Pathology Conference
Presented by F1 林立原
Commented by Dr.薛綏
2011/07/20
CASE 1: 2516217
CASE 2: 2847619
CASE 1: 2516217
General Data
Age: 48-year-old
 Gender: male
 Ethnic: Taiwanese
 Marital status: Married
 Occupation: 工人
 Admission date: 2011/05/26

Chief Complaint
 Increased
urine BKV titer
Present illness
This 48 year-old male has end stage renal
disease on hemodialysis since 1992, post
kidney transplantation on 2010/11/02 in
Mainland China(廣州醫學第二附屬醫院)
 He has regular Nephrology OPD followup with immunosuppressents. In 2011/05,
elevated urinary BKV titer(>1000000000)
was noticed. Thus, he was admitted for
graft kidney biopsy.

Past History



Impaired glucose tolerance
Chronic hepatitis C
Current medication:
 Prednisolone 5mg QD
 Tacrolimus 0.5mg QN
 Sirolimus 2mg QD
 Mycophenolate 500mg BID
 Leflunomide 20mg QD
 Clopidogrel 75mg QD
 Glimepiride 1mg QD
Personal History
No known allergy to drug or food
 He denies smoking, alcohol, or betel nut
chewing.

Physical Examination
Vital signs: BT 36.1℃ PR: 76/min, RR: 15/min,
BP: 146/84 mmHg
 General appearance: fair
 Consciousness: alert and oriented
 HEENT: conjunctiva: not pale, anicteric sclera
 Chest: symmetrical chest expansion, bilateral
clear breathing sounds.
 Heart: regular heart beats, no murmurs.
 Abdomen: soft and flat normal bowel
sounds
 Extremity: freely movable, no pitting edema.

Laboratory Findings
Hemogram
unit
5/26
WBC
/uL
6100
PT
RBC
million/uL
4.87
INR
Hemoglobin
g/dL
13.4
aPTT
Hematocrit
%
42.5
MCV
fL
87.3
MCH
pg/cell
27.5
MCHC
g/dL
31.5
RDW
%
14.9
Platelets
/uL
132
Segment
%
76.2
Lymphocyte
%
16.6
Monocyte
%
7.2
Eosinophil
%
0
Basophil
%
0
unit
5/26
sec
11.9
1.1
sec
26.9
Urinalysis
5/26
Color
Yellow
Turbidity
Clear
Biochemistry Unit
5/26
Cr
mg/dL
1.20
Sp. Gravity
1.014
eGFR
ml/min/1.73m2
> 60
pH
6.0
AST
U/L
56
Leukocyte
Negative
Na
mEq/L
143
Nitrite
Negative
K
mEq/L
3.5
Protein
Negative
Glucose
Negative
Ketone
Negative
Urobilinogen
0.1
Bilirubin
Negative
Blood
trace
RBC
4
WBC
2
Epi.
0
2011/05/26
CXR
2010/12/06 Kidney Echo
2010/12/06 Kidney Echo
2010/12/06 Kidney Echo
Left Kidney Length: 12.8 cm
 Right Kidney Length: 9.6 cm
 Transplant kidney: 12.3cm
 The contour and size of transplanted
kidney is normal. The cortical echogenicity
is mildly increased with adequate
thickness.
 The resistence indeces are as follows:
Upper pole: 0.630, Middle pole: 0.667,
Lower pole: 0.667.

2010/12/06 Kidney Echo
The left native kidney is enlarged in size
with irregular appearance. The normal
renal architexture is distorted.
 The right native kidney is normal in size
with irregular appearance. There are
numerous cysts of varying size scattering
in cortex and central sinus of both
kidneys (The largest: 5.8 x 5.4 cm in the
left kidney and 3.0 x 3.0 cm in the right
kidney).

2011/05/27 Kidney Biopsy

•
Kidney, graft, needle biopsy
----Consistent with viral nephritis
H & E l sections have 10 glomeruli with
focal mild sclerosis. The interstitium has
focal mild to moderae chronic
inflammation. Tubules have scattered large
nucleated cells with inranuclear inclusions,
minimal tubulitis and protein casts.
Arteries have mild sclerosis.
2011/05/27 Kidney Biopsy

•
•
Kidney, graft, needle biopsy
----Viral nephritis, IgA nephropathy
Immunohistochemical study: C4D(-), BK
virus (+) in the large nucleated tubular
cells
Immunofluorescence sections show 7
glomeruli with 3+ IgA, 1+ IgI, 2+ IgM and
2~3+ C1q in mesangium.
2011/05/27 Kidney Biopsy
•
Electron microscopic study: one
glomerulus show scattered mesangial
deposits and focal fusion of foot
processes.
Diagnosis
BKV nephritis with IgA nephropathy
 End stage renal disease on hemodialysis
since 1992, post kidney transplantation in
2010/11/02 in Mainland China

Discussion
CASE 2: 2847619
General Data
Age: 32-year-old
 Gender: female
 Ethnic: Taiwanese
 Marital status: divorced
 Admission date: 2011/06/07

Chief Complaint

Progressive right lower limb swelling for 1
month
Present Illness
This 32-year-old female has major
depression and chronic hepatitis B under
regular OPD follow up
 She presents to the ED because of
progressive right lower limb swelling for 1
month, associated symptoms including
abdominal fullness, abdominal pain, nausea
vomiting, dry cough, and watery diarrhea.

Present illness
At the beginning, she visited a local
hospital, where acute gastroenteritis was
impressed and treated. Her symptoms
improved a little bit.
 Several days prior to admission, she
developed intermittent fever, urinary
hesitancy, difficult urination, general
weakness, and left flank pain. Thus, she
visited CGMH ED for help.

