Case 18

Published on 18/02/2015 by admin

Filed under Allergy and Immunology

Last modified 18/02/2015

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CASE 18

Doris is a 25-year-old married black woman. Over the past 6 months she has noticed increasing swelling in her legs with “frothy” dark urine and she has had intermittent severe headaches, unrelated to menses. Despite her and her husband’s wishes, she has been unable to conceive for 5 years and now has had three spontaneous abortions, all in the first 8 to 12 weeks of pregnancy. Query into the family history indicated that she was an adopted child. A detailed analysis of Doris’s serum immunoglobulin, a complete blood cell count, and blood chemistry was ordered. Laboratory results indicated a mild increase in leukocytes, elevated IgG and serum creatinine levels, but a mild thrombocytopenia. Additionally, urinalysis indicated that she was spilling protein in her urine, along with some red cells.

QUESTIONS FOR GROUP DISCUSSION

1. What is the significance of leg swelling and urinary problems in an otherwise healthy 25-year-old? List the three facts that indicate that Doris has urinary problems.

2. Explain why a kidney infection or kidney stone is not high on your list of considerations. In the absence of these conditions, what would the spilling of protein and red blood cells into the urine suggest?

3. Noninfectious inflammation in the kidneys as a consequence of autoantibodies could trigger an inflammatory response. In some conditions, autoantibodies bind directly to cells forming immune complexes. In other conditions, autoantibodies form complexes with soluble antigens. These complexes may lodge in small vessels and trigger inflammatory processes. Explain how the inflammatory response would be triggered, irrespective of which of these two scenarios was occurring (see Case 23).

4. Despite the similarities with respect to urinalysis and elevated serum creatinine, there are differences with respect to clinical presentation in this patient and the one described in Case 17. Discuss these differences.

5. Doris has had severe intermittent headaches. Although this could be a forerunner of a central nervous system (CNS) malignancy, we should consider immunologic causes of headaches, given the apparent noninfectious inflammation in the kidney. What immunologic conditions can cause headaches?

6. Doris has had three spontaneous abortions. Are there any immunologic causes that can lead to spontaneous abortions? Explain how this would occur.

7. Given the diverse spectrum of symptoms, we could consider multiple causes or focus on a systemic autoimmune disorder. Explain how immune complex deposition could account for both the renal problems and the headaches.

8. What might you expect to see if we measured the serum C3 levels? Why? How could you use this “marker” to monitor active disease or therapy?

9. What would you expect to see if you performed a biopsy with immunofluorescence staining? Compare/contrast with what was reported in Case 17.

10. This patient has a mild thrombocytopenia. Explain the role that the indirect and the direct Coombs’ tests have in determining the cause of thrombocytopenia.

RECOMMENDED APPROACH

Implications/Analysis of Family History

At 25 years of age, congenital defects are unlikely to make their first appearance. Unfortunately, because Doris is adopted we cannot trace any potential genetic susceptibility for her disease. However, we need to consider those disorders in which data indicate a significant ethnic susceptibility in black females.

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