Case presentation
A 50-year-old Ethiopian woman presented with a 2-week history of facial
swelling, and reddish discoloration of urine. She was in her usual state
of health until 2-week before admission, when she developed a
non-projectile vomiting of ingested matter and facial swelling that
progressed to involve both legs. She also complained of reddish
discoloration of urine, decreased urine volume, dull aching left flank
pain with no radiation, anorexia, and fatigue. She also provided history
of shortness of breath on exertion and intermittent dry cough. Otherwise
she denied any hemoptysis, nasal discharge, epistaxis, skin rash, joint
pain, atopy, asthma, fever, night sweat and other systemic symptom. She
didn’t have preceding diarrhea, gastrointestinal bleeding, sore throat,
orthopnea, PND, visual disturbance, headache, neck pain, neck stiffness,
and change in mentation. Her past medical history was non-revealing.
Similarly, her sexually history was also unremarkable. She have never
been diagnosed or treated for syphilis. She is not on any medication;
she did not smoke tobacco, use illicit drugs, or drink alcohol. Her
family history was unremarkable.
On examination, her blood pressure was 190/100 mmHg, the pulse rate 77
beats per minute, respiratory rate 20 breaths per minute, the
temperature 36.8 degree Celsius, and the oxygen saturation 98% while
breathing ambient air. There was peri-orbital swelling and grade one
symmetric bilateral pitting edema of legs. Cardiac examination revealed
grade 2 diastolic murmur heard at aortic area, but JVP was not raised
and there was no pericardial rub. There was no sinus tenderness, nasal
mucosal ulceration and septal deviation, skin rash, lymphadenopathy,
genital ulcer, joint swelling and tenderness. Chest and neurologic
examination was non-revealing.
Laboratory workup disclosed Serum creatinine of 9.28 mg/dl, blood urea
nitrogen 145 mg/dl, and hemoglobin 10.3 mg/dl with MCV of 79.8 fl (Table
1). Urinalysis was positive for +2 albumin and +3 blood. On urine
microscopy, there was 10-15 RBC/HPF and 0-4 WBC/HPF. Rapid plasma reagin
was and confirmatory Treponema pallidum hemaglutination agglutination
(TPHA) reactive. But other serologic tests like ANA, ANCA, ant-GBM and
complement level were not done because of financial reason and
unavailability of laboratory setting in the region. Abdominopelvic
ultrasound showed normal sized kidneys with increased parenchymal
echogenicity and mild ascites. Chest radiography revealed minimal
bilateral pleural effusion and increased cardiothoracic ratio.
Trans-thoracic echocardiography showed thickening of aortic valve with
mild aortic regurgitation but no signs of vegetation and intracardiac
abscess. Renal biopsy wasn’t done due to lack of service in our
institution.
Table 1. Laboratory data on admission