pathology conference presented by f1 潘恆之 commented by dr. 薛綏 2011/12/28

Pathology ConferencePathology Conference

Presented by F1 潘恆之Commented by Dr. 薛綏2011/12/28

CASE 1: 8866550CASE 1: 8866550CASE 2: 3751673 CASE 2: 3751673 CASE 3: 21542459CASE 3: 21542459

CASE 1: 8866550CASE 1: 8866550

General DataGeneral DataAge: 32-year-oldGender: FemaleEthnic: TaiwaneseMarital status: MarriedOccupation: Service industryAdmission date: 2011/12/03

Chief ComplaintChief ComplaintProgressive bilateral lower legs

swelling for 1 month

Present IllnessPresent Illness This 32-year-old woman has history of

diabetes mellitus and dyslipidemia. She had experienced progressive

bilateral legs swelling in recent one month.

She denied fever, dizziness, nausea, vomiting, chest tightness, chest pain, exertional dyspnea, orthopnea, easy fatigue, foamy urine, diarrhea, or dysuria recently.

Present IllnessPresent Illness

Due to above symptoms, she visited our Nephro OPD, where the urinalysis revealed heavy proteinuria.

Under the impression of nephrotic syndrome, she was admitted for evaluation via kidney biopsy and further management.

Past historyPast history1. Type 1 diabetes mellitus,

diagnosed at the age of 25 years, under insulin control, HbA1c 15.1(2011/11/10)

2. Dyslipidemia

Personal HistoryPersonal HistoryNo known allergy to drug or foodShe denies smoking, alcohol, or

betel nut chewing.

Medication HistoryMedication History 2011/11/18 Endocrine OPD

◦Novomix --------------------- 38U QD

2011/11/18 Nephro OPD◦Furosemide (40mg) --------- 0.5# QD◦Atorvastatin (10mg)----------- 1# QD

2011/12/02 Nephro OPD◦Bumetanide (1mg) ------------- 2# BID◦Atorvastatin (10mg)----------- 1# QD◦Losartan pottasium (50mg)----1# QD

Family historyFamily history

Mother: diabetes mellitusBrother: type 1 diabetes mellitus

Physical ExaminationPhysical ExaminationVital signs: BT:36.2/℃ HR:95/min RR:16/min

BP:109/73mmHgGeneral appearance: fair lookingConsciousness: alert and oriented, E4V5M6HEENT: conjunctiva: not pale, sclera: anictericChest: symmetrical expansion, bilateral clear

breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat normal bowel sounds, no local tendernessExtremity: freely movable, bilateral lower legs pitting edema

Hemogram

unit 12/05 12/23

WBC /uL 10000

RBC million/uL

3.15

Hemoglobin

g/dL 8.8 9.7

Hematocrit % 26.7 29.4

MCV fL 84.8

MCH pg/cell 27.9

MCHC g/dL 33.0

RDW % 14.8

Platelets 1000/uL 290

PT sec 10.0/10.5

INR 1.0

aPTT sec 27.2/28.5

Laboratory FindingsLaboratory Findings

Biochemistry 11/10(OPD)

11/18(OPD)

12/02 12/23

BUN 23.5 22.1

Cr 0.44 0.39 0.53 0.62

AST

ALT 8 15 14

Sugar (AC) 166 412

HbA1C 15.1 11.7

Na 138

K 4.0 4.7

Cortisol 5.2

TSH 1.144

Albumin 3.12 3.00

Uric acid 5.5

Total cholesterol

264 235

Triglyceride 61 93

LDL 163 140

HDL 87

Urinalysis 11/08 12/06 12/23

Color Yellow Yellow Yellow

Turbidity Cloudy Clear Clear

Sp. Gravity

1.027 1.011 1.024

pH 5.5 6.0 6.5

Leukocyte 2+ Negative

Negative

Nitrite 1+ Negative

Negative

Protein 3+(300)

2+(100)

3+(300)

Glucose 3+(1000)

3+(1000)

3+(1000)

Ketone Negative

Negative

Negative

Urobilinogen

1.0 0.1 0.1

Bilirubin Negative

Negative

Negative

Blood 3+ 2+ 3+

Bacteria Positive

Positive

Positive

RBC 28 28 99

WBC 4 3 4

Epi. 26 3 29

11/18

T-protein(U)

