LSU INTERNAL MEDICINE CASE CONFERENCE

Silsbee Kemp MDInternal medicine HO IIIJuly 17, 2012

Chief Complaint

“I feel tired and my legs are swollen.”

History of Present Illness

38 year-old man with no previous significant past medical history was in his usual state of health until two months ago when he began experiencing progressively worsening fatigue and decreased exercise tolerance Denies chest pain Denies SOB or DOE Denies PND

HPI

1 month ago, the patient was seen at an Urgent Care clinic complaining of a sore throat Denies respiratory symptoms Admits to subjective fevers Per patient, positive “rapid Strep test” Prescribed amoxicillin

Only completed 3 days

HPI

Soon after his Urgent Care clinic visit, the patient began experiencing progressively worsening lower extremity edema

1 week prior to admission, the patient presented to an outside facility for evaluation of this edema Diagnosed with renal failure Sent home with prescription for

furosemide

HPI

Since that time, the patient has not received any relief of his symptoms Difficulty standing on his feet for any

significant duration at work (+) nocturnal frequency,

Denies dysuria, urgency, polyuria, gross hematuria, decreased urine output

Denies excessive NSAID use Denies nausea, vomiting, diarrhea,

decreased oral intake

History continued…

PMHx: Denies PSHx: Denies Home Medications: Denies Allergies: NKDA FHx:

Mom with DM II Father unknown

History continued…

Social Hx: Lives with wife and children in Metairie,

LA 2 children ages 5 and 9 Denies tobacco, ETOH, IVDA or illicit

drugs Denies recent travel

Health Maintenance: Up to date on Tetanus only No PCP

Additional ROS:

Endorses : Generalized fatigue Weight gain

Denies : Lightheadedness,

Dizziness Headaches Blurry vision Abdominal pain Changes in bowel

habits Rashes

Vital signs

At initial presentation to UH: Temp 98.6° F BP 155/88 mmHg HR 61/min RR 12/min BMI 51; Ht 5’2 Weight 283lbs

Physical Exam

General: Alert & oriented, NAD HEENT: NC/AT, EOMI, PERRLA, Sclera

nonicteric, oropharynx clear with no exudates

Neck: FROM; No cervical LAD appreciated

CVS: RRR, No murmurs/S3/S4, JVP 12 Chest: CTA bilaterally, No crackles

/wheezes/rhonchi

Physical Exam

Abdomen: Nondistended, normoactive bowel sounds; soft, nontender, No organomegaly or masses appreciated

Ext: Bilateral pitting edema extending to upper thigh/lower back;2+ peripheral pulses

Skin: No rashes Neuro:

Cranial nerves II-XII intact Motor strength 5/5 Reflexes 2+ B/L upper and lower extremities

Labs:

WBC 6.4 Hg/Hct 13.7/40.0 Platelets 236 MCV 83 RDW 14.6 N52 % L 27 % M16 % E 6 % B 0 %

Na 142 K 4.8 Cl 108 CO2 27 BUN 53 (7-25) Cr 7.10 (0.7-1.4) Glucose 92 Ca 8.2 Phos 6.2 GFR 11 (>60)

Labs continued…

Total protein 6.1 Albumin 2.4 (3.4-

5.0) Bilirubin 0.5 AST 31 ALP 82 ALT 19

UA: Protein 500 (neg), 0-2 WBC/RBC, 2-20 squam , rare bacteria Hyaline casts

BNP 221 (<100) PT 10.1 INR 0.9 PTT 28.6

CXR

Renal Ultrasound Right kidney 12.8 x 6.2 6.3 Left Kidney 1 x 6.9 x 6.6 No hydronephrosis Increased echogenicity of cortex consistent with medical renal

disease

Hospital course cont….

Urine studies FENA 2.6% FEUrea 47.6% Spun urine: No casts or significant

sediment Urine Culture: No growth Urine Eos present Total protein 25943 mg/24hr (<100) Total protein/Creatinine ratio 12910

mg/g (<200)

Hospital course cont….Other significant lab values

HIV nonreactive RPR nonreactive Acute Hep panel: Hep

B Surface Ag + C3 111; C4 22 ESR 55 (0-15) Rheumatoid Factor

162 (normal <20) Total cholesterol 190 Triglycerides 44 HDL 54 LDL 127

ANA negative Anti-DS DNA negative LDH 289 (<201) CK 371 (<231) SPEP: Hypoalbuminemia

and increased fraction of alpha 2 consistent with Nephrotic syndrome

iPTH 296 (12-65); Calcium 8.2

25-OH Vit D 5.1 (32-100)

Follow-Up

Patient discharged 5/15/12 with diagnosis of nephrotic syndrome and Hepatitis B infection BUN 50; Cr 6.72; GFR 11 Discharge meds: furosemide, carvedilol,

amlodipine, atorvastatin, sevelamer No clear risk factors for Hepatitis B Hepatitis E Ag and Ab, HBV viral load Renal biopsy pathology pending at time

of discharge

After Discharge….Renal biopsy performed 5/14/12Diffuse foot process effacement with microvillus transformation and vacuolization. Unremarkable mesangial matrix and no deposits identified.Consistent with minimal change disease

Normal glomerulus

Light micrograph of an essentially normal glomerulus in minimal change disease.

Follow up

Patient seen in Nephrology clinic BUN 53; Cr 70.1; GFR 11 Hep B E Ag negative Hep B E Ag AB positive HBV viral load 3317 Oral prednisone 60mg daily started GI referral for hepatitis B management

Follow up

GI clinic 6/1/12 Chronic Hepatitis B carrier state Initiation of tenofovir renally dosed Monitoring with repeat labs at 2 and 6

months with repeat ultrasound at 6 months

Currently

Final Renal biopsy path report: Minimal Change

Weight 250 lbs BUN 32; CR 1.45 Total protein/Creat 3148 Tapering prednisone based on renal

function and proteinuria Requiring less fursoemide Tenofovir daily

THANK YOU