croup upper respiratory tract disease with clinical correlaton.

1. Case Presentation
Group 10A

2. A 25-year-old woman presents to the clinic due to
blood while urinating & recently developed sharp
abdominal pain while moving.

3. What are the additional
information you need to know
from the patient?

4. ● Onset of symptoms
● Past Medical History
● Past drug history
● Family history
● Vital signs
● Physical Examinations

5. Onset of symptoms
● She noticed decreased urine output and bloody urine since 3
days.
● She developed abdominal pain 1 day ago.
● Her joint pain became worse since past week.

6. Past medical history
● She has a history of systemic lupus erythematosus, initially diagnosed 6 years ago,
● She has been hospitalized twice in the past 5 years for lupus-related symptoms and
has received immunosuppressive therapy.
● She had joint pain since 6 months.
● She visited a rheumatologist a week ago, due to the worsening of her joint pain.

7. Drug history
● She has been taking 200-mg ibuprofen each day for joint pain
● but discontinued those a week ago on the advice of her rheumatologist.
● She is currently on
■ oral steroids,
■ Hydroxychloroquine,
■ Azathioprine
■ oral contraceptives
■ a multivitamin.

8. Family history
● She is married and has no children.
● She does not smoke or drink alcohol.
● She denies a family history of autoimmune or kidney disease.

9. Physical examination
● On Inspection Her skin looks pale with a mild, red to purple rash involving
the cheeks and bridge of the nose, with sparing of the nasolabial folds.
● Examination of the eyes, ears, nose, and throat are unremarkable.
● Examination of the upper extremities reveals 1 ring-shaped, scaly, red lesion
on the left forearm.
● Examination of the lower extremities finds mild (1+) edema bilaterally. No
other skin rashes are noted on legs.

10. ● Neurological examination reveals no significant findings, specifically with
no proximal or distal weakness noted in the extremities.
● Cardiac examination reveals a normal S1 and S2 with no murmurs, gallops,
or rubs.
● Respiratory examination reveals that the friction rub on auscultation.
● Abdominal examination reveals rebound tenderness while palpating.

11. Vital signs
● Temperature = 98.6°F (37°C),
● Pulse rate = 76 beats per minute,
● Blood pressure (supine) = 160/91 mm Hg
● Respiratory rate = 12 breaths per minute
● Body mass index = 24.9 kg/m2
● Oxygen saturation = 97%

12. What are the additional Diagnosis
tests you need to perform on this
patient?

13. ● Complete blood count (CBC)
● Serum electrolytes and metabolic profile
● Complete urinalysis
● Quantitative urine study or use of urine protein:creatinine ratio
● Serum complement levels (C3 and C4)
● serum antinuclear antibody test

14. Complete blood count
WBC 3.5 × 109/L 4.8-10.8 × 109/L
RBC 3.96 × 1012/L 4.70-6.10 × 1012/L
Hemoglobin 11.4 g/dL 14.0-18.0 g/dL
Hematocrit 33.6% 42.0-52.0%
MCV 91.9 fL 80.0-94.0 fL
Platelet count 250 × 109/L 150-450 × 109/L

15. Complete metabolic profile
● Serum creatinine 2.3 mg/dL 0.50-1.30 mg/dL
● Blood urea nitrogen 31 mg/dL 7-22 mg/dL
● Serum sodium 142 meq/L 136-145 meq/L
● Serum potassium 4.0 meq/L 3.5-5.3 meq/L
● Serum chloride 111 meq/L 97-111 meq/L
● Carbon dioxide 22 meq/L 22-30 meq/L
● Serum calcium 9.6 mg/dL 8.6-10.5 mg/dL
● Glucose 91 mg/dL 70-100 mg/dL

16. ● Total protein 6.4 g/dL 6.0-8.0 g/dL
● Albumin 3.0 g/dL 3.4-5.2 g/dL
● Total bilirubin 0.3 mg/dL 0.2-1.2 mg/dL
● Alkaline phosphatase 62 IU/L 34-130 IU/L
● SGOT (AST) 19 IU/L 0-40 IU/L
● SGPT (ALT) 14 IU/L 0-68 IU/L
● Estimated GFR 15 mL/min/1.73m2 >60 mL/min/1.73m2