348.4 mg/dL

Creatinine(U)

193.67 mg/dL

Serology 12/02

IgA 304

IgE 41.50

C3 121.0

C4 32.10

ANA Negative

HBs Ag Nonreactive

Anti-HCV Nonreactive

2011/12/06 Kidneys 2011/12/06 Kidneys echoecho

2011/12/06 Kidneys 2011/12/06 Kidneys echoecho Left / Right : 12.7cm / 12.2cm

The both kidneys are large in size with regular contour. The cortical echogenicity is increased with adequate thickness. The pelvicalyceal systems are not dilated. There is a cystic lesion (2.1 x 1.9 cm) with round hyperechoic nodule over the low pole of left kidney. No renal stone is noted.

Impression: Left renal cystic lesion, suspect hematoma due to biopsy

2011/12/05 Kidney 2011/12/05 Kidney BiopsyBiopsyKidney, left, needle biopsy ---- Diabetic nodular glomerulosclerosis

H & E sections show 9 glomeruli. 2 are obesolete. 2 have Kimmelstiel-Wilson type nodules and glomerulosclerosis. Others also have mild to moderate slcerosis. The tubules have mild atrophy and protein casts. The interstitium shows mild fibrosis and minimal chronic inflammation. The arterioles have mild atherosclerosis.

The Immunofluorescence sections show 9 glomeruli with irregular staining of IgA & C3 (1+). The efferent arteroles have focal staining of C3(2+)

Urinalysis 12/06

Color Yellow

Turbidity Clear

Sp. Gravity 1.011

pH 6.0

Leukocyte Negative

Nitrite Negative

Protein 2+(100)

Glucose 3+(1000)

Ketone Negative

Urobilinogen 0.1

Blood 2+

Bacteria Positive

RBC 28

WBC 3

Epi. 3

Pregnancy test

Positive

2011/12/05 Kidney 2011/12/05 Kidney BiopsyBiopsy

Immunohistochemical study (IHC2011-4552):

Result: The renal tubules are 3+ with β-HCG , αFP(polyclonal) is negative.

DiagnosisDiagnosisDiabetes mellitus, type 1,

complicated with diabetic nephropathy

PregnancyNormocytic anemia

DiscussionDiscussion

12/23

Creatinine(U)

30.61 mg/dL

Alb/Cre ratio

4337.1 mg/g

MicroALB(U)

1327.6 mg/L

12/23

AFP 1.3

B-HCG 4760

CASE II:3751673CASE II:3751673

General DataGeneral DataAge: 34-year-oldGender: FemaleEthnic: TaiwaneseMarital status: SingleOccupation: Electronics industryAdmission date: 2011/03/28

Chief ComplaintChief ComplaintProgressive generalized swelling

for 10 days

Present IllnessPresent Illness This 34-year-old denied any systemic

diseases such as diabetes mellitus or hypertension.

She experienced progressive generalized swelling for 10 days. The swelling initially developed from lower legs then gradually progressed to the face. Decreased urine amount and body weight gain of 5 Kg in recent 3 months were also mentioned. Besides, she had suffered from foamy urine since 2009/11.

She denied fever, dizziness, nausea, vomiting, chest tightness, abdominal pain, exertional dyspnea, orthopnea, easy fatigue, diarrhea, or dysuria.

She denied HBV/HCV infection, upper respiratory infection nor any medication use such as NSAID, steroid or antibiotics before this episode.

She ever went to General medicine OPD where diuretic was prescribed. However, the swelling still persisted so she came to ER for help.

Past historyPast historyDenied diabetes mellitus,

hypertension or other systemic diseases history

Personal HistoryPersonal HistoryAllergy to an unknown pain-killer She denied smoking, alcohol, or

betel nut chewing.

Medication HistoryMedication History

2010/03/23 General medicine OPD

◦Amiloride 5mg ---------- 1# QD

+ Hydrochlorothiazide 50mg


No family history of diabetes mellitus, hypertension, malignancy, chronic kidney disease or other systemic diseases.

