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Upstate Medical university Case Study

Missed That Train (return to case list)

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A 35 year-old woman has proteinuria (7 grams/day) and an "active urinary sediment" (usually means RBC, WBC and cellular casts). She has a complicated neurologic history which includes a diagnosis of pseudotumor cerebri made 20 years ago and an extensive workup for seizures that has been inconclusive. There is also a diagnosis of rheumatoid arthritis made 4 years earlier (and treated at various times with DMARDs and Etanercept). Serologic workup now shows negative ANA, positive rheumatoid factor, hypocomplementemia (low CH50, low C3 and low C4) and cryoglobulinemia.

A renal biopsy was performed.

Renal Biopsy Pathology

Case X Biopsy Thumbnail Image 1
Slide 1
Case X Biopsy Thumbnail Image 2
Slide 2
Case X Biopsy Thumbnail Image 2
Slide 3
Case X Biopsy Thumbnail Image 2
Slide 4
Case X Biopsy Thumbnail Image 2
Slide 5

All of the glomeruli were similar to that shown in Slide 1. Immunofluorescence results are shown in Slides 2-3 and electron micrographs in Slides 4-5.

1. What is the pathologic diagnosis? (select from List 2).

2. Which of the following could be the underlying cause for these findings?
     A. Bacterial endocarditis
     B. Hepatitis C antigenemia
     C. Rheumatoid arthritis (RA) treatment-related glomerular injury
     D. Shunt nephritis
     E. All of the above