17. Urinalysis
● Color Light brown color Yellow
● Appearance Hazy Clear–hazy
● Specific gravity 1.025 1.005-1.030
● pH 6.5 5.0-8.0
● Glucose Negative Negative
● Protein 4+ Neg-Trace mg/dL
● Ketones Trace Negative
● Blood 3+ Negative
● Bilirubin Negative Negative
● Urobilinogen <2 IU/L <2 IU/L
● Nitrite Negative Negative
● Leukocyte esterase 1+ Negative

18. Based on the above examinations
What could be the Possible
diagnosis?

19. Lupus nephritis

20. What are the Classes of
lupus nephritis?

21. ● Class I - Minimal mesangial LN
● Class II - Mesangial proliferative LN
● Class III - Focal proliferative LN
● Class IV - Diffuse proliferative LN
● Class V - Lupus membranous nephropathy
● Class VI - Advanced sclerosing LN

22. What are the additional
investigations you need to
perform ?

23. Biopsy for
● Histological; findings
● light microscope
● Electron microscope
● Immunofluorescence staining

24. ● Global endocapillary
hypercellularity in
glomerulus(indicated by yellow
stars),
● Neutrophil infiltration
(indicated by yellow
arrowheads)
● Wire looping of capillaries
(indicated by blue arrow;

25. Hypercellularity on only…
● Class I - Minimal mesangial LN
● Class II - Mesangial proliferative LN
● Class III - Focal LN
● Class IV - Diffuse LN
● Class V - Lupus membranous nephropathy
● Class VI - Advanced sclerosing LN

26. Transmission Electron Microscopy
● Glomerulus with extensive
subendothelial dense
deposits (indicated by red
arrowheads)
● Intramembranous -dense
deposits (indicated by red stars
● C indicates capillary lumen
and GBM, glomerular
basement membrane.

27. Immunofluorescence Microscopy
● positive staining in anti
immunoglobulins (anti-
IgG), C3 and C1q)
● IC deposits on more
than 50% of
Glomerulus in granular
pattern diffusely.

28. What is the final
diagnosis?

29. ● Class I - Minimal mesangial LN
● Class II - Mesangial proliferative LN
● Class III - Focal LN
● Class IV - Diffuse proliferative LN
● Class V - Lupus membranous nephropathy
● Class VI - Advanced sclerosing LN

30. Diffuse proliferative
Lupus Nephritis

31. Introduction
● Kidney involvement is common in systemic lupus erythematosus (SLE).
An abnormal urinalysis with or without an elevated plasma creatinine
concentration is present in a large proportion of patients at the time of
diagnosis of lupus nephritis.
● Lupus nephritis (LN) typically develops early in the disease course .
Clinically evident kidney disease eventually occurs in up to one-half of
patients with SLE, and up to 10 percent of patients with LN will develop
end-stage kidney disease (ESKD)

32. Epidemiology
● There is a higher incidence of LN among patients with SLE in the United States as compared with
Europe, which may in part reflect racial and ethnic differences.
● Black patients and Hispanic patients also tend to present with more severe underlying
histopathology, higher serum creatinine concentrations, and more proteinuria than White patients.
● The time course for the development of LN varies with sex, age, and ethnicity. In a retrospective
study in the United States, males, younger patients (eg, less than 33 years of age at diagnosis), and
patients who are not White were at enhanced risk of developing nephritis earlier in the course of the
disease.
● A number of patient characteristics place patients with LN at greater risk for progressive kidney
disease including African or Hispanic ancestry, male sex, pediatric onset, frequent relapses or
incomplete remission, and proteinuria >4 g/day at diagnosis

33. Management
● Initial therapy with IV cyclophosphamide (0.5 to 1 g/m in monthly pulses with
daily glucocorticoids prednisolone till renal function turn to normal
● lower dose of immunosuppression over a longer term can help a patient
maintain a flare-free state.
● oral cyclophosphamide with azathioprine plus methylprednisolone 10 mg/day
prescribed.