1. Presented by F1 潘恆之 Commented by Dr.薛綏 2011/12/28
Pathology Conference
Presented by F1 潘恆之
Commented by Dr.薛綏
2011/12/28

2. CASE 1: CASE 2: CASE 3:

3. CASE 1:

4. General Data Age: 32-year-old Gender: Female Ethnic: Taiwanese
Marital status: Married
Occupation: Service industry
Admission date: 2011/12/03

5. Chief Complaint
Progressive bilateral lower legs swelling for 1 month

6. Present Illness
This 32-year-old woman has history of diabetes mellitus and dyslipidemia.
She had experienced progressive bilateral legs swelling in recent one month.
She denied fever, dizziness, nausea, vomiting, chest tightness, chest pain, exertional dyspnea, orthopnea, easy fatigue, foamy urine, diarrhea, or dysuria recently.

7. Present Illness
Due to above symptoms, she visited our Nephro OPD, where the urinalysis revealed heavy proteinuria.
Under the impression of nephrotic syndrome, she was admitted for evaluation via kidney biopsy and further management.

8. Past history
1. Type 1 diabetes mellitus, diagnosed at the age of 25 years, under insulin control, HbA1c 15.1(2011/11/10)
2. Dyslipidemia

9. Personal History No known allergy to drug or food
She denies smoking, alcohol, or betel nut chewing.

10. Medication History 2011/11/18 Endocrine OPD 2011/11/18 Nephro OPD
Novomix U QD
2011/11/18 Nephro OPD
Furosemide (40mg) # QD
Atorvastatin (10mg) # QD
2011/12/02 Nephro OPD
Bumetanide (1mg) # BID
Losartan pottasium (50mg)----1# QD

11. Family history Mother: diabetes mellitus
Brother: type 1 diabetes mellitus

12. Physical Examination
Vital signs: BT:36.2/℃ HR:95/min RR:16/min BP:109/73mmHg
General appearance: fair looking
Consciousness: alert and oriented, E4V5M6
HEENT: conjunctiva: not pale, sclera: anicteric
Chest: symmetrical expansion, bilateral clear breathing sounds.
Heart: regular heart beats, no murmurs.
Abdomen: soft and flat normal bowel sounds,
no local tenderness
Extremity: freely movable, bilateral lower legs
pitting edema

13. Laboratory Findings Hemogram unit 12/05 12/23 WBC /uL 10000 RBC
million/uL
3.15
Hemoglobin
g/dL
8.8
9.7
Hematocrit %
26.7
29.4
MCV fL
84.8
MCH
pg/cell
27.9
MCHC
33.0
RDW
14.8
Platelets
1000/uL
290 PT
sec
10.0/10.5
INR
1.0
aPTT
27.2/28.5

14. Biochemistry
11/10(OPD)
11/18(OPD)
12/02
12/23
BUN
23.5
22.1 Cr
0.44
0.39
0.53
0.62
AST
ALT 8 15 14
Sugar (AC)
166
412
HbA1C
15.1
11.7 Na
138 K
4.0
4.7
Cortisol
5.2
TSH
1.144
Albumin
3.12
3.00
Uric acid
5.5
Total cholesterol
264
235
Triglyceride 61 93
LDL
163
140
HDL 87

15. Urinalysis
11/08
12/06
12/23
Color
Yellow
Turbidity
Cloudy
Clear
Sp. Gravity
1.027
1.011
1.024 pH
5.5
6.0
6.5
Leukocyte 2+
Negative
Nitrite 1+
Protein
3+(300)
2+(100)
Glucose
3+(1000)
Ketone
Urobilinogen
1.0
0.1
Bilirubin
Blood 3+
Bacteria
Positive
RBC 28 99
WBC 4 3
Epi. 26 29
11/18
T-protein(U)
348.4 mg/dL
Creatinine(U)
mg/dL
Serology
12/02
IgA
304
IgE
41.50 C3
121.0 C4
32.10
ANA
Negative
HBs Ag
Nonreactive
Anti-HCV

