1. U05-22801

2. Clinical History (16894925): Generalized decline in health since Feburary 2005 including: Wt loss/recurrent ‘Pneumonia’/ arthralgia and joint pain. New-A fib. Anemia (80s) and  Alb (20). Cr ~140  190 over/ 5 mo. For Xfer to Nephro Nov 27/05 ‘coded’ on route with ?sz vs pulse loss. Intubated. Inotropes ++, PRISMA Nov 29/05 and now anuric PmHx: DMN/ HTN/Bicuspid Ao/repaired AAA Meds: Abx -? Type. No known NSAIDs or toxins pANCA + x 2 Nov 15 - Norm C3/C4  Nov 28 low C3- 0.42, C4- 0.17, Nov 15 Norm ANA  Nov 28 ANA +, Negative HBV/HCV, Anti-GBM, SPEP/Urine Bence Jones. ASOT. Intermittent Cryoglobumins and +DAT Urine: +ptn/+3hgb - +hemegran +WBC/RBC casts Renal Bx: LM- No significant glomerular changes beyond DMN. +RBC casts. ++Toxic vacoulization of tubular cells, and ?crystal TEE – possible vegetation. B/C 4/4 Staph Aureus. CT head – bilateral hypodensities - ?mets/emboli R knee aspirate – 8000 WBC – no growth

3. IMMUNOFLUORESCENCE IgG – Mild mesangial staining IgA - Mild to moderate mesangial staining IgM – Trivial to mild mesangial staining C3 - Moderate vascular staining, moderate mesangial staining C1q - Negative Kappa - Mild to moderate mesangial staining Lambda - Negative Fibrinogen Mild mesangial staining Albumin - Negative

4. IgG

5. IgA

6. IgM

7. C3

9. Kappa

10. Fibrin

11. EM Pending……

12. Diagnosis IgA Nephropathy with focal proliferative glomerulonephritis and unexplained striking vacuolization of tubules with white cell casts and unusual crystalline material seen in glomerular capillaries. Rule out some kind of toxic exposure