Casos clnicos en ingls- mdulo Nefrologa

CASE 1

A 27-year-old female presents to your office complaining of dyspnea and

cough productive of blood. She has had fever, arthralgias, and weight loss as
well. She is a smoker. Chest radiograph shows patchy infiltrates. You consider
SARS but find that she hasn't traveled. You consider Goodpasture's syndrome
and take an occupational history. It is of note that she is an office worker
without any exposure to hydrocarbons.

1. Your interpretation of this information is:

A) Smoking is a common precipitant of Goodpasture's syndrome.

B) Goodpasture's syndrome is unlikely because she is not exposed to

hydrocarbons.

C)This presentation is more consistent with SARS and health authorities should
be contacted despite the lack of travel.

D)"Nil" disease with pulmonary involvement is the more likely explanation for
this patient's symptoms.

E) None of the above is true.

The correct answer is A. While the classic description of anti-glomerular

basement antibody disease (Goodpastures syndrome) involves exposure to
hydrocarbons, this is not the most common precipitator of anti-GBM disease.
Anti-GBM disease can occur as a result of any pulmonary injury, and smoking
is the most common precipitant of the disease. For this reason, B is incorrect.
Answer C is possibly correct given the fever and dyspnea. However, SARS is
not associated with hemoptysis. Nil, or minimal change disease, is not
associated with pulmonary findings. Thus, D is effectively ruled out.
CASE 2

2. Since this is the nephrology chapter, you of course want to order a

urinalysis. For some unknown reason, your laboratory staff has forgotten to
stock urine dipsticks and all of the microscopes are broken (seems like a
common occurrence in our hospital!!). However, you are able to get a CBC,
which shows a normal white count with a normal differential.

Given her history and laboratory findings, diagnostic considerations in

this patient include all of the following EXCEPT:

A) Wegener's granulomatosis.

B) Neoplasm.

C) Lupus erythematosus.

D) Churg-Strauss disease.

E) All of the above.

The correct answer is D. While all of the answers can cause hemoptysis with
fever, Churg-Strauss disease is effectively ruled out with a normal CBC since
the diagnosis requires at least 10% eosinophils in the peripheral smear. Churg-
Strauss syndrome is also known as allergic granulomatosis and angiitis. It is
associated with the use of steroids plus leukotriene inhibitors in patients with
asthma as well as with other allergic causes of angiitis, including freebase
cocaine. All of the others are diagnostic possibilities. Note that all of these can
cause a nephritic urine sediment.
CASE 3

3. The next day the laboratory staff finds the dipsticks and the patient is noted
to have an active sediment (protein, white cells, red cell casts, etc.) along with
an elevated creatinine of 2.5 mg/dl. You decide to check an anti-glomerular
basement membrane titer (anti-GBM). This returns positive and you make the
presumptive diagnosis of Goodpasture's syndrome.

The next step in the treatment of this patient is to:

A) Initiate steroids.

B) Initiate dialysis to preserve renal function.

C) Initiate plasmapheresis to remove anti-GBM from the serum.

D) Initiate plasmapheresis, steroids, and cyclophosphamide.

E) Begin watchful waiting since most cases are self-limited.

The correct answer is D. One must start immunosuppressants as well as

plasmapheresis. The other answer choices are incorrect. Answer E is of
particular note. This is not the patient to watch: she already has evidence of
renal failure. Helpful Tip: Most patients with Goodpastures disease (anti-GBM
disease) who have intact renal function in the first year of the disease do well.
This is generally a self-limited disease, although relapses may occur.
CASE 4

You are asked to consult on a patient who is hospitalized by an orthopedic

surgeon. The patient is a 25-year-old female who has a history of osteomyelitis
from an open fracture sustained in a skiing accident. She has recently begun to
spike a fever and have a rapid increase in her creatinine.
Medications: Methicillin, ibuprofen, morphine PDA
Labs: Cr = 3.5mg/dl, BUN = 25 mg/dl
CBC shows mild eosinophilia.

11. All things being equal, what would you expect to find?
A)FENA > 2%, Urine Sodium < 20.

B)FENA < 1%, Urine Sodium < 20.

C)FENA > 2%, Urine sodium > 40.

D)FENA < 1%, Urine sodium > 40.

The correct answer is C. Remember . . .her BUN/Cr < 20, therefore it is likely
not prerenal disease. Thus, the patient likely has intrinsic kidney disease. This
means that the FENa should be > 2% and the urine sodium > 40 mg/dl. The
kidney is not trying to hold on to sodium in an attempt to correct a prerenal
cause of increasing creatinine.

INCORRECT
2. The patients exam shows a diffuse rash and the urine contains
white cell casts. The most likely diagnosis is:

A) Acute tubular necrosis.

B) Interstitial nephritis.

C) Renal infarction.

D) Glomerulonephritis.

E) Nephrotic syndrome.

The correct answer is B. The combination of fever, rash, mild eosinophilia,

exposure to a new drug (methicillin), and white cell casts in the urine
essentially makes the diagnosis of interstitial nephritis. Answer A is incorrect.
The urine in ATN may show the same FENa and urine sodium, but should have
renal tubular cells in the urine and should not be associated with fever or rash.
Answer C, renal infarction, is unlikely in a young patient, and the rest of the
clinical picture does not fit. Answer D, glomerulonephritis, is a possibility (for
example, lupus could cause a rash and fever). However, glomerulonephritis is
associated with red cell casts and not white cell casts. Finally, as you already
learned, nephrotic syndrome presents with a bland urine, and the presence of
white cell casts alone should make you think this is not nephrotic syndrome.
3. How long after drug exposure does interstitial nephritis generally
begin?

A)23 days.

B) 1014 days.

C) Several months.

D) A and B.

E) All of the above.

The correct answer is E. Patients can develop interstitial nephritis anywhere

from 1day to several months after beginning a drug. Rifampin can often cause
interstitial nephritis on day one; interstitial nephritis can begin within 25 days
if there has been a prior exposure to the drug, will typically begin within 1014
days on first exposure to a drug, and may be delayed for months in the case of
NSAID exposure.