CASE 40 (June 2009)

Clinical information

The patient is a 5-year-old African-American girl. She was diagnosed with acute lymphoid leukemia, with pre-B phenotype and philadelphia chromosome, 18 months earlier. His treatment included methotrexate, leucovorin, vincristine, cytarabine, etoposide, L-asparginase, ifosfamide, razoxane. Several episodes of febrile neutropenia during treatment. Presented an episode of sepsis, with otomastoiditis and pansinusitis requiring surgery and antibiotics. She also presented avascular necrosis of femoral head.

Now she is evaluated by nephrologist due to edema and creatinine increase. She has also fever, sepsis and pancytopenia. By ultrasound she has increased kidneys size. A diagnosis of Mycoplasma pneumoniae lung infection was also done. A treatment with meropenem and clarithromycin was started. The patient continued still with leukemia chemotherapy.

She does not have hypertension and does not have required dialysis.

Serum creatinine: 2.0 mg/dL; creatinine clearance 50 ml/min, serum albumin: 1.1 g/dL, VIH and hepatitis virus: negative. Proteinuria: 497 mg/m2/h, leukocytes: 6 hpf, erythrocytes: 8 hpf.

What is your diagnosis?

See the images of the renal biopsy.

Figure 1. H&E, X200.

Figure 2. H&E, X400.

Figure 3. Masson's trichrome stain, X400.

Figure 4. Methenamine-silver stain, X400.

Figure 5. Methenamine-silver stain, X400.

Figure 6. Methenamine-silver stain, X400.

Direct immunofluorescence for IgA; IgG, IgM, C3, C1q, kappa, lambda, and fibrinogen: Negative.

What is your diagnosis?

See diagnosis and discussion

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