This is case presentation regarding bilimbi fruit induced crystal nephropathy which was diagnosed & managed in my institution Shaheed Suhrawardy Medical College Hospital (ShSMCH), Dhaka, Bangladesh
2. A middle aged man presented
with oliguria
Dr. Md. Mostafa-Al-Rasel
Indoor medical Officer (Medicine)
Shaheed Suhrawardy Medical
College Hospital, Dhaka
7/29/2019
3. Particulars of the patient
• Name : Md. Barkat Ali
• Age : 48 years
• Sex : Male
• Marital status : Married
• Religion : Islam
• Occupation : Farmer
• Address : Narshingdi
• Date of admission : 24.11.2018
• Date of examination : 24.11.2018
7/29/2019
5. History of Present Illness
• According to the statement of the patient, he was
reasonably well 5 days ago, then he developed nausea
& vomiting after taking 2 glass of home made fruit juice.
Vomiting was 5-6 times in a day, non projectile in
nature, vomitus volume was about 300-400 ml on each
episode of vomiting, contained watery secretions &
there was no bile or blood.
7/29/2019
6. History of Present Illness….Cont’d
• Vomiting was associated with loose motion for 3-4
times, which was watery , mixed with mucus but not
with blood, volume was approximately 150-200 ml per
defecation.
• He also developed reduced urine output for last 3 days.
Initially urine volume was about 500 ml within 24 hours,
high in color. Gradually his urine output became scanty
and it was 100 ml within last 24 hours.
7/29/2019
7. History of present illness ….. Cont’d
• He complained of fever for last 3 days which was
high grade, intermittent in nature, highest
temperature was not recorded, associated with
chills & rigor, relieved by taking Paracetamol. Fever
was associated with bilateral loin pain which was dull
aching in nature with no radiation.
• He denied any history of taking NSAIDs or other
drugs prior to development of his current illness.
7/29/2019
8. History of present illness ….. Cont’d
• He is known to be hypertensive for 5 years. He has no
history of facial or leg swelling. There was no history of
urinary frequency, urgency or burning sensation during
micturition. There was no joint pain, redness of eye,
blood loss, sore throat, skin rash, skin infection, yellow
coloration of skin, passage of black tarry stool, chest
pain, palpitation or any other cardiac events.
7/29/2019
9. History of present illness ….. Cont’d
• On query , patient mentioned of taking fruit juice of
locally available bilimbi prior to this illness.
• With above complaints he was admitted into
department of Nephrology at Shaheed Suhrawardy
Medical College Hospital for further evaluation and
managment .
7/29/2019
13. Treatment history:
He was on anti hypertensive (Losartan 50mg daily )
with controlled blood pressure. He had history of
intake of antibiotics (Azythromycin) and ORS .
He gave no H/O taking any NSAID prior to this current
illness.
7/29/2019
14. Family history:
He has 07 siblings. He was married, and had 03
children. His family members were in good health.
There was no history of consanguinity in his family.
None of his family member suffered from this similar
type of illness .
7/29/2019
16. Socio-economic history:
Patient belongs to a low socio-economic conditon. His
monthly income is about 15,000 BDT. He used to live in
a tin-shed house, uses sanitary latrine and drinks tube
well water.
7/29/2019
17. Personal history:
He is a smoker (28 pack year), does not take alcohol,
betel nuts and tobacco leaf. He has no history of I/V
drug abuse & extra marital sexual exposure. His sleep
pattern was normal .
7/29/2019
18. Psycho-social history
His mood is good, relation with his fellow workers &
family members is fine, participates in different social
program.
7/29/2019
19. Travel history:
He has no significant history of travelling.
Immunization history:
He is not immunized as per EPI schedule.
7/29/2019
26. Genito-urinary system examination:
• Inspection: Normal
• Palpation: Kidneys not ballotable
Mild renal angle tenderness (Bilateral)
present
• Auscultation: There is no renal bruit.
• External genitalia: Normal
7/29/2019
27. Respiratory system examination:
• Inspection:
Chest :
Shape and size - normal.
Movement -symmetrical. Not restricted.
Visible deformity, scar mark, engorged vein or visible
pulsation-absent.
Respiratory rate- 16 breaths/min.
There is no sign of respiratory distress.
7/29/2019
28. • Palpation:
Trachea - centrally placed.
Apex beat - left 5th ICS, 9 cm from the midline.
Chest expansion and vocal fremitus- normal.
• Percussion:
Percussion - resonant.
Upper border of liver dullness - right 5th ICS along the MCL
Respiratory system examination……. Cont’d
7/29/2019
30. Cardiovascular system:
• Pulse- 88 bpm, regular, normal in volume, bilaterally
symmetrical. No radio-femoral delay.
• Blood pressure: 110/70 mmHg
• JVP: Not raised
7/29/2019
31. •Precordium:
• Inspection: Apex beat visible at left side , no other
pulsation seen
• Palpation:
Apex beat - left 5th ICS 9 cm from the midline, normal
in character.
There is no thrill, palpable P2 or left parasternal
heave.
7/29/2019
32. • Auscultation:
1st and 2nd heart sounds are normal.
There is no murmur or added sound.
