lasix 3.Lab f/u: BUN/Cr, ABGA, CXR 4.Emergent dialysis, if indicated 5. Steroid needed #1,3 Acute renal failure r/o IgAN aggravation (RPGN, type II) r/o Post-infectious GN r/o ATN, ATIN

11. Culture Specific labs Treatment Blood culture, Sputum culture, Throat swab culture Blood culture, Sputum culture, Throat swab culture ASO titer Antibiotics: Ceftriaxone + Clarithromycin Antibiotics: Ceftriaxone + Clarithromycin Diagnostic & Therapeutic Plans #2 Acute pharyngotonsilitis

12. Clinical Course

13. 2005 2010/1 2 Tonsilitis Hematuria Tonsilitis Hematuria 2011/4/19 Resolved Biopsy 4/204/214/224/23 Tonsilitis Hematuria Losartan 50mg CefaclorMeiact admission

14. 4/254/284/23 axon+clari Levofloxacin STEROID (IV MPD -> PO PDL) 5/6 Acute generalized exematous pustulosis r/o Drug eruption d/t antibiotics antihistamine(plakon) Esperson lotion & Desowen 도포 Burrow solution dressing markertiter IgG (164- 1618) 1060mg/dL IgA (68-378)270 mg/dL IgM (60-263)58.3 mg/dL IgE (-100)267 IU/mL C3 (88-201)119 mg/dL C4 (16-47)39.2 mg/dL ASO titier(- 200) 69.1 ANA- P-ANCA- C-ANCA- Cryoglobulin- Renal Bx

16. 16 Renal biopsy

17. 17 Renal biopsy

18. 18 Renal biopsy

19. Ⅰ. Glomerulus 1. Number of Glomerulus: 3 2. Glomerulosclerosis (GS): (Y) Global glomerulosclerosis: 1/3 (%) 3. Capillary wall thickening: 0 4. Lumen of capillary: intact 5. Capsular adhesion: (N) 6. Duplication(Tram-track) of capillary wall: 0 7. Wire-loop formation of capillary wall: 0 8. Intraluminal hyalinosis: 0 9. Capillary necrosis: 0 10. Mesangial matrix expansion: 1 11. Mesagnial cell proliferation: 1 12. Mesangiolysis: 0 13. Inflammatory cell infiltration: 0 14. Crescent: (N) 15. Glomerulitis: 0 16. Periglomerular fibrosis: (N) [ Microscopic Findings ] Ⅱ. Tubulointerstitium 1. Mononuclear cell infiltration: 2 2. Neutrophilic infiltration: 0 3. Interstitial fibrosis: 0 4. Tubular atrophy: 0 5. Acute tubular necrosis: 0 6. Tubular cast: 0 7. Tubulitis (No) 8. Eosinophilic infiltration: 2 Ⅲ. Vessels 1. Vasculitis, endotheliitis: 0 2. Necrosis: 0 3. Intraluminal thrombi: 0 4. Art. intimal hyalinosis: 0 5. Art. medial nodular hyalinosis: 0 6. Fibrous wall thickening: 0 <Diagnosis> Kidney, needle biopsy: 1.Acute tubulointerstitial nephritis, focal: Probably drug-induced toxicity 2. Mild increase of mesangial matrix and cells

20. 4/254/284/23 axon+clari Levofloxacin STEROID (IV MPD -> PO PDL) 5/6 DISCHARGE Renal Bx ATIN

21. Final Diagnosis #1. ATIN, drug induced #2. Acute pharyngotonsilitis #3. IgA nephropathy, known