os 214 [a]: digestive and excretory lab 01.3: lab skills session – case 2 dr. sonia l. chicano...

OS 214 [A]: Digestive and ExcretoryLab 01.3: Lab Skills Session – Case 2

Dr. Sonia L. Chicano

March 12, 2014

2

NIKA, ADA, GUDO

History and PE

• 68/F, known diabetic, presenting with a 5-mo history of hyperpigmented patches on both LE

• She later developed grade 3 bipedal edema, frothy urine, occasional tea-colored urine, and right flank pain.

NIKA, ADA, GUDOLab 01.3: Lab Skills Session – Case 2

Work-Up

• Work-ups revealed consistent hematuria on urinalysis but with (-) dysmorphic RBCs.

• Proteinuria was in the nephrotic range, and serum creatinine was 188.

• She was started on enalapril and losartan for proteinuria, and she was admitted for kidney biopsy.

• ANA (+), normal C3NIKA, ADA, GUDOLab 01.3: Lab Skills Session – Case 2

No mesangial and endothelial proliferation

Segmental sclerosis(-) Mesangial and endothelial proliferationThin and delicate capillary loops (normal)

Silver stain*

Silver stain

Segmental sclerosis

What’s the pattern?

• For case 2: 27 glomeruli– 10 global sclerosis– 1 segmental sclerosis

• 1 out of 27 Focal segmental glomerulosclerosis (FSGS)

NIKA, ADA, GUDOLab 01.3: Lab Skills Session – Case 2

Global sclerosis

Tubular atrophy

Collagen deposition in Bowman’s space, not crescent*

Colloid casts*

Inflammatory interstitial infiltrates

Normal tubules

Inflammatory interstitial infiltrates

H&E

Colloid cast

Arteriole

Calcification* inside a tubule

Global sclerosis (2)Colloid castsTubular atrophy

Colloid cast

Arterioles

Tubular atrophy

Normal tubules

Masson Trichome Stain

Fibrosis(blue green)

1+ trace 1+

Trace-1+

54

1 – Mesangial cells2 – Endothelial cell*3 – Capillary loops4 – Parietal epithelial cell5 – Bowman’s capsule – Effaced foot processes2

31

1

3

Capillary loop

No deposits in GBM

Preserved endothelial fenestrations

Effaced foot processes

No deposits in GBM

Preserved endothelial fenestrations

Effaced foot processes

Effaced foot processes

Effaced foot processes

1 – Nuclei of mesangial cells2 – Cytoplasm of mesangial cells3 – Mesangial matrix

2

1

1

2

3

No mesangial deposits

Summary of Findings

• LM: FSGS• IF: None• EM: Foot process effacement

NIKA, ADA, GUDOLab 01.3: Lab Skills Session – Case 2

Diagnosis

• FSGS with 76% global GS (31/41 glomeruli) and 15% segmental GS (4/41 glomeruli)

• Moderate interstitial fibrosis and tubular atrophy

• R/O: 2º FSGS

NIKA, ADA, GUDOLab 01.3: Lab Skills Session – Case 2