USMLE Forums banner

1 - 20 of 21 Posts

·
Registered
Joined
·
21 Posts
Discussion Starter · #1 ·
An 18 year-old college freshman notices difficulty in removing and replacing his shoes at the end of the day and his face appears to be "puffy" and swollen. Over the ensuing two weeks he develops noticeable swelling of his legs all the way up to his thighs. Other than tonsillectomy at age 3, he has never had any medical problems and takes no medications.

On physical examination at the health center, his blood pressure is 118/72, pulse 76, respiration 12, and he is afebrile. Weight is 80 kilograms, an increase of 7 kilograms over his usual weight . He appears well, with no evidence of acute illness. The only finding on physical exam is a 3+ to 4+ pitting edema extending all the way up his legs into the presacral area.

Laboratory evaluation reveals:
-CBC normal
-sodium 140 mmol/L, potassium 3.7 mmol/L, chloride 101 mmol/L, CO2 29 mEq/L
-BUN 17 mg/dL (6 mmol/L) [normal 8-25 mg/dL or 2.5-9 mmol/L]
-creatinine 1 g/dL (88.4 μmol/L) [normal 0.6-1.5 mg/dL or 53-132.6 μmol/L]
-urinalysis: pH 5, specific gravity 1.012, 4+ protein with no blood or glucose
-urine microscopy: occasional oval fat bodies and rare hyaline casts

Additional labs:
-serum albumin 1.1 g/dL (11 g/L) [normal 3-5 g/dL or 35-50 g/L]
-calcium 7.9 mg/dL (2 mmol/L) [normal 8.5-10.3 mg/dL or 2.1-2.6 mmol/L]
-phosphorus 3.3 mg/dL (1.07 mmol/L) [normal 3-4.5 mg/dL or 0.97-1.45 mmol/L]
-total cholesterol 393 (10.16 mmol/L) [normal < 200 mg/dL or < 5.2 mmol/L]
-24-hour urine: protein 13.2 g, creatinine 2.248 g
-Complement levels: normal
-Serology: ANA, HBV, HCV negative

What is your preliminary diagnosis?

A. Nephritic syndrome
B. Nephrotic syndrome
C. Acute kidney injury
D. A and C
E. B and C

?????????????
 

·
Registered
Joined
·
405 Posts
B. Nephrotic syndrome

OR

E. B and C

I don't know the exact time criteria for the kidney injury to be called Acute.

It surely seems to be Nephrotic Syndrome though.
 

·
Registered
Joined
·
373 Posts
B. Nephrotic syndrome
 

·
Registered
Joined
·
405 Posts
In this question i feel the options actually direct you to the correct information, when i was reading the question i was thinking more on Endocrinological terms but the options proved me wrong. Does anyone else feel like that with big questions?
 

·
Registered
Joined
·
741 Posts

·
Registered
Joined
·
405 Posts
Thanks a lot for the post Raheed. I really need to inculcate the discipline of reading through all the options instead of just choosing the first one that seems feasible to me without looking at the rest of them.
 

·
Registered
Joined
·
17 Posts
I think the answer seems obvious. Nephrotic fits all the criteria (hypoalbuminemia, hypercholesterolemia, no signs of nephritis). Nothing is suggestive of AKI (BUN, Cr within normal range). Answer B. Since I cannot find a way to deviate in this one, lets discuss wat could be the cause of nephrosis in an 18yr old.
 

·
Registered
Joined
·
17 Posts
FSGS
In favour of - "Possible substance abuse" (Guess I'll leave someone in this thread to find that), HIV
Against - Hypoalbuminemia (it is non selective proteinuria in FSGS), no haematuria, no hypertension

Diffuse membranous GP
SLE, Captopril, gold, HBV, malignancy - all unlikely in this kid

MPGN
HBV, HCV, Ht, possible nephritic, low complements - ruled ou

MCD - Most likely
 

·
Registered
Joined
·
625 Posts
FSGS
In favour of - "Possible substance abuse" (Guess I'll leave someone in this thread to find that), HIV
Against - Hypoalbuminemia (it is non selective proteinuria in FSGS), no haematuria, no hypertension

Diffuse membranous GP
SLE, Captopril, gold, HBV, malignancy - all unlikely in this kid

MPGN
HBV, HCV, Ht, possible nephritic, low complements - ruled ou

MCD - Most likely
Yeah MCD was my analysis too, but I thought that was mostly young girls. Still, it fits best with these symptoms. Nephrotic syndrome, B.
 

