NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Matko Kalac, MD PGY-2 9/18/2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient is a 35-year-old Hispanic female with six years of dark urine and urinary urgency.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient presented to clinic with intermittently brownish urine and urinary urgency for six years. • Over the past year she developed an erythematous pruritic rash over her arms, legs, face, chest and abdomen.

4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • She also reported swelling of her fingers and lower extremities bilaterally, associated with pain and morning stiffness in her fingers that last several minutes.

5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Pyelonephritis • Gestational diabetes • Past Surgical History: • None • Social History: • No smoking, no alcohol or illicit drug use • Family History: • No history of kidney disease or arthritis • Allergies: • No known drug allergies • Medications: • Ibuprofen as needed

6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Patient was in no apparent distress • Vital Signs: T: 97.1 BP:118/68 HR:77 RR:18 O2 saturation: 98% • Systolic murmur 2/6 best heard over left lower sternal border, 1+ bilateral lower extremity edema • Purpura on lower extremities, abdomen and chest, diffuse scattered erythematous papular eruptions on upper extremities • Remainder of physical exam was normal

7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Complete Blood Count was within normal limits • Basic Metabolic panel was within normal limits • Hepatic Panel: Albumin 3.3 g/dL • Lipid Panel: • - Cholesterol 194 mg/dL • - Triglycerides 378 mg/dL • - HDL 52 mg/dL • - LDL 66 mg/dL

8. Further Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Urinalysis: • Specific gravity 1.012, • Protein > 300mg/dL, • Positive nitrite • WBC 5-10 • RBC 15-30 • Many bacteria • Coarse granular casts 2-5 • Urine random protein 742mg/dL • Random creatinine 106.7 mg/dL • Protein/creatinine ratio 7 • 24h urine protein 8.9g

9. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ANA, anti-dsDNA, rapid HIV negative • Hepatitis B and C negative • Complement levels were normal • A skin biopsy showed urticarial vasculitis.

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Differential diagnosis – nephritic syndrome with nephrotic range proteinuria: • Henoch-Schonlein purpura • Subacute ANCA associated vasculitis • Mixed cryoglobulinemic syndrome • Early ANA negative lupus with membranous and some proliferative features

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Kidney biopsy showed necrotizing and cresentic glomerulonephritis with mesangial IgA and segmental sclerosis consistent with IgA nephropathy • Of 27 and 29 glomeruli on biopsy, 2 were globally sclerotic and an additional 3/27 and 12/29 were segmentally sclerotic • The patient was started on lisinopril and prednisone 1mg/kg daily

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Henoch-Schoenlein purpura with crescentic IgA nephropathy