Case 45
With discussion
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CASE 45 (November 2009)

Clinical information

A 82-year-old woman presented with a 1-month history of macular and papular lesions on lower limbs, the lesions were purplish, symmetrical, and some confluent, accompanied by progressive edema. Skin lesions progressively involved upper limbs. On questioning, the patient reported having nonspecific abdominal pain since 10 days before admission. There were not associated urinary symptoms.

The patient's previous medical history included hypothyroidism (15 years), type II diabetes mellitus (40 years) and hypertension (15 years). She had no known drug or food allergies.

Four months previous to admission a serum creatinine was 1.1 mg/dL and an urinalysis showed proteins: 25 mg/dL.

Laboratory tests: blood cells count and coagulation tests: normal. Urinalysis: Proteinuria: 4,181 mg/24h, leukocytes: 4 hpf; erythrocytes: 18 hpf, there are granular casts; Bence-Jones protein: negative. Creatinine cleareance: 11 mg/m2/h; BUN 76 mg/dL. Serum calcium: 7.5 mg/dL. Serum proteins: 8.0 g/dL, albumin: 3.2 g/dL. Alkaline phosphatase: 137 IU/L.

ANAs: 1:80 speckled pattern, anti-DNA: negative, C3: 182 (90-180); C4 30 (10-40). HIV, hepatitis virus B and C, cryoglobulins, ANCA, and VDRL: negative.

Due to the clinical features, the diagnostic impression was rapidly progressive glomerulonephritis.

Abdominal pain was intermittent and disappeared spontaneously several days after. There was not diarrhea or other gastrointestinal symptoms.

Ultrasound doppler showed bilateral high resistance index: 0.72. Both kidneys appear normal on ultrasound.

A skin biopsy was reported as necrotizing vasculitis (slides or images not available).

A renal biopsy was carried out. See the images.

Figure 1. Although it is not the better clinical photography, it was the clinical image sent us. The arrow marks the site where the biopsy was taken.

Figure 2. H&E, X200.

Figure 3. Masson's trichrome stain, X200.

Figure 4. Masson's trichrome stain, X400.

Figure 5. Masson's trichrome stain, X400.

Figure 6. Methenamine-silver stain, X400.

Figure 7. PAS stain, X400.

Figure 8. H&E, X400.

Figure 9. Left, Masson's trichrome stain; right, PAS stain; both X400.

Figure 10. Direct immunofluorescence using antiserum to IgA, X400.

Direct immunofluorescence for IgG, IgM, C3 and C1q: Negative.

What is your diagnosis?

Acknowledgements: To Dr. Vibian Angélica Coy and Dr. Mauricio Sánchez for the clinical information on this case.

See diagnosis and discussion