Renal, Male Renal, Male Reproductive Reproductive

ModuleModule

Normando C. Gonzaga, M.D, F.P.SP., Normando C. Gonzaga, M.D, F.P.SP., I.F. CAPI.F. CAP

Case 1Case 1

A 10-year old boy consulted a physician A 10-year old boy consulted a physician because of tea colored urine and puffiness of because of tea colored urine and puffiness of the eyelids especially noted in the morning. the eyelids especially noted in the morning. Blood pressure of the patient is 140/90. Blood pressure of the patient is 140/90. These symptoms were noticed 3 weeks after These symptoms were noticed 3 weeks after he had fever and sore throat. Laboratory he had fever and sore throat. Laboratory examinations disclose the following: examinations disclose the following: urinalysis: protein-4+, sugar, - neg,leucocytes urinalysis: protein-4+, sugar, - neg,leucocytes – 0-1/hpf, rbc- 10-20/hpf, red cell cast- 1-2/lpf, – 0-1/hpf, rbc- 10-20/hpf, red cell cast- 1-2/lpf, granular cast – 0-1/lpf, waxy cast- 0-1/lpf;.granular cast – 0-1/lpf, waxy cast- 0-1/lpf;.

1. Describe the H&E 1. Describe the H&E section. section.

2. Describe and locate the 2. Describe and locate the dense depositsdense deposits

seat work/ homeworkseat work/ homework

1.1. What is your syndrome diagnosis, What is your syndrome diagnosis, morphologic diagnosis? Give the bases for morphologic diagnosis? Give the bases for your diagnoses.your diagnoses.

2.2. What is the most important laboratory finding What is the most important laboratory finding which is highly suggestive of the clinico-which is highly suggestive of the clinico-morphologic diagnosis?morphologic diagnosis?

3.3. What other laboratory work-ups could could What other laboratory work-ups could could suggest that this is a post infectious lesion?suggest that this is a post infectious lesion?

4.4. What immunofluorescence finding is What immunofluorescence finding is expected. Describe the classical pattern.expected. Describe the classical pattern.

5.5. What would be the prognosis in children? In What would be the prognosis in children? In adults?adults?

Case 2Case 2

A 16-year old female was discovered to have A 16-year old female was discovered to have microscopic hematuria on routine urinalysis microscopic hematuria on routine urinalysis during the entrance physical examination. during the entrance physical examination. Immunofluorescent microscopy shows the Immunofluorescent microscopy shows the following: IgG – negative; IgM- 1+, following: IgG – negative; IgM- 1+, basement membrane; IgA – 2+, mesangium; basement membrane; IgA – 2+, mesangium; C3-1+, basement membrane and C3-1+, basement membrane and mesangium; C1q – negative; Fibrinogen – 2+ mesangium; C1q – negative; Fibrinogen – 2+ basement membrane and mesangium. basement membrane and mesangium.

Case 2.. Case 2.. Slide 2.a.Slide 2.a. Below is the Below is the appearance of immunofluorescence to IgA appearance of immunofluorescence to IgA

antibody. IgG and IgM are negative. antibody. IgG and IgM are negative. Describe the IF findings.Describe the IF findings.

Describe the light microscopic findings (PAS STAIN)Describe the light microscopic findings (PAS STAIN)

Seatwork/homeworkSeatwork/homework

1.1. What is your syndrome and clinico-morphologic What is your syndrome and clinico-morphologic diagnoses?diagnoses?

2.2. Describe the possible light microscopic patterns Describe the possible light microscopic patterns of this type of glomerulopathy based on WHO.of this type of glomerulopathy based on WHO.

3.3. Describe the expected pattern of dense deposits Describe the expected pattern of dense deposits in the electron microscope.in the electron microscope.

4.4. What would be the best diagnostic tool for this What would be the best diagnostic tool for this particular case?particular case?

5.5. If this patient manifests dermatologic and If this patient manifests dermatologic and abdominal symtptoms aside from hematuria, what abdominal symtptoms aside from hematuria, what would be the most apropriate clinico-pathologic would be the most apropriate clinico-pathologic diagnosis? diagnosis?

Case 3.Case 3.

A 5-year old boy was noticed to have periorbital A 5-year old boy was noticed to have periorbital and pedal edema for the last 2 months. and pedal edema for the last 2 months. Urinalysis shows 3+ protein. Blood exam shows Urinalysis shows 3+ protein. Blood exam shows 1.5 mg/ dl protein and 250 mg/dl cholesterol. 1.5 mg/ dl protein and 250 mg/dl cholesterol. Renal biopsy discloses normocellular glomeruli. Renal biopsy discloses normocellular glomeruli. Immunofluorescence is negative to all Immunofluorescence is negative to all antibodies. antibodies.

Electron Electron microscopymicroscopy

Scanning Scanning electronmicrographelectronmicrograph→→

←Transmission electronmicrograph

• Correlate the two micrographs and describe the common finding.

Seatwork/homeworkSeatwork/homework

1.1. What is your syndrome diagnosis and clinico-What is your syndrome diagnosis and clinico-morphologic diagnoses? morphologic diagnoses?

2.2. What is the most specific diagnostic tool used What is the most specific diagnostic tool used in renal biopsy for the diagnosis of this case?in renal biopsy for the diagnosis of this case?

3.3. What is the prognosis of this case?What is the prognosis of this case?

4.4. What pathologic variant would show light What pathologic variant would show light microscopic findings and possible microscopic findings and possible immunofluorescent findings. In a table form, immunofluorescent findings. In a table form, give the differences between this case and the give the differences between this case and the other clinicopathologic variant. other clinicopathologic variant.

