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An unusual case of chronic renal failure
  1. A L Manoj,
  2. A Dhaygude
  1. Department of Medicine, Peterborough District Hospital, Peterborough PE3 6DA, UK
  1. Correspondence to:
 Dr Manoj;
 manojal{at}hotmail.com

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Answers on p 110.

A previously healthy 47 year old driver presented with a six week history of headache, vomiting, tiredness, and unsteadiness of feet. Examination revealed marked pallor, the pulse was regular at 97 beats/min, blood pressure was raised at 180/116 mm Hg, and the minimental test score was 6/10. The cranial nerves were normal, as was his power in all four limbs. Bulk and tone were normal, but all the deep tendon reflexes were brisk. Sensation were intact. The finger, nose, and heel shin test were normal. Gait was wide based. Cardiovascular examination revealed a short ejection systolic murmur at the mitral area. The rest of the clinical examination was unremarkable.

Investigations on admission revealed a normochromic, normocytic anaemia with a haemoglobin of 86 g/l, and a normal white cell and platelet count. His erythrocyte sedimentation rate was raised at 38 mm in the first hour. The patient had a normal sodium concentration of 138 mmol/l and serum potassium of 4.6 mmol/l. His urea and creatinine concentrations were raised at 26 mmol/l (reference range 2.5–8.0) and 609 μmol/l (60–100) respectively. His 24 hour urine collection showed proteinuria of 1.7 g/day. His serum B12, serum folate, and thyroid stimulating hormone were normal. Antineutrophil cytoplasmic antibody and antinuclear factor were negative and serum C3 and C4 were normal. Protein electrophoresis was normal. His electrocardiogram showed left ventricular hypertrophy with strain pattern and his chest radiograph was normal. Ultrasound of the kidneys revealed bilateral small kidneys with a biparietal diameter of 9 cm. A computed tomogram of the head showed wide spread ischaemic changes notably in the periventricular white matter and basal ganglia. Magnetic resonance imaging (MRI) and computed tomography of the head were done (figs 1 and 2). The patient was transferred to a tertiary centre where a renal biopsy was performed which revealed that most of the glomeruli was sclerosed with tubular atrophy, interstitial fibrosis, and severe blood vessel hypertrophy. During his stay in the hospital a rash was noted on the bathing trunk area (fig 3).

Figure 1

Magnetic resonance image of the brain.

Figure 2

Computed tomogram of the head showing widespread ischaemic changes.

Figure 3

Bathing trunk area showing rash (reproduced with patient's permission).

QUESTIONS

  1. What does the MRI scan show?

  2. What is shown in fig 3?

  3. What is the diagnosis?

  4. What do you expect to see in the electron microscopic examination of the kidney?

  5. What investigation will you do to confirm the diagnosis?

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