1. NYU Medical Grand Rounds Clinical Vignette Phillip Joseph, MD, PGY-2 September 25 th, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 22-year-old man who presents with one month of cough and sore throat and two weeks of abdominal pain, nausea, and vomiting. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was in his usual state of good health until one month prior to admission when he developed an acute non-productive cough and sore throat These symptoms persisted until two weeks prior to admission, when he developed suprapubic and right lower quadrant abdominal pain, associated with nausea and vomiting He started to take bismuth which relieved his pain and vomiting History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. The patient also noticed dyspnea upon walking up stairs and arthralgias of his elbows and knees One day prior to admission, the patient saw his primary care provider for these symptoms Labs were drawn and upon learning the results, the patient was sent to the urgent care center for further management History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: None Past Surgical History: None Social History: No tobacco, alcohol, or drug abuse No recent travel Family History: None Allergies: None Medications: Bismuth subsalicylate as needed; naproxen 2 tabs once per day, approximately three times per week for 5 years U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination General: Well-developed young man, anxious, alert and oriented Vital Signs: T: 99.2 F BP: 203/127 HR: 99 RR: 14 and O2 sat: 98% on room air Abdomen: Tender to palpation of right lower quadrant and suprapubic region Lower Extremities: Multiple petechiae over dorsum of feet bilaterally Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings CBC: Hemoglobin 8.8, Hematocrit 24.8, Platelets 123, 2+ schistocytes Remainder of CBC was within normal limits BMP: Na 134, K 6.3, Cl 116, HCO3 14, BUN 93, Cr 7.1, Ca 7.0 LFT: AST 46, ALT 34, totoal protein 5.7, albumin1.6 Remainder of hepatic panel was within normal limits Urinalysis: Large blood, protein greater than 300 mg, RBC 179, WBC 11, negative bacteria CRP 8, ESR 138, LDH 1130, FOBT negative, rheumatoid factor negative, C3 and C4 undetectable U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Other Studies Chest X-Ray: Moderate left pleural effusion. Cardiac silhouette is enlarged Bedside transthoracic echocardiogram with hyperdynamic left ventricle and moderate pericardial effusion U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Lupus nephritis Post-infectious glomerulonephritis TTP-HUS Henoch-Shonlein Purpura NSAID-induced acute renal failure Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Hospital Day 1: –Nicardipine drip started for blood pressure control –Pulse dose steroids started –Labs returned with positive ANA, positive anti- dsDNA, positive anti-Ro Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hospital Day 2: –Hemodialysis initiated because of persistent hyperkalemia –Pulse dose steroids continued Hospital Day 3: –Cyclophosphamide administered –Pulse dose steroids completed –Hemodialysis continued Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Hospital Day 4: –Transferred from ICU Hospital Day 7: –Renal biopsy performed: 33 glomeruli in total, 17 were globally sclerotic, 10 with circumferential cellular and fibrocellular crescents, all others with proliferation, several with hyaline thrombi with granular deposits of complements and immunoglobulins Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Class IV Lupus Nephritis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS