Pathology Conference

Presented by F1 林立原Commented by Dr.薛綏2011/07/20

CASE 1: 2516217CASE 2: 2847619

CASE 1: 2516217

General DataAge: 48-year-oldGender: maleEthnic: TaiwaneseMarital status: MarriedOccupation: 工人Admission date: 2011/05/26

Chief Complaint

Increased urine BKV titer

Present illnessThis 48 year-old male has end

stage renal disease on hemodialysis since 1992, post kidney transplantation on 2010/11/02 in Mainland China(廣州醫學第二附屬醫院 )

He has regular Nephrology OPD follow-up with immunosuppressents. In 2011/05, elevated urinary BKV titer(>1000000000) was noticed. Thus, he was admitted for graft kidney biopsy.

Past HistoryImpaired glucose tolerance Chronic hepatitis CCurrent medication:

Prednisolone 5mg QD Tacrolimus 0.5mg QN Sirolimus 2mg QD Mycophenolate 500mg BID Leflunomide 20mg QD Clopidogrel 75mg QD Glimepiride 1mg QD

Personal HistoryNo known allergy to drug or foodHe denies smoking, alcohol, or

betel nut chewing.

Physical ExaminationVital signs: BT 36.1℃ PR: 76/min, RR:

15/min, BP: 146/84 mmHgGeneral appearance: fairConsciousness: alert and orientedHEENT: conjunctiva: not pale, anicteric

scleraChest: symmetrical chest expansion,

bilateral clear breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat normal bowel

soundsExtremity: freely movable, no pitting edema.

Laboratory FindingsHemogram

unit 5/26

WBC /uL 6100

RBC million/uL

4.87

Hemoglobin

g/dL 13.4

Hematocrit % 42.5

MCV fL 87.3

MCH pg/cell 27.5

MCHC g/dL 31.5

RDW % 14.9

Platelets /uL 132

Segment % 76.2

Lymphocyte

% 16.6

Monocyte % 7.2

Eosinophil % 0

Basophil % 0

unit 5/26

PT sec 11.9

INR 1.1

aPTT sec 26.9

Biochemistry

Unit 5/26

Cr mg/dL 1.20

eGFR ml/min/1.73m2

> 60

AST U/L 56

Na mEq/L 143

K mEq/L 3.5

Urinalysis 5/26

Color Yellow

Turbidity Clear

Sp. Gravity 1.014

pH 6.0

Leukocyte Negative

Nitrite Negative

Protein Negative

Glucose Negative

Ketone Negative

Urobilinogen 0.1

Bilirubin Negative

Blood trace

RBC 4

WBC 2

Epi. 0

2011/05/26 CXR

2010/12/06 Kidney Echo

2010/12/06 Kidney Echo

2010/12/06 Kidney EchoLeft Kidney Length: 12.8 cmRight Kidney Length: 9.6 cmTransplant kidney: 12.3cm The contour and size of

transplanted kidney is normal. The cortical echogenicity is mildly increased with adequate thickness.

The resistence indeces are as follows: Upper pole: 0.630, Middle pole: 0.667, Lower pole: 0.667.

2010/12/06 Kidney EchoThe left native kidney is enlarged in

size with irregular appearance. The normal renal architexture is distorted.

The right native kidney is normal in size with irregular appearance. There are numerous cysts of varying size scattering in cortex and central sinus of both kidneys (The largest: 5.8 x 5.4 cm in the left kidney and 3.0 x 3.0 cm in the right kidney).

2011/05/27 Kidney BiopsyKidney, graft, needle biopsy ----Consistent with viral nephritis• H & E l sections have 10 glomeruli

with focal mild sclerosis. The interstitium has focal mild to moderae chronic inflammation. Tubules have scattered large nucleated cells with inranuclear inclusions, minimal tubulitis and protein casts. Arteries have mild sclerosis.

2011/05/27 Kidney BiopsyKidney, graft, needle biopsy ----Viral nephritis, IgA nephropathy• Immunohistochemical study:

C4D(-), BK virus (+) in the large nucleated tubular cells

• Immunofluorescence sections show 7 glomeruli with 3+ IgA, 1+ IgI, 2+ IgM and 2~3+ C1q in mesangium.

2011/05/27 Kidney Biopsy• Electron microscopic study: one

glomerulus show scattered mesangial deposits and focal fusion of foot processes.

DiagnosisBKV nephritis with IgA

nephropathyEnd stage renal disease on

hemodialysis since 1992, post kidney transplantation in 2010/11/02 in Mainland China

Discussion

CASE 2: 2847619

General DataAge: 32-year-oldGender: femaleEthnic: TaiwaneseMarital status: divorcedAdmission date: 2011/06/07

Chief ComplaintProgressive right lower limb

swelling for 1 month

Present IllnessThis 32-year-old female has

major depression and chronic hepatitis B under regular OPD follow up

She presents to the ED because of progressive right lower limb swelling for 1 month, associated symptoms including abdominal fullness, abdominal pain, nausea vomiting, dry cough, and watery diarrhea.

Present illnessAt the beginning, she visited a

local hospital, where acute gastroenteritis was impressed and treated. Her symptoms improved a little bit.

Several days prior to admission, she developed intermittent fever, urinary hesitancy, difficult urination, general weakness, and left flank pain. Thus, she visited CGMH ED for help.