16. 2011/12/ Kidneys echo

17. 2011/12/06 Kidneys echo Left / Right : 12.7cm / 12.2cm
The both kidneys are large in size with regular contour. The cortical echogenicity is increased with adequate thickness. The pelvicalyceal systems are not dilated. There is a cystic lesion (2.1 x 1.9 cm) with round hyperechoic nodule over the low pole of left kidney. No renal stone is noted.
Impression:
Left renal cystic lesion, suspect hematoma due to biopsy

18. 2011/12/05 Kidney Biopsy Kidney, left, needle biopsy
---- Diabetic nodular glomerulosclerosis
H & E sections show 9 glomeruli. 2 are obesolete. 2 have Kimmelstiel-Wilson type nodules and glomerulosclerosis. Others also have mild to moderate slcerosis. The tubules have mild atrophy and protein casts. The interstitium shows mild fibrosis and minimal chronic inflammation. The arterioles have mild atherosclerosis.

19. The Immunofluorescence sections show 9 glomeruli with irregular staining of IgA & C3 (1+). The efferent arteroles have focal staining of C3(2+)

20. Urinalysis
12/06
Color
Yellow
Turbidity
Clear
Sp. Gravity
1.011 pH
6.0
Leukocyte
Negative
Nitrite
Protein
2+(100)
Glucose
3+(1000)
Ketone
Urobilinogen
0.1
Blood 2+
Bacteria
Positive
RBC 28
WBC 3
Epi.
Pregnancy test

21. 2011/12/05 Kidney Biopsy Immunohistochemical study (IHC2011- 4552):
Result:
The renal tubules are 3+ with β-HCG ,
αFP(polyclonal) is negative. *

22. Diagnosis
Diabetes mellitus, type 1, complicated with diabetic nephropathy
Pregnancy
Normocytic anemia
* 出院後7/15 又recurrent bilateral lower legs edema 又住桃園5天 albumin + diuretics (7/15-7/20)

23. Discussion

24. 12/23
Creatinine(U)
mg/dL
Alb/Cre ratio
mg/g
MicroALB(U)
mg/L
12/23
AFP
1.3
B-HCG
4760

25. CASE II:

26. General Data Age: 34-year-old Gender: Female Ethnic: Taiwanese
Marital status: Single
Occupation: Electronics industry
Admission date: 2011/03/28

27. Chief Complaint
Progressive generalized swelling for 10 days

28. Present Illness
This 34-year-old denied any systemic diseases such as diabetes mellitus or hypertension.
She experienced progressive generalized swelling for 10 days. The swelling initially developed from lower legs then gradually progressed to the face. Decreased urine amount and body weight gain of 5 Kg in recent 3 months were also mentioned. Besides, she had suffered from foamy urine since 2009/11.

29. She denied fever, dizziness, nausea, vomiting, chest tightness, abdominal pain, exertional dyspnea, orthopnea, easy fatigue, diarrhea, or dysuria.
She denied HBV/HCV infection, upper respiratory infection nor any medication use such as NSAID, steroid or antibiotics before this episode.
She ever went to General medicine OPD where diuretic was prescribed. However, the swelling still persisted so she came to ER for help.

30. Past history
Denied diabetes mellitus, hypertension or other systemic diseases history

31. Personal History Allergy to an unknown pain-killer
She denied smoking, alcohol, or betel nut chewing.

32. Medication History 2010/03/23 General medicine OPD
Amiloride 5mg # QD
+ Hydrochlorothiazide 50mg

33. Family history
No family history of diabetes mellitus, hypertension, malignancy, chronic kidney disease or other systemic diseases.

34. Physical Examination BH: 158cm BW: 126kg BMI: 50.4
Vital signs: BT:36.6/℃ HR:97/min RR:20/min BP:157/101mmHg
General appearance: fair looking
Consciousness: alert and oriented, E4V5M6
HEENT: conjunctiva: not pale, sclera: anicteric
Chest: symmetrical expansion, bilateral clear breathing sounds.
Heart: regular heart beats, no murmurs.

