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