7/29/2019
33. Musculo-skeletal system examination:
• Posture: Normal
• Inspection: There is no visible deformity, swelling,
muscle wasting or hypertrophy anywhere in the body.
• Palpation: Temperature is normal. There is no
tenderness. Muscle bulk, tone and power is normal.
• Joint movement:
Joint movements are not restricted. All active and
passive movements are normal.7/29/2019
34. Examination of the Abdomen :
• Inspection:
Size and shape -scaphoid.
Flanks - not full.
Umbilicus -centrally placed and inverted.
Visible peristalsis-absent,
There is no epigastric pulsation, scar mark,
pigmentation in skin, striae or cough impulse.
7/29/2019
35. • Palpation:
Skin temperature over the abdomen is normal. There
is no tenderness, rigidity or palpable lump.
There is no organomegaly. Hernial orifices are intact.
• Percussion:
Percussion note is tympanic.
There is no fluid thrill or shifting dullness.
Examination of the Abdomen ……..Cont’d
7/29/2019
36. • Auscultation:
Bowel sound is present.
There is no bruit or rub.
Examination of the Abdomen ……..Cont’d
7/29/2019
37. Nervous system examination:
• Higher psychic function including speech: Normal
• Cranial nerves: Intact
• Motor function: Normal
• Sensory function: Normal
• Cerebellar function: Normal
7/29/2019
38. • Signs of meningeal irritation: Absent
• Gait: Normal
• Fundoscopy: Normal
Nervous system examination……..Cont’d
7/29/2019
39. Salient features:
Md. Barkat Ali, 48 years old, non diabetic, hypertensive,
muslim, married, male farmer hailing from Narshingdi
presented with nausea & vomiting after taking 2 glass of
home made bilimbi juice. Vomiting was 5-6 times daily,
non projectile in nature, large in volume, contained
watery secretions ,but no bile or blood. Vomiting was
associated with loose motion for 3-4 times, which was
watery , mixed with mucus but not with blood, volume
was approximately 150-200 ml per defecation.
7/29/2019
40. Salient features…..Cont’d
Patient also developed oliguria for last 3 days. Initially
urine volume was about 500 ml per day, but the volume
reduced to 100 ml for last 24 hours. He complained of
fever which was high grade, intermittent, highest
temperature was not recorded, associated with chills &
rigor, relieved by taking Paracetamol. Fever was
associated with bilateral loin pain which was dull aching
in nature with no radiation.7/29/2019
41. He denied any history of taking NSAIDs or other drugs
prior to his current illness. He is known to be
hypertensive for 5 years. He has no history of facial or
leg swelling. There was no history of urinary
frequency, urgency or dysuria. There was no joint pain,
redness of eye, blood loss, sore throat, skin rash, skin
infection, jaundice, passage of black tarry stool, chest
pain, palpitation or any other cardiac events.
Salient features…..Cont’d
7/29/2019
42. He has history of taking Losartan tablets for HTN &
intake of antibiotics (Azythromycin) and ORS . On
general examination, he was ill looking, mildly anaemic,
mildly dehydrated, vitals were within normal limit
except sinus tachycardia, bedside urine heat
coagulation test was positive (+)
Genito-urinary system examination revealed mild
bilateral renal angle tenderness. All other systemic
examination revealed no abnormality.
Salient features…..Cont’d
7/29/2019
50. 7/29/2019
Test Result Reference value
S. Calcium 8.75 mg/dl 8.1-10.4 mg/dl
S. Inorganic
Phosphate
7.20 mg/dl 2.5-5.0 mg/dl
S. Uric Acid 8.90 mg/dl 3.0-7.0 mg/dl
HBsAg Non reactive Non reactive
Anti HCV Non reactive Non reactive
56. Renal Biopsy
• 16 glomeruli of which 02 are
globally sclerosed and one
shows segmental sclerosis.
• All other glomeruli show
normal mesangial cellularity
& normal thickness of
basement membrane.
• No endocapillary
proliferation, necrotizing
lesion or crescent formation
is seen.
• Silver methanamine staining
reveals no spike or crater.7/29/2019
57. Renal biopsy
7/29/2019
There are calcium oxalate crystals packed in 3 of the
tubular lumen.
Interstitium shows oedematous changes with focal mixed
inflammatory cell infiltration.
No interstitial fibrosis & tubular atrophy is seen in cortical
area.
There are patchy moderate to severe acute tubular injury
with flattening & sloughening of lining epithelium.
58. Renal biopsy
Arteries show moderate fibro-intimal thickening
& arterioles are unremarkable.
Direct immuno-fluroscence study reveals 08
glomeruli .
Mild mesangial deposits of IgM is seen.
No IgG, IgA, C3, Kappa, Lambda, or C1q deposit
is seen.
7/29/2019
67. 7/29/2019
Test Result before
treatment
Result after
treatment
Reference
value
S. Creatinine 13.92 mg/dl 1.9 mg/dl 0.4-1.4
mg/dl
S. Inorganic
Phosphate
7.20 mg/dl 3.40 mg/dl 2.5-5.0
mg/dl
S. Uric Acid 8.90 mg/dl 2.94 mg/dl 3.0-7.0
mg/dl