35. Abdomen: soft and flat normal bowel sounds,
no local tenderness
Back: No knocking pain over bilateral flank area
Extremity: freely movable,
bilateral lower legs grade I pitting edema
Skin: no rash, no petechiae nor ecchymosis
fair skin turgor

36. Laboratory Findings Hemogram unit 03/25 03/27 03/31 04/16 WBC /uL
23600
RBC
million/uL
5.93
Hemoglobin
g/dL
17.4
14.0
15.7
Hematocrit %
50.2
41.5
48.4
MCV fL
84.7
MCH
pg/cell
29.3
RDW
12.5
Platelets
1000/uL
349
Segment 85
Lymphocyte 11
Monocyte 3
Eosinophil 1 PT
sec
10.2
INR
0.9
APTT
29.5

37. Biochemistry
03/23(OPD)
03/25
03/27
BUN
9.8
Creatinine
0.63
0.90
ALT 19 12
Bilirubin (T)
0.2
Alk-P 50
Na/K/Cl
131/4.2/102 Ca
7.6
CO2
24.1
Albumin
2.27
2.11
Total protein
5.4
Sugar
114
Uric acid
8.8
10.6
Free-T4
0.97
TSH
3.409
Cortisol
2.0
Total cholesterol
456
Triglyceride
322
03/31
T-protein(U)
mg/dL
Creatinine(U)
67.74 mg/dL
24hr U/O
2900 ml
24hr TP(U)
33.2 g
24hr Ccr
151.6 ml/min

38. Urinalysis
03/23
03/25
03/30
Color
Yellow
Turbidity
Cloudy
Clear
Sp. Gravity
1.023
1.037
1.025 pH
5.5
7.0
Leukocyte
Negative
Trace(15)
Nitrite
Protein
4+(1000)
Glucose
Ketone
Blood
2+(80)
1+(25)
Hyaline Cast 4
Granular Cast 3
Bacteria
Positive
RBC 16 8 20
WBC 22 10 1
Epi. 32 21
Serology
03/27
RPR
Negative
ASLO
65.40
HBsAg
IgG
552
IgA
237
IgM
175
IgE
1090 C3
215 C4
42.2
ANA
1:40(Nucleolar)
HBs Ag
Nonreactive
Anti-HCV

39. 2010/03/27 CXR

40. 2010/03/27 KUB

41. 2010/03/26 Kidneys echo

42. 2010/03/26 Kidneys echo Bilateral pelviectasis Left large kidney
Left / Right : 12.5 cm / 11.4 cm
The left kidney is large in size and the right kidney is normal in size and both kidneys have slightly irregular outline. The cortical echogenicity and thickness are normal. There is mild separation in the central sinus of both kidneys. No evidence of renal stone, mass, or cyst exists.
Impression:
Bilateral pelviectasis
Left large kidney
Parenchymal renal disease

43. 2010/03/30 Kidney Biopsy Kidney, needle biopsy
---- Pauci-immune glomerulonephritis
---- Focal interstitial nephritis
H & E sections show 9 glomeruli. 4 of them have mild hyperplasia with capsular adhesions and 1 has a small cecllular cresent. Fibrosis of bowman’s capsule is also seen focally. The changes suggest “cellular variant” of FSGS. The interstitium has focal fibrosis with moderate chronic inflammation and some eosinophils. The tubules have focal atrophy in sclerotic area. The arteries are unremarkable.

44. The Immunofluorescence sections have 3 glomeruli with irregular 1+ IgM
Electron microscopic study (EM ) :
1 glomerulus on electron microscopic study shows moderate sclerosis with fusion of foot processes. No immune deposits are seen.