Physical ExaminationPhysical ExaminationBH: 158cm BW: 126kg BMI: 50.4Vital signs: BT:36.6/℃ HR:97/min

RR:20/min BP:157/101mmHgGeneral appearance: fair lookingConsciousness: alert and oriented,

E4V5M6HEENT: conjunctiva: not pale, sclera:

anictericChest: symmetrical expansion,

bilateral clear breathing sounds.Heart: regular heart beats, no

murmurs.

Abdomen: soft and flat normal bowel sounds,

no local tendernessBack: No knocking pain over bilateral

flank area Extremity: freely movable, bilateral lower legs grade I pitting

edemaSkin: no rash, no petechiae nor

ecchymosis fair skin turgor

Hemogram

unit 03/25 03/27 03/31 04/16

WBC /uL 23600

RBC million/uL

5.93

Hemoglobin

g/dL 17.4 14.0 15.7

Hematocrit

% 50.2 41.5 48.4

MCV fL 84.7

MCH pg/cell 29.3

RDW % 12.5

Platelets 1000/uL 349

Segment % 85

Lymphocyte

% 11

Monocyte % 3

Eosinophil % 1

PT sec 10.2

INR 0.9

APTT sec 29.5


Biochemistry

03/23(OPD)

03/25 03/27

BUN 9.8

Creatinine 0.63 0.90

ALT 19 12

Bilirubin (T) 0.2

Alk-P 50

Na/K/Cl 131/4.2/102

Ca 7.6

CO2 24.1

Albumin 2.27 2.11

Total protein 5.4

Sugar 114

Uric acid 8.8 10.6

Free-T4 0.97

TSH 3.409

Cortisol 2.0

Total cholesterol

456

Triglyceride 322

03/31

T-protein(U)

1144.6 mg/dL

Creatinine(U)

67.74 mg/dL

24hr U/O 2900 ml

24hr TP(U) 33.2 g

24hr Ccr 151.6 ml/min

Urinalysis 03/23 03/25 03/30


Turbidity Cloudy Cloudy Clear

Sp. Gravity 1.023 1.037 1.025

pH 5.5 7.0 7.0

Leukocyte Negative

Trace(15)

Negative

Nitrite Negative

Negative

Negative

Protein 4+(1000)

4+(1000)

4+(1000)

Glucose Negative

Negative

Negative

Ketone Negative

Negative

Negative

Blood 2+(80) 1+(25) 1+(25)

Hyaline Cast

4

Granular Cast

3

Bacteria Positive

Positive

RBC 16 8 20

WBC 22 10 1

Epi. 32 4 21

Serology 03/27

RPR Negative

ASLO 65.40

HBsAg Negative

IgG 552

IgA 237

IgM 175

IgE 1090

C3 215

C4 42.2

ANA 1:40(Nucleolar)

HBs Ag Nonreactive

Anti-HCV Nonreactive

2010/03/27 CXR2010/03/27 CXR

2010/03/27 KUB2010/03/27 KUB

2010/03/26 Kidneys echo2010/03/26 Kidneys echo

Left / Right : 12.5 cm / 11.4 cm The left kidney is large in size and the right kidney is normal in size and both kidneys have slightly irregular outline. The cortical echogenicity and thickness are normal. There is mild separation in the central sinus of both kidneys. No evidence of renal stone, mass, or cyst exists.

Impression: Bilateral pelviectasis Left large kidney Parenchymal renal disease


2010/03/30 Kidney 2010/03/30 Kidney BiopsyBiopsyKidney, needle biopsy

---- Pauci-immune glomerulonephritis ---- Focal interstitial nephritis

H & E sections show 9 glomeruli. 4 of them have mild hyperplasia with capsular adhesions and 1 has a small cecllular cresent. Fibrosis of bowman’s capsule is also seen focally. The changes suggest “cellular variant” of FSGS. The interstitium has focal fibrosis with moderate chronic inflammation and some eosinophils. The tubules have focal atrophy in sclerotic area. The arteries are unremarkable.

The Immunofluorescence sections have 3 glomeruli with irregular 1+ IgM

Electron microscopic study (EM2010-54) :

1 glomerulus on electron microscopic study shows moderate sclerosis with fusion of foot processes. No immune deposits are seen.

DiagnosisDiagnosisNephrotic syndrome due to focal

segmental glomerulosclerosisHypertension Obesity

CASE III: 21542459 CASE III: 21542459

General DataGeneral DataAge: 25-year-oldGender: MaleEthnic: TaiwaneseOccupation: Office clerkAdmission date: 2011/11/08

Chief ComplaintChief ComplaintProgressive headache for one

week.

