case presetation

1. By
Ehab Metwally khokha
Nephrology specialist
NMGH
Case presentation

2.  Male patient named Wael Bedir Tawfik
Mahmoud aged 38years from Sinbellaween,
married 2 years ago working as
accountant,smoker from15 y(12:15 cigarette
per day).
Personal history

3. • Difficulty of breathing at rest
• Easy fatigability
complaint

4. • The condition started at 1/10/2017 by dyspnea with
gradual onset and progressive course with cough
and fever 38c and Bp 130/80.
• After 1 week, he noticed puffy eyelid .
• After another 1 week he noticed edema lower limb
and Bp 160/100.
• Not diabetic, Not hypertensive.
• History of NSAIDS for 5 years one tab every day
History

5. • Vital signs: Bp 160/90, pulse 80, RR
20,temp 38.
• Pallor, puffy eye lid.
• Chest→mild bilateral pleural effusion.
• lower limb →mild bilateral edema.
Physical examination on admission

6. Right and left kidney:
• Normal size.
• Grade I echogenicity
• Good CMD
• No backpressure
• No stones
Abdominal ultrasound

7. • Hb 8.9,TLC 14.9,PLT 289, INR 1.15
• Sr cr 2.4, Sr urea 56
• Urine analysis: yellow color, SP.G 1015, pus
4-6, RBCS over 100,Ptn
+++,granularcast+++,crystal nil
• Alb/Creatinine ratio 5006 mg/gm. creat
Laboratory investigation

8. • HCV Ab reactive, HBV sAg -ve
• cANCA,pANCA,ANA→-ve
• C3 →73,C4 →2.6, both consumed.
• CRP 8.8
• Widal test and brucella test →-ve
• Albumin →2.4
• Total protein →4.3
• Ptn electrophoresis →↑@1,@2 globulin bands,
↓gamma globulin band
Laboratory investigation

9. • SLE
• MPGN, IgA nephropathy.
• Cryoglobulinemia.
• Atheroembolic renal disease
• Hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura
• Severe sepsis, acute pancreatitis, and advanced liver disease all can lower
plasma complement levels.
• Rheumatoid vasculitis and heavy chain deposition disease.
• To confirm diagnosis →we recommend renal
biopsy.
Differential diagnosis

10. Follow up pulse, bp,temp every 6 hrs.
Ptn diet →1gm/kg.
Lasix 40mg tab once per day
IVfluids →input=output+800 ml
Flazacor 30 mg tab →1*3
Ceftriaxone 1gm amp for 5 days
Tavacin 500mg tab ½ tab for 10 days
Mosepride 5mg 1*3
Pantoloc 40mg 1*1
Treatment on admission

11.  Bp→130/90
 After lasix 40mg tab once per day , edema
subside.
 Serum creatinine →2.4 →1.2
 Alb/creat ratio → 6000 mg/gm creatinine.
 Rheumatoid factor →26 +ve.
after treatment:

12. Thank you