Past History OPD medications

◦Silymarin 150mg BID◦Venlafaxine 75 mg QN◦Mirtazapine 30mg QN◦Alprazolam 0.5 mg BID◦Estazolam 2mg HS

Gallstones with chronic cholecystitis status post laparoscopic cholecystectomy on 2010/7/26

Personal HistoryNo known allergy to drugsSmoking: 1PPD for 10+ yearsAlcohol: heavy drinker, quit nowBetel nuts chewing: no

Physical ExaminationVital signs: BT 37.6℃ PR: 125/min, RR:

17/min, BP: 138/100mmHgBH: 164cm, BW: 80kgGeneral appearance: fairConsciousness: alert and orientedHEENT: pink conjunctiva, anicteric scleraChest: symmetrical chest expansion,

bilateral clear breathing soundsHeart: regular heart beats, no murmurs.Abdomen: soft, tenderness over left

quadrants CV angle knocking pain: (+), L't > R'tExtremity: grade 2 pitting edema.

Hemogram

unit 6/6

WBC /uL 7500

RBC million/uL

3.39

Hemoglobin

g/dL 11.9

Hematocrit % 34.6

MCV fL 102.1

MCH pg/cell 35.1

MCHC g/dL 34.4

RDW % 13.9

Platelets /uL 252

Segment % 66.8

Lymphocyte

% 24.7

Monocyte % 7.0

Eosinophil % 1.1

Basophil % 0.4

Biochemistry

6/6 6/10

BUN 21.3 mg/dL

Cr 1.15 mg/dL

Na 135 meq/L

K 3.3 meq/L

ALT 27 U/L

Albumin 2.37 g/dL

Sugar 110 mg/dL

CRP 15 mg/L

T-Cholesterol 313

Triglyceride 185

F-T4 0.76ng/dL

TSH 1.77 uIU/ml

Cortisol 12.3 ug/dL

Urinalysis 6/6

Color Yellow

Turbidity Turbid

Sp. Gravity 1.029

pH 6.0

Leukocyte Trace

Nitrite Negative

Protein 4+

Glucose Negative

Ketone Negative

Urobilinogen 0.1

Bilirubin 1+

Blood 3+

Bacteria/Yeast

Positive

RBC 158

WBC 33

Epi. 35

6/10

24 hrs U/O 1800 ml

T-protein 416.8mg/dL

Daily protein(U)

7.5 gm/day

Serology 6/10

C3 135

C4 28.2

ANA Negative

Anti-dsDNA <40.5 (6/27)

Anti-Smith Negative

RNP Negative

SSA/SSB Negative

Anti-cardiolipin

Negative

Cryoglobulin IgG2+, IgA+, IgM+

Cryofibrinogen

Positive

ASLO 258 IU/ml

Serology 6/10

IgG 717

IgA 289

IgM 102

IgE <16.9

ANCA Negative

Anti-HCV Negative

Anti-HIV Negative

RPR Negative

6/9

PEP/IFE Protein loss or malnutrition pattern. No monoclonal protein, no paraprotein

2011/6/6CXR

2011/6/6KUB

2011/06/07 Kidney Echo

2011/06/07 Kidney EchoLeft Kidney Length: 13.3 cmRight Kidney Length: 13.1 cmThe cortical echogenicity is mildly

increased with adequate cortical thickness. There is one isoechoic band separating the the left central sinus in some views.

Impressions: 1. Bilateral large kidneys with possible

parenchymal change 2. Left columnar hypertrophy

Course and treatmentAfter admitted to ID ward, antibioitcs

was discontinued on 06/08, for infection is less likely. Instead, proteinuria(7.5g/day), hyperlipidemia(TG: 185mg/dL, T-Chole: 313 mg/dL), hypoalbuminemia(2.37 g/dL on 06/07) and lower limbs edema were noticed. Due to nephrotic syndrome, she was transferred to Nephrology ward for kidney biopsy.

Course and treatmentIn Nephrology ward, serologic

study was done for survey of nephrotic syndrome, cryoglubulin (IgG(2+),IgA(1+),IgM(2+)) and cryofibrinogen were positive; ASLO was 258 IU/ml, other tests were negative, including serum IgG/A/M/E, ANA, Anti-dsDNA, anti-Sm, RNP, SSA/SSB, C3/C4, Anti-HCV, PEP/IFE, ANCA, anti-cardiolipin, RPR, and anti-HIV antibodies.

Course and treatmentOn 6/27, kidney biopsy was

performedBesides, she developed

nosocomial urinary tract infection(U/C: E coli-ESBL strain, post Cefuroxime 6/23-7/2, Ciprofloxacin 7/2~7/7). Suspecting left calf cellulitis, ertapenem was administered since 7/7, and planned to 7/21.

2011/06/27 Kidney BiopsyKidney, needle biopsy ----C/W Proliferative glomerulonephritisH & E sections have 7 glomeruli with

moderate hyperplasia and lobular pattern formation.

The interstitium has mild fibrosis and chronic inflammation. Tubules have casts, arteries are normal.

Immunofluorescence sections have no glomeruli with all stains negative.

DiagnosisProliferative glomerulonephritisUrinary tract infection Suspect left calf cellulitisMajor depressionChronic hepatitis B

Discussion