45. Diagnosis Nephrotic syndrome due to focal segmental glomerulosclerosis
Hypertension
Obesity
* 出院後7/15 又recurrent bilateral lower legs edema 又住桃園5天 albumin + diuretics (7/15-7/20)

46. Discussion

47. CASE III:

48. General Data Age: 25-year-old Gender: Male Ethnic: Taiwanese
Occupation: Office clerk
Admission date: 2011/11/08

49. Chief Complaint
Progressive headache for one week.

50. Present illness
This 25 years old man with history of hypertension and IgA nephropathy was admitted via ED due to headache with nausea and vomiting for a week.
He experienced progressive headache since one week before admission. The discomfort was getting severe at night and always was relieved by anti-hypertensives. Abdominal discomfort with heartburn sensation, nausea, vomited with foot content after getting meal for several hours were also mentioned.

51. He denied vertigo, aura before headache, eye pain, nasal discharge, facial pain, dysphagia, bowel habit change, tarry stool, oliguria, urine output decrease or lower legs swelling.
Unfortuantely, fever, chills, dysuria, weak stream and void difficulty developed since 3 days before admission
Due to above, he came to our ER for help.

52. Past History IgA nephropathy Haas Class 4, diagnosed for 5 years
Chronic kidney disease
Secondary hypertension under medical control for 4 years, SBP around 120~130mmHg at home
Hyzaar (Losartan 100mg + HCTZ 12.5mg)

53. Personal History No known allergy to drug or food
Smoking: 0.5PPD~1PPD, quit for 5 years
Alcohol: social drinking, quit for 5 years
Betel nut chewing: denied
No recent travel history
No contact history

54. Medication History 2011/10/24 Nephro OPD 2011/10/31 Nephro OPD
Cyclosporin (25mg) # QD
Propranolol (10mg) # TID
Co-Diovan (Valsartan 160mg # QD
+ HCTZ 12.5mg )
A. M. D # QID
Dimethicone (36.7mg) # QID
2011/10/31 Nephro OPD
Kept above medication and added on :
Labetalol (200mg) # BID
Metoclopramide (5mg) # TID

55. Family history Grandmother: stroke, hypertension
No family history of diabetes mellitus, malignancy, chronic kidney disease or other systemic diseases.

56. Physical Examination
Vital signs: BT:37.7/℃ HR:105/min RR:20/min BP:162/104 mmHg
General appearance: acute-ill looking
Consciousness: alert, E4V5M6
HEENT: conjunctiva: not pale, sclera:anicteric
Neck: supple, no jugular vein engorgement,
no lymphadenopathy
Chest: symmetrical expansion,
bilateral clear breathing sounds.
Heart: regular heart beats, no murmurs.
No abdominal tenderness

57. Physical Examination Abdomen: soft and flat, epigastria tenderness
normoactive bowel sounds
Back: no knocking pain over bilateral flank area
Extremity: freely movable, no pitting edema
Skin: no skin rash, no petechiae nor ecchymosis
Neurologic exam: no Kernig's nor Brudzinski's sign

58. Laboratory Findings Hemogram unit 10/31 11/05 11/17 11/21 WBC /uL 6700
6100
5700
RBC
million/uL
3.86
3.52
3.31
Hemoglobin
g/dL
11.8
11.4
10.1
9.4
Hematocrit %
35.4
32.5
29.0
27.5
MCV fL
84.1
82.4
83.1
MCH
pg/cell
29.5
28.7
28.4
RDW
13.7
13.1
13.5
Platelets
1000/uL
101
146
127
Segment
87.5
58.0
57.6
Lymphocyte
7.1
33.9
32.6
Monocyte
4.8
6.1
7.3
Eosinophil
0.6
1.8
2.3 PT
sec
11.3
INR
1.1
APTT
30.4
28.9

59. Biochemistry
10/31
11/05
11/17
11/21
BUN
109.8
102.8
75.4
85.7 Cr
6.80
6.99
6.64
7.15
AST
ALT 19
Bilirubin
0.2
Alk-P 59 Na
138
140 K
4.4
4.9
4.7 Ca
8.5
8.1 P
7.4
CO2
19.8
17.8
CRP
9.47
1.44
1.01
Albumin
4.11
Troponin I
0.012
Sugar
153

