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Admission course 0/8/14~08/1908/14 ER 8D wardS/S: fever, nausea vomitingRocephin 1g q12h

08/15Arrange kidneys echoleptospirosis, Q fever, srub typhus, murine typhus Rocephin 1g q12h + Doxycyline 100mg BID

08/16S/S: Fever subsided, no nausea nor vomiting=> Arrange renal biopsy ** 08/15 + history atypical infection472011/08/16 Kidney BiopsyKidney, needle biopsy --- tubulointerstitial nephritisH & E sections have 2 glomeruli with congestion. The interstitial has mild edema and moderate inflammation. The inflammatory cells are most mononulcear, with few eosinophils and neutrophils. Tubules have focal protein casts, with focal epithelial cell necrosis and regeneration. Arteries are normal. Immunofluorescence sections have 5 glomeruli with irregular 1+ IgA. *

Case 1: 9578264General DataAge: 57-year-oldGender: MaleEthnic: TaiwaneseMarital status: MarriedOccupation: WorkerAdmission date: 2011/05/13

Chief ComplaintProgressive bilateral lower legs swelling for 1 monthPresent IllnessThis 57-year-old male has diagnosed as a victim of diabetes mellitus and hypertension in 2011/02.He suffered from progressive bilateral lower legs swelling for 1 month, accompanied with poor appetite, abdominal fullness, decrease urine amount, and foamy urine. Mild nausea sensation and dyspnea also developed since 2 weeks before this admission. At the beginning, he visited hospital, where nephrotic syndrome was diagnosed.

Then the patient was referred to our nephrologic and ophthalmic clinic for help. Diabetic retinopathy was diagnosed by our ophthalmologist. Lab data showed heavy proteinuria, hypoalbuminemia, dyslipidemia, decreased IgG and elevated IgE level.

However, bilateral lower legs swelling progressed in spite of diet restriction and medication given. So the patient was admitted to for further management. Past HistoryHypertension was diagnosed in 2011/02Type 2 diabetes mellitus was diagnosed in 2011/02Medication History 2011/04/07 Nephro OPDFurosemide (40mg) --------- 2# QDSennoside (12mg) ----------- 2# HSMetoclopramide (3.84mg)-- 1# TID

2011/04/28 Nephro OPDFurosemide (40mg) --------- 3# BIDSennoside (12mg) ----------- 2# HSExforge (Amlodipine 5mg + Valsartan 80mg) ---------------------------------- 1# QDRosuvastatin (10mg) ------- 1# QD

Medication History 2011/04/15 Meta OPDGlucomet (Glyburide 5mg + Metformin 500mg) -------------------------------- 2# QDPersonal HistoryNo known allergy to drugs or foodSmoking: 1PPD for 10+ yearsAlcohol: heavy drinker, quit for 6 monthsBetel nuts chewing: quit for 10 yearsPhysical ExaminationVital signs: BT:37.3/ HR:84/min RR:20/min BP:227/153mmHgGeneral appearance: fairConsciousness: alert and orientedHEENT: conjunctiva: not pale, sclera: anictericChest: symmetrical expansion, bilateral clear breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat normal bowel sounds, shifting dullness (+) Extremity: freely movable, bilateral legs grade III pitting edemaHemogramunit5/6 (OPD)5/17 WBC/uL5900RBCmillion/uL4.65Hemoglobing/dL17.413.8Hematocrit%49.838.5MCVfL82.8MCHpg/cell29.7MCHCg/dL35.8RDW%13.4Platelets1000/uL187Segment%36.4Lymphocyte%56.1Monocyte%4.6Eosinophil%2.7Basophil%0.2Laboratory FindingsBiochemistry4/8 (OPD)5/6 (OPD)5/13 BUN42.8 25.429.7Cr1.46 2.01.83K/Ca/P3.8 / 8 / 3.8AST14ALT27 U/L11Albumin/T-Protein2.17 / 4.21.881.51Sugar72 mg/dL136191HbA1C9.67.8T-Cholesterol528567Triglyceride299255HDL6240LDL406476MicroALB (U)28316.2Creatinine (U)136.98399.35Alb/Cre ratio (U)7090.6Urinalysis4/8(OPD)5/13ColorYellowDark yellowTurbidityCloudyCloudySp. Gravity1.0241.043pH6.06.5LeukocyteTraceTraceNitriteNegativeNegativeProtein4+ (1000)4+(1000)GlucoseNegative2+(500)KetoneNegativeNegativeUrobilinogen0.11.0Bilirubin-NegativeBlood2+3+Granular cast538RBC1327WBC2515Epi. 5155/2324 hrs U/O2400 mlT-protein923.0mg/dLCreatinine(U)37.74mg/dLDaily protein(U)22.15 gm/day *Serology4/14(OPD)RPRNonreactiveASLO< 49.70IgG197IgA354IgM143IgE886HBs AgNegativeAnti-HCVNegativeAnti-HIVNegativeSerology5/266/07C3100C433.4ANANegativeP-ANCANegativeC-ANCANegativeRF Colloid fluid hydration, Teicoplanin + Fortum, inotropic agent Taoyuan ICU (05/20)05/20~05/26 Taoyuan ICU S/S: fever, abdominal fullness05/23 Whole body CTConsult GS : suggest MRCP Consult INF: a. shift antibiotics to Tienam b. arrange Cardiac 2D echo for FUO survey c. Check tumor markers Transffer to Linkou 8D ward*consult GS : MRCP, NSF (BUN/Cr 22.6/3.2) consult Inf1.anti Tienam 2. 2D echo and Ga-67 scan for FUO 3. check tumor marker to exclude tumor fever* surgical intervention or PTGBD

192011/05/30KUB

* and intermittent abdominal pain => KUB and PES242011/05/30 Gallium-67 scanImpression:Ga-67 avid lesion in left lower lung field, probably infection/ inflammatory response.

