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OS 214 [A]: Digestive and Excretory

2. OS 214 [A]: Digestive and Excretory. Lab 01.3: Lab Skills Session – Case 2. March 12, 2014. Dr. Sonia L. Chicano. NIKA, ADA, GUDO. History and PE. 68/F, known diabetic, presenting with a 5-mo history of hyperpigmented patches on both LE

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OS 214 [A]: Digestive and Excretory

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  1. 2 OS 214 [A]: Digestive and Excretory Lab 01.3: Lab Skills Session – Case 2 March 12, 2014 Dr. Sonia L. Chicano NIKA, ADA, GUDO

  2. History and PE • 68/F, known diabetic, presenting with a 5-mo history of hyperpigmented patches on both LE • She later developed grade 3 bipedal edema, frothy urine, occasional tea-colored urine, and right flank pain. Lab 01.3: Lab Skills Session – Case 2 NIKA, ADA, GUDO

  3. Work-Up • Work-ups revealed consistent hematuria on urinalysis but with (-) dysmorphic RBCs. • Proteinuria was in the nephrotic range, and serum creatinine was 188. • She was started on enalapril and losartan for proteinuria, and she was admitted for kidney biopsy. • ANA (+), normal C3 Lab 01.3: Lab Skills Session – Case 2 NIKA, ADA, GUDO

  4. No mesangial and endothelial proliferation

  5. Silver stain* Segmental sclerosis (-) Mesangial and endothelial proliferation Thin and delicate capillary loops (normal)

  6. Silver stain Segmental sclerosis

  7. What’s the pattern? • For case 2: 27 glomeruli • 10 global sclerosis • 1 segmental sclerosis • 1 out of 27  Focal segmental glomerulosclerosis (FSGS) Lab 01.3: Lab Skills Session – Case 2 NIKA, ADA, GUDO

  8. Global sclerosis

  9. Collagen deposition in Bowman’s space, not crescent* Tubular atrophy

  10. Inflammatory interstitial infiltrates Colloid casts* Normal tubules

  11. H&E Inflammatory interstitial infiltrates Arteriole Colloid cast

  12. Calcification* inside a tubule

  13. Global sclerosis (2) Colloid casts Tubular atrophy

  14. Tubular atrophy Arterioles Colloid cast

  15. Normal tubules

  16. Masson Trichome Stain Fibrosis (blue green)

  17. 1+ 1+ trace Trace-1+

  18. 1 – Mesangial cells 2 – Endothelial cell* 3 – Capillary loops 4 – Parietal epithelial cell 5 – Bowman’s capsule – Effaced foot processes 1 3 1 2 3 4 5

  19. Capillary loop

  20. Effaced foot processes Preserved endothelial fenestrations No deposits in GBM

  21. Effaced foot processes Preserved endothelial fenestrations No deposits in GBM

  22. Effaced foot processes Effaced foot processes

  23. 1 2 3 No mesangial deposits 1 – Nuclei of mesangial cells 2 – Cytoplasm of mesangial cells 3 – Mesangial matrix 1 2

  24. Summary of Findings • LM: FSGS • IF: None • EM: Foot process effacement Lab 01.3: Lab Skills Session – Case 2 NIKA, ADA, GUDO

  25. Diagnosis • FSGS with 76% global GS (31/41 glomeruli) and 15% segmental GS (4/41 glomeruli) • Moderate interstitial fibrosis and tubular atrophy • R/O: 2º FSGS Lab 01.3: Lab Skills Session – Case 2 NIKA, ADA, GUDO

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