Present illnessPresent illness

This 25 years old man with history of hypertension and IgA nephropathy was admitted via ED due to headache with nausea and vomiting for a week.

He experienced progressive headache since one week before admission. The discomfort was getting severe at night and always was relieved by anti-hypertensives. Abdominal discomfort with heartburn sensation, nausea, vomited with foot content after getting meal for several hours were also mentioned.

He denied vertigo, aura before headache, eye pain, nasal discharge, facial pain, dysphagia, bowel habit change, tarry stool, oliguria, urine output decrease or lower legs swelling.

Unfortuantely, fever, chills, dysuria, weak stream and void difficulty developed since 3 days before admission

Due to above, he came to our ER for help.

Past HistoryPast HistoryIgA nephropathy Haas Class 4,

diagnosed for 5 yearsChronic kidney diseaseSecondary hypertension under

medical control for 4 years, SBP around 120~130mmHg at home

Personal HistoryPersonal HistoryNo known allergy to drug or foodSmoking: 0.5PPD~1PPD, quit for

5 yearsAlcohol: social drinking, quit for 5

yearsBetel nut chewing: deniedNo recent travel historyNo contact history

Medication HistoryMedication History 2011/10/24 Nephro OPD

◦Cyclosporin (25mg) --------------- 1# QD◦Propranolol (10mg) ---------------- 1# TID◦Co-Diovan (Valsartan 160mg ---- 1# QD + HCTZ 12.5mg )◦ A. M. D ------------------------------- 2# QID◦Dimethicone (36.7mg) ------------- 2# QID

2011/10/31 Nephro OPD Kept above medication and added

on :◦Labetalol (200mg) ------------------- 1# BID◦Metoclopramide (5mg)------------- 1# TID


Grandmother: stroke, hypertension

No family history of diabetes mellitus, malignancy, chronic kidney disease or other systemic diseases.

Physical ExaminationPhysical Examination

Vital signs: BT:37.7/℃ HR:105/min RR:20/min BP:162/104 mmHg

General appearance: acute-ill lookingConsciousness: alert, E4V5M6HEENT: conjunctiva: not pale,

sclera:anictericNeck: supple, no jugular vein

engorgement, no lymphadenopathy Chest: symmetrical expansion, bilateral clear breathing sounds.Heart: regular heart beats, no murmurs.

Abdomen: soft and flat, epigastria tenderness

normoactive bowel soundsBack: no knocking pain over bilateral flank

area Extremity: freely movable, no pitting edemaSkin: no skin rash, no petechiae nor

ecchymosisNeurologic exam: no Kernig's nor

Brudzinski's sign

Physical ExaminationPhysical Examination

Hemogram

unit 10/31 11/05 11/17 11/21

WBC /uL 6700 6100 5700

RBC million/uL

3.86 3.52 3.31

Hemoglobin

g/dL 11.8 11.4 10.1 9.4

Hematocrit

% 35.4 32.5 29.0 27.5

MCV fL 84.1 82.4 83.1

MCH pg/cell 29.5 28.7 28.4

RDW % 13.7 13.1 13.5

Platelets 1000/uL 101 146 127

Segment % 87.5 58.0 57.6

Lymphocyte

% 7.1 33.9 32.6

Monocyte % 4.8 6.1 7.3

Eosinophil % 0.6 1.8 2.3

PT sec 11.3

INR 1.1

APTT sec 30.4 28.9


Biochemistry 10/31 11/05 11/17 11/21

BUN 109.8 102.8 75.4 85.7

Cr 6.80 6.99 6.64 7.15

AST

ALT 19

Bilirubin 0.2

Alk-P 59

Na 138 140 138

K 4.4 4.9 4.7

Ca 8.5 8.1

P 7.4 4.7

CO2 19.8 17.8

CRP 9.47 1.44 1.01

Albumin 4.11

Troponin I 0.012

Sugar 153

Urinalysis 10/31 11/05 11/18


Turbidity Clear Clear Clear

Sp. Gravity

1.010 1.010 1.009

pH 5.5 5.5 6.0

Leukocyte Negative

Negative

Negative

Nitrite Negative

Negative

Negative

Protein 2+(100)