60. Urinalysis
10/31
11/05
11/18
Color
Yellow
Turbidity
Clear
Sp. Gravity
1.010
1.009 pH
5.5
6.0
Leukocyte
Negative
Nitrite
Protein
2+(100)
3+(300)
Glucose
Trace
Ketone
Urobilinogen
0.1
Bilirubin
Blood 2+ 3+
RBC 12
127 23
WBC 1 2
Epi.
11/10
T-protein(U)
101.1 mg/dL
Creatinine(U)
38.89 mg/dL
24hr U/O
1800 ml
24hr TP(U)
1.819 g
24hr Ccr
7.61 ml/min
Serology
10/31
IgA
420 C4
19.10
ANA
Negative

61. 2011/11/05 CXR

62. 2011/10/31 Kidneys Echo
Left / Right Kidney Length: 10.3cm / 10.3cm
The both kidneys are normal in size with mildly irregular contour. The cortical echogenicity is
increased with adequate thickness.

63. 2011/10/31 Kidney Echo
The pelvicalyceal systems are not dilated. There is an echo-free lesion (0.4cm) with posterior wall enhancement over the middle portion of right kidney. No renal mass, or stone is noted.
Impression:
1.Right renal cyst
2.Parenchymal renal disease with chronic change

64. 2011/11/ Brain CT

65. 2011/11/14 Panendoscopy

66. 2011/11/18 Kidney Biopsy Kidney, needle biopsy
---- IgA nephropathy, class V
---- tubulointerstitial nephritis
H & E sections showe 11 glomeruli. Two of them are obsolete. Others have hyperplasia and severe diffuse sclerosis. Two have focal fibrous crescent. The tubules show severe atrophy and have protein casts and focal RBC casts. The interstitium have severe chronic inflammation and severe fibrosis. The arterioles have mild to moderate atherosclerosis.

67. 2011/11/18 Kidney Biopsy
The immunoflurorescence section shows 5 glomeruli with severe slcerosis and staining of IgA (3-4+), IgM(1+) and C3(3+) in mesangial and focal loop pattern. Focal tubules have C3 (2+)

68. Diagnosis Immunoglobumin A nephropathy, class V
Tubulointerstitial nephritis
Chronic kidney disease, stage V, Immunoglobumin A nephropathy related
Normocytic anemia, suspect chronic kidney disease related
Hypertension, suspect chronic kidney disease related
Upper respiratory airway infection
Gastrointerstinal bleeding, favor hemorrhagic gastritis over cardia related

69. Discussion

70. CASE IV:

71. General Data Age: 43-year-old Gender: Male Ethnic: Taiwanese
Marital status: Married
Occupation: Restaurant business
BH:166.6cm, BW:85kg, BMI:30.6
Admission date: 2011/11/03

72. Chief Complaint
Progressive bilateral lower legs swelling for 1+ year

73. Present Illness
This 43 year-old male has history of hypertension, diabetic mellitus, chronic kidney disease, and coronary artery disease.
He had experienced bilateral lower limb swelling and numbness for 1+ year. Mild exertional dyspnea recently was also mentioned.
He denied chest pain, dizziness, fever, dysuria, nausea, vomiting, orthopnea, easy fatigue, bowel habit change, tarry stool or bloody stool.
Due to the persisting bilateral lower limb swelling, he was admitted for further survey.

74. Past history Hypertension for 10+ yrs, under medical control
Diabetes mellitus for 10+ yrs, complicated with triopathy, under medical control
Vitreous hemorrhage
Anteroseptal myocardial infarction in 2011/10

75. Personal History No known allergy to drug or food Alcohol : denied
Smoking : 2 PPD for 20+ yrs
Betel nut: occasionally

76. Medication History 2011/09/26 Ophthalmologist OPD
Ketorolac oph. solution 0.5% GT BID
Tears(artificial) 15ml/bot GT QID
2011/10/07 Nephrologist OPD
Aliskiren 150mg/F.C # QD
Bumetanide 1mg/tab # QD
Benzyl hydrochlorothiazide 4mg/tab -- 1# BID
Acarbose 50mg/tab # BID
Pentoxifylline S.R 400mg/s.c tab # QD

