A 42-year old male teacher presented with swelling in his lower limbs and was found to have proteinuria. He has a history of rheumatoid arthritis and hepatitis C. A renal biopsy showed mesangial glomerulonephritis. He was started on treatment for rheumatoid arthritis which decreased his proteinuria.

1. ‫الرحمي‬ ‫الرمحن‬ ‫هللا‬ ‫سم‬‫ب‬

3. Male patient, 42 years old, from
Mansoura,teacher, married ,has three
offspring, the youngest is thirteen
years old ,with no special habit of
medical importance.

4. swelling in his lower
limbs.

5. He had a history of HCV treatment since2009 by
lnterferone but no response .
He took sovaldi and ribavirin tablets with response in
the form of two successive negative PCR of heptitis c
virus in 2016.
There is past history of arthralgia in hip joint in 2009
.the patient did rheumatoid factor was negative in2009
The patient took hostacortine 5mg tablet once daily
from 2009 uptill now the arthralgia was relieved.

6.  No past history of TB.
 No past history of surgical operations.
 past of analgesic intake in the form of
NSAIDS.

7. The patient presented by mild oedema
lower limbs and accidently discovered
proteiuria during routine follow up of
HCV treatment .
He did 24 hours protein in urine was
8gm
The patient has good urine output.

8.  No mouth ulcers or photosensitivity
or rash.
 No chest pain or palpitation.
 No present history of hypertension
or diabetes mellitus.

9.  There is family history of hypertension
 There is no family history of renal disease
or autoimmune disease.

10. Patient appears well, Fully
conscious , oriented and
cooperative.
Bilateral edema lower limb
up to the knee.

11. ABP 140/80mmhg , HR 85beats/ min
regular equal pulse.
Body temperature is 37.3.
No palpable LNs.
Heart examination normal.
Neurologically free.
Tenderness in both knee and hip
joints.
No bone deformity.

12.  CBC:
Hb: 13.5g/dl
RBCs: 4.78
Haematocrit: 36.3%
MCV:76
MCH: 28.2Pg
MCHC:37.1 g/dl
TLC: 4000
Platelets:166000

13.  ABG:
PH: 7.31
Hco3:23.7
Pco2:29.9
 Creatinine:1.5
 Urea:84
 Sodium:125
 Potassium:4.8
 Albumin:2.5

14. INR: 1.01.
PT:12.6.
Antids DNA AB: negative.
ANA: positive.
Rheumatoid factor: positive.
Anti CCP antibody :positive.
ANCA: negative.
C3and C4 within normal range.
CRP: negative.
Virology screen: negative except HCV Ab: positive PCR: negative
Serum uric acid:6.1 mg/dl . serum cholesterol: 291mg/dl.
Corrected serum calcium: 9.9mg/dl.

15.  URINE ANALYSIS:
Colour: yellowish.
Aspect :clear.
PH: acidic.
SG:1020.
Protein:+++
Crystal: nil.
RBC: 20-30.
Pus cell:3-4.
Cast: hyaline cast.

16. Pelviabdominal us:
Liver: enlarged size, coarse echopatern.
Spleen: mild enlarged in size.
Kidneys: average size with increased
echogenicity ,good corticomedullary
differentiation, with no back pressure or
stones.
Chest x ray: minimal bilateral pleural effusion.

17. Medications
Plasma infusion.
Lasix 40mg ampule iv every 12 hours.
Capotril 25 mg tab half a tab three time daily.
Ator 10mg tab one tab once daily.
Aspocid 75 mg two tablet once daily.
.

18. We did renal biopsy

21. The patient went to a rheumotolagist untill the
result of biopsy appear to start giving him
treatment for rheumatoid arthritis
He gave him soluoprid tab 60mg daily
Cellecept 250mg 2tablets twice daily
For 3 months.
The patient 24h protein decrease to 2gm
He is now on soluoprid 15 mg daily

22.  In RA nephropathies, mesangial glomerulonephritis
is the most frequent histological lesion (35-60 % out
of biopsies from patients with urinary abnormalities
and/or kidney impairment), followed by minimal
change glomerulopathy (3-14%) and p-ANCA
positive necrotizing crescentic glomerulonephritis.