2+(100)

3+(300)

Glucose Negative

Trace Trace

Ketone Negative

Negative

Negative

Urobilinogen

0.1 0.1 0.1

Bilirubin Negative

Negative

Negative

Blood 2+ 3+ 2+

RBC 12 127 23

WBC 1 2 2

Epi. 0 0 0

11/10

T-protein(U)

101.1 mg/dL

Creatinine(U)

38.89 mg/dL

24hr U/O 1800 ml

24hr TP(U) 1.819 g


Serology 10/31

IgA 420

C4 19.10

ANA Negative

2011/11/052011/11/05 CXR CXR

2011/10/31 Kidneys Echo2011/10/31 Kidneys Echo

Left / Right Kidney Length: 10.3cm / 10.3cm

The both kidneys are normal in size with mildly irregular contour. The cortical echogenicity is increased with adequate thickness.

2011/10/31 Kidney Echo2011/10/31 Kidney Echo

Impression: 1.Right renal cyst 2.Parenchymal renal disease with

chronic change

The pelvicalyceal systems are not dilated. There is an echo-free lesion (0.4cm) with posterior wall enhancement over the middle portion of right kidney. No renal mass, or stone is noted.

2011/11/06 Brain CT2011/11/06 Brain CT

2011/11/14 2011/11/14 PanendoscopyPanendoscopy

2011/11/18 Kidney 2011/11/18 Kidney BiopsyBiopsy

Kidney, needle biopsy ---- IgA nephropathy, class V ---- tubulointerstitial nephritis

H & E sections showe 11 glomeruli. Two of them are obsolete. Others have hyperplasia and severe diffuse sclerosis. Two have focal fibrous crescent. The tubules show severe atrophy and have protein casts and focal RBC casts. The interstitium have severe chronic inflammation and severe fibrosis. The arterioles have mild to moderate atherosclerosis.

2011/11/18 Kidney 2011/11/18 Kidney BiopsyBiopsyThe immunoflurorescence section

shows 5 glomeruli with severe slcerosis and staining of IgA (3-4+), IgM(1+) and C3(3+) in mesangial and focal loop pattern. Focal tubules have C3 (2+)

DiagnosisDiagnosisImmunoglobumin A nephropathy, class VTubulointerstitial nephritisChronic kidney disease, stage V,

Immunoglobumin A nephropathy related Normocytic anemia, suspect chronic

kidney disease relatedHypertension, suspect chronic kidney

disease relatedUpper respiratory airway infection Gastrointerstinal bleeding, favor

hemorrhagic gastritis over cardia related

CASE IV: 21395164CASE IV: 21395164

General DataGeneral DataAge: 43-year-oldGender: MaleEthnic: TaiwaneseMarital status: MarriedOccupation: Restaurant business BH:166.6cm, BW:85kg, BMI:30.6 Admission date: 2011/11/03

Chief ComplaintChief ComplaintProgressive bilateral lower legs

swelling for 1+ year

Present IllnessPresent Illness This 43 year-old male has history of

hypertension, diabetic mellitus, chronic kidney disease, and coronary artery disease.

He had experienced bilateral lower limb swelling and numbness for 1+ year. Mild exertional dyspnea recently was also mentioned.

He denied chest pain, dizziness, fever, dysuria, nausea, vomiting, orthopnea, easy fatigue, bowel habit change, tarry stool or bloody stool.

Due to the persisting bilateral lower limb swelling, he was admitted for further survey.

Past historyPast historyHypertension for 10+ yrs, under

medical controlDiabetes mellitus for 10+ yrs,

complicated with triopathy, under medical control

Vitreous hemorrhageAnteroseptal myocardial infarction in

2011/10

Personal HistoryPersonal HistoryNo known allergy to drug or food Alcohol : deniedSmoking : 2 PPD for 20+ yrsBetel nut: occasionally

Medication HistoryMedication History2011/09/26 Ophthalmologist OPD

◦Ketorolac oph. solution 0.5% ---------- 1GT BID◦Tears(artificial) 15ml/bot -------------- 1GT QID

