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Upstate Medical university Case Study

Conventional Folly (return to case list)

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A 59 year-old woman is admitted to the hospital with complaints of vomiting and progressive weakness.  For the past two months, she has had general malaise, anorexia, and right flank pain (treated with non-steroidal anti-inflammatory drugs (NSAIDs)).

On admission, she is noted to have gross hematuria and a serum creatinine of 4.2 mg/dl.  Her serum creatinine is known to have been normal two months earlier.  Blood pressure is 150/84 mmHg.  There is no edema. 

Urinalysis shows red blood cells and 2+ protein.  No casts were seen. 
The chest X-ray is negative.  The patient developed anuria and a rapidly rising serum creatinine. 

1. Characterize the renal presentation (select from List 1.)

A renal biopsy was done.

Pathology Report

Case B Thumbnail Image 1
Slide 1
Case B Thumbnail Image 2
Slide 2
Case B Thumbnail Image 3
Slide 3
Case B Thumbnail Image 4
Slide 4

Nearly all of the glomeruli were obliterated by necrosis and crescents (slides 1 (Masson-Trichrome), 2 (Jones Silver) and 3 (immunofluorescence for fibrinogen)). Immunofluorescence was strongly positive for IgG and C3 in a linear GBM pattern (slide 4).

2. What is the diagnosis? (select from either List 2 or List 3).

3. What is the most appropriate management in this case?
     A. Corticosteroids alone are indicated and should be sufficient to induce remission
     B. Cyclophosphamide (cytoxan) and plasmapheresis are indicated for best hope of remission
     C. Supportive care only; expect spontaneous resolution of renal problems
     D. Supportive care only; prepare patient for long-term renal replacement therapy