Case 4Case 4

A 25-year old female consulted a A 25-year old female consulted a nephrologist because of bubbly urine. nephrologist because of bubbly urine. The physician after working her up find The physician after working her up find out that she also has sign and symptoms out that she also has sign and symptoms of nephrotic syndrome. On top of that of nephrotic syndrome. On top of that her BP is 160/100.Her urinalysis shows her BP is 160/100.Her urinalysis shows numerous sediments. The patient has numerous sediments. The patient has been diagnosed with lupus been diagnosed with lupus erythematosus 5 years ago. erythematosus 5 years ago.

Below are the LM, IF, and EM Below are the LM, IF, and EM findings:findings:

Seatwork/homeworkSeatwork/homework

1.1. Immunofluorescent findings show”full house” Immunofluorescent findings show”full house” effect. Explain what full house effect means. effect. Explain what full house effect means. Give the significanceGive the significance

2.2. Enumerate the WHO classification of lupus Enumerate the WHO classification of lupus nephritis. Compare this classification with the nephritis. Compare this classification with the ISN/RPS classification.ISN/RPS classification.

3.3. Which class is the most common and has the Which class is the most common and has the worst prognosis?worst prognosis?

4.4. Explain the term ‘transformation’ in lupus Explain the term ‘transformation’ in lupus nephritis.nephritis.

5.5. What do you mean by activity index and What do you mean by activity index and chronicity index in lupus nephritis.?chronicity index in lupus nephritis.?

Case 5Case 5A 25-year old male was admitted in A 25-year old male was admitted in the emergency room because of high the emergency room because of high fever associated with flank pain. fever associated with flank pain. CBC shows WBC of 15, 000/cu. mm. CBC shows WBC of 15, 000/cu. mm. Urinalysis shows:Urinalysis shows:protein = 2 +protein = 2 +RBC = 4/lpfRBC = 4/lpfWBC = too numerous to countWBC = too numerous to count

The patient died 3 days after admission The patient died 3 days after admission because of septic shock. In autopsy, because of septic shock. In autopsy, below are the findings in the kidney. below are the findings in the kidney. Describe the histologic findings.Describe the histologic findings.

Summary QuestionsSummary Questions

1.1. Give your diagnosis.Give your diagnosis.

2.2. What is the most common etiologic What is the most common etiologic agent of this lesion?agent of this lesion?

3.3. What are the routes of infection?What are the routes of infection?

4.4. What laboratory exam confirms the What laboratory exam confirms the diagnosis? Why?diagnosis? Why?

Case 6Case 6

A 40-year old male suddenly experienced A 40-year old male suddenly experienced severe headache. Upon consultation, his severe headache. Upon consultation, his BP is noted to be 200/ 120. Past history BP is noted to be 200/ 120. Past history shows normal BP on regular check-ups. shows normal BP on regular check-ups. Antihypertensives are immediately given. Antihypertensives are immediately given. However, BP remains in the range of However, BP remains in the range of 200/120 – 180/ 100. Nicardipine drip is 200/120 – 180/ 100. Nicardipine drip is instituted. 2 days later, patient died instituted. 2 days later, patient died because of intracerebral hemorrhage.because of intracerebral hemorrhage.

If autopsied, which of the two gross specimens If autopsied, which of the two gross specimens of the kidney would be compatible with the of the kidney would be compatible with the patient’s condition? Describe each.patient’s condition? Describe each.

Which of the 2 microscopic findings of the Which of the 2 microscopic findings of the arteriole of the kidney is compatible with this arteriole of the kidney is compatible with this case? Describe each .case? Describe each .

Case 7Case 7A 45 year old female consulted a A 45 year old female consulted a physician because of blood clot in physician because of blood clot in the urine. Six months prior to the urine. Six months prior to consultation, she has been consultation, she has been experiencing on and off flank experiencing on and off flank pain. On physical, examination, pain. On physical, examination, the physician appreciated an the physician appreciated an abdominal mass.abdominal mass.

Below is the H& E section Below is the H& E section of the tumorof the tumor

Summary QuestionsSummary Questions

1.1. Give your diagnosis.Give your diagnosis.

2.2. What are the factors in the What are the factors in the prognosis of this case?prognosis of this case?

3.3. If the tumor of this patient If the tumor of this patient originated in the pelvis of the originated in the pelvis of the kidney, what would be the kidney, what would be the histologic type?histologic type?

Case 8Case 8A 65-year old male consulted a A 65-year old male consulted a physician because of difficulty of physician because of difficulty of urination for the past 6 months. urination for the past 6 months. He has also observed his urine He has also observed his urine to be tea colored. On rectal to be tea colored. On rectal examination, a firm enlarged examination, a firm enlarged mass is palpated anteriorly. mass is palpated anteriorly. Ultrasound shows calcification in Ultrasound shows calcification in the enlarged prostate. Six the enlarged prostate. Six months ago, his PSA level months ago, his PSA level showed 6 ng/ml. Repeat PSA on showed 6 ng/ml. Repeat PSA on admission shows 15 ng/ml.admission shows 15 ng/ml.

Which of the two histologic sections is Which of the two histologic sections is compatible with the patient’s condition? compatible with the patient’s condition? Describe each.Describe each.

1.1. What is the significance of the PSA What is the significance of the PSA determination in the diagnosis of prostatic determination in the diagnosis of prostatic diseases?diseases?

2.2. Differentiate free PSA from predicted Differentiate free PSA from predicted PSA level.PSA level.

3.3. Why should PSA determination be Why should PSA determination be repeated within 3 to 6 months after the repeated within 3 to 6 months after the first determination?first determination?