2011/10/07 Nephrologist OPD◦Aliskiren 150mg/F.C --------------------- 1# QD◦Bumetanide 1mg/tab --------------------- 2# QD◦Benzyl hydrochlorothiazide 4mg/tab -- 1# BID◦Acarbose 50mg/tab ----------------------- 1# BID◦Pentoxifylline S.R 400mg/s.c tab -------- 1# QD


Mother: hypertensionFather: unknown systemic

disease

Physical ExaminationPhysical ExaminationVital signs: BT:36.5/℃ HR:90/min RR:18/min

BP:186/120mmHgGeneral appearance: fair lookingConsciousness: alert and oriented, E4V5M6HEENT: conjunctiva: not pale, sclera: anictericChest: symmetrical expansion, bilateral clear

breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat normal bowel sounds, no local tendernessExtremity: freely movable, bilateral lower legs grade I pitting

edema

Hemogram

unit 10/31 11/05 11/17 11/21

WBC /uL 6700 6100 5700

RBC million/uL

3.86 3.52 3.31

Hemoglobin

g/dL 11.8 11.4 10.1 9.4

Hematocrit

% 35.4 32.5 29.0 27.5

MCV fL 84.1 82.4 83.1

MCH pg/cell 29.5 28.7 28.4

RDW % 13.7 13.1 13.5

Platelets 1000/uL 101 146 127

Segment % 87.5 58.0 57.6

Lymphocyte

% 7.1 33.9 32.6

Monocyte % 4.8 6.1 7.3

Eosinophil % 0.6 1.8 2.3

PT sec 11.3

INR 1.1

APTT sec 30.4 28.9


Biochemistry 10/31 11/05 11/17 11/21

BUN 109.8 102.8 75.4 85.7

Cr 6.80 6.99 6.64 7.15

AST

ALT 19

Bilirubin 0.2

Alk-P 59

Na 138 140 138

K 4.4 4.9 4.7

Ca 8.5 8.1

P 7.4 4.7

CO2 19.8 17.8

CRP 9.47 1.44 1.01

Albumin 4.11

Troponin I 0.012

Sugar 153

Urinalysis 10/31 11/05 11/18


Turbidity Clear Clear Clear

Sp. Gravity

1.010 1.010 1.009

pH 5.5 5.5 6.0

Leukocyte Negative

Negative

Negative

Nitrite Negative

Negative

Negative

Protein 2+(100)

2+(100)

3+(300)

Glucose Negative

Trace Trace

Ketone Negative

Negative

Negative

Urobilinogen

0.1 0.1 0.1

Bilirubin Negative

Negative

Negative

Blood 2+ 3+ 2+

RBC 12 127 23

WBC 1 2 2

Epi. 0 0 0

11/10

T-protein(U)

101.1 mg/dL

Creatinine(U)

38.89 mg/dL

24hr U/O 1800 ml

24hr TP(U) 1.819 g


Serology 12/02

IgA 420

C4 19.10

ANA Negative

2011/11/04 CXR2011/11/04 CXR

Left / Right : 10.2 cm / 10.0 cm Both kidneys are normal in size with mildly irregular contour. The cortical echogenicity is increased with adequate thickness. The pelvocalyceal systems are not dilated. No evidence of stone or cyst

Impression: Parenchymal renal disease


Cardiac echoCardiac echo

2011/11/09 Thallium 2011/11/09 Thallium scanscan

2011/11/07 Kidney 2011/11/07 Kidney BiopsyBiopsyKidney, left, needle biopsy

---- Diabetic nodular glomerulosclerosis

H & E sections show 27 glomeruli. 15 of them are obesolete. 4 have Kimmelstiel Wilson nodules. Others have global slcerosis and macrophages infiltrates. The tubules have moderate to marked atrophy and protein casts. The interstitium shows moderate to marked fibrosis. The arterioles have marked atherosclerosis. The Immunofluorescence sections show 8 glomeruli with slcerosis and irregular staining of IgM (1+) & C3 (2+) and C1Q (1+)

Electron microscopic study (EM2011-161):

One glomerlus on electron microscopic study shows global sclerosis with oliterated loops. Hyaline globules are present.

DiagnosisDiagnosisDiabetes mellitus, complicated

with diabetic nephropathy, neuropathy and retinopathy

Chronic kidney disease due to diabetic nephropathy

Hypertension

pathology conference presented by f1 潘恆之 commented by dr. 薛綏 2011/12/28

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