·
Registered
Joined
·
17 Posts
Just to discuss more.. Lets say if the urinalaysis part was not mentioned in the question and the patient also has signs of difficulty in vision, what other possibility can be thought of? (All other lab values stand as they are)
 

·
Registered
Joined
·
21 Posts
Discussion Starter · #12 ·
Just to discuss more.. Lets say if the urinalaysis part was not mentioned in the question and the patient also has signs of difficulty in vision, what other possibility can be thought of? (All other lab values stand as they are)
This is exactly what we need more of, DISCUSSION!
 

·
Registered
Joined
·
1 Posts
While reading it at first I thought it to be Acromegaly/Myxoedema..
But after the Lab investigation part..I think it's B..
But how can we exclude option E?
pls help
 

·
Registered
Joined
·
17 Posts
AKI is characterised by elevated BUN Cr. Since they are normal it is not AKI. (I just mentioned that in my prev post)
 

·
Registered
Joined
·
55 Posts
B...............would be the answer.

Definitely Nephrotic syndrome......................B.:)
 

·
Registered
Joined
·
21 Posts
Discussion Starter · #18 ·
ANSWER+EXPLANATION (From MedicalExams.com)

When will the answer be posted by the question guy? :p
Right now! haha. Great discussion everyone, let's see how you all did!

The correct answer is Choice B.

This young man has nephrotic syndrome, which is characterised by:

-heavy proteinuria (> 3.5 g / 1.73m2 / day)
-hypoalbuminemia due to urinary protein losses
-edema due to salt and water retention and reduced oncotic pressure
-hyperlipidemia
-lipiduria

There are a number of pointers to his not having nephritic syndrome:

-his urinary protein losses are too high
-he does not have acute kidney injury
-he does not have hematuria
-he has severe hyperlipidemia which is not a component of nephritic syndrome

Nephrotic syndrome results from glomerular damage which leads to an increase in glomerular permeability. This causes proteins
and other large substances that would normally not be filtered to pass into the urine. Although albumin is easily measured and
most talked about, you should not forget that other proteins including immunoglobulin and complement proteins are often being
lost as well.

Nephrotic syndrome results from primary or secondary glomerular damage, primary causes being diagnoses of exclusion when no
secondary casue can be found. Pathologically the glomerular manifestations include:

-focal segmental glomerulosclerosis (FSGS) in up to 35% of cases
-membranous nephropathy in up to 33% of cases
-minimal change disease in up to 15% of cases
-membranoproliferative glomerulonephritis in up to 14% of cases

Secondary causes include:

-Diabetes mellitus
-Infections such as hepatitis B & C, HIV, mycoplasma
-Sjogren's syndrome
-SLE
-Sarcoid
-Malignancy including lymphoma and myeloma
-Obesity
-Drugs such as gold/penicilliamine/NSAIDs/antibiotics/tamoxifen

Patients should be referred to a nephrologist for investigation and likely renal biopsy. While this is pending, management often
involves salt and fluid restriction, diuretics for edema, statins for hyperlipidemia, and angiotensin ceonverting enzyme inhibitors in
an attempt to reduce protein spillage.

Nephrotic syndrome patients are at risk of DVT (1.5%) or renal vein thrombosis (0.5%), as well as infection (loss of
immunoglobulins and complement).

Suggested References
Hull RP, Goldsmith DJ. Nephrotic syndrome in adults. BMJ 2008; 336: 1185-1189.
 
1 - 20 of 21 Posts
Top