Past History

OPD medications
◦
◦
◦
◦
◦

Silymarin 150mg BID
Venlafaxine 75 mg QN
Mirtazapine 30mg QN
Alprazolam 0.5 mg BID
Estazolam 2mg HS
Gallstones with chronic cholecystitis
status post laparoscopic cholecystectomy
on 2010/7/26
Personal History
No known allergy to drugs
 Smoking: 1PPD for 10+ years
 Alcohol: heavy drinker, quit now
 Betel nuts chewing: no

Physical Examination
Vital signs: BT 37.6℃ PR: 125/min, RR:
17/min, BP: 138/100mmHg
 BH: 164cm, BW: 80kg
 General appearance: fair
 Consciousness: alert and oriented
 HEENT: pink conjunctiva, anicteric sclera
 Chest: symmetrical chest expansion, bilateral
clear breathing sounds
 Heart: regular heart beats, no murmurs.
 Abdomen: soft, tenderness over left
quadrants
 CV angle knocking pain: (+), L't > R't
 Extremity: grade 2 pitting edema.

Hemogram
unit
6/6
WBC
/uL
7500
RBC
million/uL
3.39
Hemoglobin
g/dL
11.9
Hematocrit
%
34.6
MCV
fL
102.1
MCH
pg/cell
35.1
MCHC
g/dL
34.4
RDW
%
13.9
Platelets
/uL
252
Segment
%
66.8
Lymphocyte
%
24.7
Monocyte
%
7.0
Eosinophil
%
1.1
Basophil
%
0.4
Biochemistry
6/6
BUN
21.3 mg/dL
Cr
1.15 mg/dL
Na
135 meq/L
K
3.3 meq/L
ALT
27 U/L
Albumin
2.37 g/dL
Sugar
110 mg/dL
CRP
15 mg/L
6/10
T-Cholesterol
313
Triglyceride
185
F-T4
0.76ng/dL
TSH
1.77 uIU/ml
Cortisol
12.3 ug/dL
Urinalysis
6/6
Color
Yellow
Turbidity
Turbid
Sp. Gravity
1.029
pH
6.0
24 hrs U/O
1800 ml
Leukocyte
Trace
T-protein
416.8mg/dL
Nitrite
Negative
Daily protein(U) 7.5 gm/day
Protein
4+
Glucose
Negative
Ketone
Negative
Urobilinogen
0.1
Bilirubin
1+
Blood
3+
Bacteria/Yeast
Positive
RBC
158
WBC
33
Epi.
35
6/10
Serology
6/10
Serology
6/10
C3
135
IgG
717
C4
28.2
IgA
289
ANA
Negative
IgM
102
Anti-dsDNA
<40.5 (6/27)
IgE
<16.9
Anti-Smith
Negative
ANCA
Negative
RNP
Negative
Anti-HCV
Negative
SSA/SSB
Negative
Anti-HIV
Negative
Anti-cardiolipin
Negative
RPR
Negative
Cryoglobulin
IgG2+, IgA+,
IgM+
Cryofibrinogen
Positive
ASLO
258 IU/ml
6/9
PEP/IFE
Protein loss or malnutrition pattern. No monoclonal
protein, no paraprotein
2011/6/6
CXR
2011/6/6
KUB
2011/06/07 Kidney Echo
2011/06/07 Kidney Echo
Left Kidney Length: 13.3 cm
 Right Kidney Length: 13.1 cm
 The cortical echogenicity is mildly increased
with adequate cortical thickness. There is
one isoechoic band separating the the left
central sinus in some views.
 Impressions:
 1. Bilateral large kidneys with possible
parenchymal change
 2. Left columnar hypertrophy

Course and treatment

After admitted to ID ward, antibioitcs was
discontinued on 06/08, for infection is less
likely. Instead, proteinuria(7.5g/day),
hyperlipidemia(TG: 185mg/dL, T-Chole:
313 mg/dL), hypoalbuminemia(2.37 g/dL
on 06/07) and lower limbs edema were
noticed. Due to nephrotic syndrome, she
was transferred to Nephrology ward for
kidney biopsy.
Course and treatment

In Nephrology ward, serologic study was
done for survey of nephrotic syndrome,
cryoglubulin (IgG(2+),IgA(1+),IgM(2+))
and cryofibrinogen were positive; ASLO
was 258 IU/ml, other tests were negative,
including serum IgG/A/M/E, ANA, AntidsDNA, anti-Sm, RNP, SSA/SSB, C3/C4,
Anti-HCV, PEP/IFE, ANCA, anti-cardiolipin,
RPR, and anti-HIV antibodies.
Course and treatment
On 6/27, kidney biopsy was performed
 Besides, she developed nosocomial
urinary tract infection(U/C: E coli-ESBL
strain, post Cefuroxime 6/23-7/2,
Ciprofloxacin 7/2~7/7). Suspecting left calf
cellulitis, ertapenem was administered
since 7/7, and planned to 7/21.

2011/06/27 Kidney Biopsy




Kidney, needle biopsy
----C/W Proliferative glomerulonephritis
H & E sections have 7 glomeruli with
moderate hyperplasia and lobular pattern
formation.
The interstitium has mild fibrosis and
chronic inflammation. Tubules have casts,
arteries are normal.
Immunofluorescence sections have no
glomeruli with all stains negative.
Diagnosis
Proliferative glomerulonephritis
 Urinary tract infection
 Suspect left calf cellulitis
 Major depression
 Chronic hepatitis B

Discussion