U05-22801

Clinical History• (16894925): • Generalized decline in health since Feburary 2005 including: Wt

loss/recurrent ‘Pneumonia’/ arthralgia and joint pain. New-A fib. Anemia (80s) and Alb (20). Cr ~140 190 over/ 5 mo. For Xfer to Nephro Nov 27/05 ‘coded’ on route with ?sz vs pulse loss. Intubated. Inotropes ++, PRISMA Nov 29/05 and now anuric

• PmHx: DMN/ HTN/Bicuspid Ao/repaired AAA• Meds: Abx -? Type. No known NSAIDs or toxins• pANCA + x 2 Nov 15 - Norm C3/C4Nov 28 low C3- 0.42, C4- 0.17, Nov

15 Norm ANANov 28 ANA +,• Negative HBV/HCV, Anti-GBM, SPEP/Urine Bence Jones. ASOT.

Intermittent Cryoglobumins and +DAT • Urine: +ptn/+3hgb - +hemegran +WBC/RBC casts• Renal Bx: LM- No significant glomerular changes beyond DMN . +RBC

casts. ++Toxic vacoulization of tubular cells, and ?crystal • TEE – possible vegetation. B/C 4/4 Staph Aureus. CT head – bilateral

hypodensities - ?mets/emboli• R knee aspirate – 8000 WBC – no growth

IMMUNOFLUORESCENCE

• IgG – Mild mesangial staining• IgA - Mild to moderate mesangial staining• IgM – Trivial to mild mesangial staining• C3 - Moderate vascular staining, moderate

mesangial staining• C1q - Negative• Kappa - Mild to moderate mesangial staining• Lambda - Negative• Fibrinogen Mild mesangial staining• Albumin - Negative

IgG

IgA

IgM

C3

C3

Kappa

Fibrin

EM Pending……

Diagnosis

• IgA Nephropathy with focal proliferative glomerulonephritis and unexplained striking vacuolization of tubules with white cell casts and unusual crystalline material seen in glomerular capillaries.

• Rule out some kind of toxic exposure