This is the Anatomic Pathology Case of the Month for February, 1996.
Curtis S. Goldblatt, M.D. and Sheldon Bastacky, M.D.
Published on line in February 1996
PATIENT HISTORY : The patient is a 73 year old white man with a history of hypertension and benign prostatic hyperplasia, who presents with a three month history of fever, malaise, anorexia, twenty-five pound weight loss, diffuse myalgias and night sweats, and most recently hemoptysis. His baseline creatinine at the time of admission was 1.9 mg%. Medications on admission included Hytrin, Digoxin, Lasix, Pepcid and Bactrim. He was also receiving steroids at an unspecified dose.
Review of systems at the time of admission was positive for hypertension (200/100) and microscopic hematuria. There was no evidence of edema, gross hematuria, flank pain, history of stones, dysuria, oliguria, anuria, nephrotic syndrome, polyuria, renal masses, family history of renal disease and diabetes.
Physical examination was remarkable for diffuse lower extremity muscle tenderness and a bilateral axillary rash. Chest x-ray showed bilateral diffuse pulmonary infiltrates.
At the time of biopsy, pertinent laboratory data included creatinine 5.4 mg%, BUN 77.0 mg%, urine protein 1+, anti-nuclear antibody (ANA) - borderline positive at a titer of 1:40, anti-streptolysin O (ASO) antibody - titer less than 1:40, perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) - positive at a titer of 1:320, anti-myeloperoxidase antibody - positive at a titer of 1:160, urine sediment - active (RBC - 116/mm3, and many RBC and granular casts). The erythrocyte sedimentation rate (ESR) was 55.0 mm/hr. The anti-double stranded DNA titer was less than 1:2. White blood cell count (WBC) was approximately 14,000/mm3 with a left shift including 16% bands five days prior to admission. Serum and urine protein electrophoreses showed no evidence of a monoclonal gammopathy.