Ga-67 avid lesion in mediastinal lymph nodes, probably reactive lymphadenopathy.

*

2011/06/21 Kidney BiopsyImmunofluorescence sections have 3 glomeruli with 1~2+ C3 irregularly in loops and mesangium.

2011/07/27 Electron microscopic study : No glomerulus is found.

*DiagnosisMembranoproliferative glomerulonephritis Cholecystopathy, favor cholecystitisSeptic shock episode, favor intra-abdominal infection due to cholecystitisDiabetes mellitus with diabetic retinopathy and nephropathy* 7/15 recurrent bilateral lower legs edema 5 albumin + diuretics (7/15-7/20)31DiscussionCase 2: 20690936

General DataAge: 44-year-oldGender: MaleEthnic: TaiwaneseMarital status: MarriedOccupation: WorkerAdmission date: 2011/08/14Chief ComplaintIntermittent high fever for one week.Present illnessThis 44-year-old male has unremarkable medical history before. This time, he had experienced intermittent fever up to 40 centigrade, accompanied with thrombing headache, general weakness, bilateral flank soreness, mild dyspnea, severe sore throat, mild cough since 08/07. Intermittent abdominal cramping pain, vomited with dark-green vomitus, and decreased urine output developed since 08/10.He denied dizziness, diplopia, chest pain, tarry stool , bloody stool or leg swelling. Fever headache36Tracing back history, he had just visited and got insect bite (mosquitoe and leech) on 07/30. There was no recent drug or toxin intake episode but he had some volatile chemical exposure on 08/06. No other family member or colleague had similar symptoms.

Due to above, he had came to local hospital for help several times where progressive deteriorated renal function was noted. Under personal factors, he was transffered to our ER for further management.Past HistoryDenied hypertension, diabetes mellitus or other systemic diseases

Hyzaar (Losartan 100mg + HCTZ 12.5mg)38Personal HistoryNo known allergy to drug or foodHe denies smoking, alcohol, or betel nut chewing.Physical ExaminationVital signs: BT:37.3/ HR:84/min RR:18/min BP:126/71/mmHgGeneral appearance: fairConsciousness: alert and orientedHEENT: conjunctiva: not pale, sclera:anicteric Chest: symmetrical expansion, bilateral clear breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat normal bowel soundsExtremity: freely movable, no pitting edema.No abdominal tenderness40Laboratory FindingsHemogram8/13()8/14WBC105408700RBC4.484.04Hemoglobin13.012.1Hematocrit38.034.3MCV85.384.9MCH29.730.0MCHC34.835.3RDW12.7Platelets255K296kSegment79.972.3Lymphocyte12.419.0Monocyte4.94.5Eosinophil2.53.9Basophil0.30.3unit8/14PTsec11.7/10.7INR1.1aPTTsec32.2/26.0Biochemistry8/07 ()8/13()8/14 8/15BUN14.253.052.538.7Cr1.26.06.463.69AST3643ALT985052Bilirubin(total)0.2Alk-P459130Na / K144 / 3.2138 / 3.4141 /3.6Ca / P8.1 / 3.6 7.9 /3.57.6 4.1Amylase / Lipase79 / 53.4Albumin / T-Protein3.123.49/6.3CRP98.82Uric acid11.7Total cholesterol152Myoglobin29.5CK8196Urinalysis8/13 ()8/14ColorYellowYellowTurbidityClearClearSp. Gravity1.0121.010pH6.05.5Leukocyte2+NegativeNitriteNegativeNegativeProtein3+ Trace (15)GlucoseNegativeNegativeKetoneNegativeNegativeUrobilinogen0.10.1Bilirubin-NegativeBlood1+1+RBC6-101WBC21-303Epi.0-508/1824 hrs U/O2800 mlT-protein12.3mg/dLCreatinine(U)58.86mg/dLDaily protein(U)0.344 gm/daySerology8/17RPRNonreactiveASLO< 52.80IgG1060IgA164IgM182IgE< 16.9HBs AgNegativeAnti-HCVNegativeAnti-HIVNegativeSerology8/17C3180C425.3ANANegativeP-ANCANegativeC-ANCANegative2011/08/14 CXR

452011/08/14 Abdominal CTImpression: No renal stone or hydronephrosis in both kidneys. APN was less likely.

abdominal pain, vomiting ?ARF nephro => history + liver and renal dysfunction => atypical infection, rocephin46Admission course 0/8/14~08/1908/18BUN/Cr:27.4/1.66, AST/ALT:41/61, Bil(T):0.2CDC report: Leptospiral IgM positivePathology report: tubulointerstitial nephritis

08/19DischargeCefuroxime 250mg BID + Doxycycline 250mg BID x 3 days

08/18 leptospirosis weakly positive => compaitable with pathologic findings, renal function

482011/08/15 Kidney Echo

There are several echo-free lesions(2.2, 6.2, 4.1cm) with posterior wall enhancement in the right kidney. No renal mass, or stone is noted.Impression: Right renal cystsDiagnosisTubulointerstitial nephritis due to leptospirosisleptospirosis weakly positive => compaitable with pathologic findings, renal function * 08/24 BUN/Cr:22.6/1.27

52Discussion