CASE 2

Randolph A. Hennigar, MD, PhD
Pathology and Laboratory Medicine
Emory University School of Medicine, Atlanta, GA

CLINICAL HISTORY

            A 33-year-old male was admitted to Emory University Hospital (EUH) complaining of nausea, vomiting and abdominal pain of several weeks duration.   His past medical history was positive for (1) rheumatic fever as a child; (2) episodic pain in the hands, feet, joints and abdomen since childhood; (3) heat intolerance and hypohidrosis since childhood; (4) chronic fatigue throughout adulthood; and (5) chronic NSAID usage.   Physical examination was remarkable for an elevated blood pressure of 167/110.   Serum chemistries revealed elevated BUN (133 mg/dL), serum Cr (19 mg/dL), serum phosphate (8.4 mg/dL), and total bilirubin (1.3 mg/dL), and decreased total protein (5.6 g/dL), albumin (3.2 g/dL), calcium (7.1 mg/dL), and magnesium (1.4 MEq/L).   PTH was elevated at 437 pg/ml. Urinalysis was remarkable for a pH of 6.0, a low specific gravity of 1.015, >300 mg protein, and moderate free Hbg. A urinary drug screen was positive for cocaine.   C3 was depressed; C4 was WNL. Serologies for ANA, ANCA, hepatitis and HIV were negative.   An echocardiogram of the heart revealed left ventricular hypertrophy and an EKG showed conduction abnormalities. LDH was increased but cardiac enzymes were WNL. Troponin I was mildly elevated at 0.16 ng/ml.   Hematologic labs revealed reduced RBC (3.19), Hgb (8.5 g/dL), Hct (25%), and MCV (78).   Serum iron and ferritin were WNL. The platelet count was 117k with a PT/PTT of 14/30 and a reduced INR of 1.09.   WBC was 9.1 with a slight drop in granulocytes, lymphocytes, monocytes, and eosinophils.   Blood cultures were negative.   Lisinopril was also initiated but discontinued after the patient developed angioedema.

            The patient was placed on dialysis for ESRD thought secondary to uncontrolled hypertension, cocaine abuse and NSAID-associated nephropathy. A kidney biopsy was performed to determine a possible etiology for the renal disease.

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