77. Family history
Mother: hypertension
Father: unknown systemic disease

78. Physical Examination
Vital signs: BT:36.5/℃ HR:90/min RR:18/min BP:186/120mmHg
General appearance: fair looking
Consciousness: alert and oriented, E4V5M6
HEENT: conjunctiva: not pale, sclera: anicteric
Chest: symmetrical expansion, bilateral clear breathing sounds.
Heart: regular heart beats, no murmurs.
Abdomen: soft and flat normal bowel sounds,
no local tenderness
Extremity: freely movable,
bilateral lower legs grade I pitting edema

79. Laboratory Findings Hemogram unit 10/31 11/05 11/17 11/21 WBC /uL 6700
6100
5700
RBC
million/uL
3.86
3.52
3.31
Hemoglobin
g/dL
11.8
11.4
10.1
9.4
Hematocrit %
35.4
32.5
29.0
27.5
MCV fL
84.1
82.4
83.1
MCH
pg/cell
29.5
28.7
28.4
RDW
13.7
13.1
13.5
Platelets
1000/uL
101
146
127
Segment
87.5
58.0
57.6
Lymphocyte
7.1
33.9
32.6
Monocyte
4.8
6.1
7.3
Eosinophil
0.6
1.8
2.3 PT
sec
11.3
INR
1.1
APTT
30.4
28.9

80. Biochemistry
10/31
11/05
11/17
11/21
BUN
109.8
102.8
75.4
85.7 Cr
6.80
6.99
6.64
7.15
AST
ALT 19
Bilirubin
0.2
Alk-P 59 Na
138
140 K
4.4
4.9
4.7 Ca
8.5
8.1 P
7.4
CO2
19.8
17.8
CRP
9.47
1.44
1.01
Albumin
4.11
Troponin I
0.012
Sugar
153

81. Urinalysis
10/31
11/05
11/18
Color
Yellow
Turbidity
Clear
Sp. Gravity
1.010
1.009 pH
5.5
6.0
Leukocyte
Negative
Nitrite
Protein
2+(100)
3+(300)
Glucose
Trace
Ketone
Urobilinogen
0.1
Bilirubin
Blood 2+ 3+
RBC 12
127 23
WBC 1 2
Epi.
11/10
T-protein(U)
101.1 mg/dL
Creatinine(U)
38.89 mg/dL
24hr U/O
1800 ml
24hr TP(U)
1.819 g
24hr Ccr
7.61 ml/min
Serology
12/02
IgA
420 C4
19.10
ANA
Negative

82. 2011/11/04 CXR

83. 2011/11/04 Kidneys echo Parenchymal renal disease
Left / Right : 10.2 cm / 10.0 cm
Both kidneys are normal in size with mildly irregular contour. The cortical echogenicity is increased with adequate thickness. The pelvocalyceal systems are not dilated. No evidence of stone or cyst
Impression:
Parenchymal renal disease

84. Cardiac echo

85. 2011/11/09 Thallium scan

86. 2011/11/07 Kidney Biopsy Kidney, left, needle biopsy
---- Diabetic nodular glomerulosclerosis
H & E sections show 27 glomeruli. 15 of them are obesolete. 4 have Kimmelstiel Wilson nodules. Others have global slcerosis and macrophages infiltrates. The tubules have moderate to marked atrophy and protein casts. The interstitium shows moderate to marked fibrosis. The arterioles have marked atherosclerosis. The Immunofluorescence sections show 8 glomeruli with slcerosis and irregular staining of IgM (1+) & C3 (2+) and C1Q (1+)

87. Electron microscopic study (EM2011-161):
One glomerlus on electron microscopic study shows global sclerosis with oliterated loops. Hyaline globules are present.

88. Diagnosis
Diabetes mellitus, complicated with diabetic nephropathy, neuropathy and retinopathy
Chronic kidney disease due to diabetic nephropathy
Hypertension
* 出院後7/15 又recurrent bilateral lower legs edema 又住桃園5天 albumin + diuretics (7/15-7/20)

89. Discussion