Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 54-year-old woman is evaluated for fatigue, anorexia, polyuria, and nocturia

mksap
Conditions
July 30, 2016
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 54-year-old woman is evaluated for fatigue, anorexia, polyuria, and nocturia of several weeks’ duration. She had otherwise felt well until the onset of her current symptoms. Medical history is significant for autoimmune pancreatitis diagnosed 1 year ago, treated with a prednisone taper that was completed 8 months ago with resolution of her symptoms. She takes no medications.

On physical examination, temperature is 36.2 °C (97.2 °F), blood pressure is 110/58 mm Hg, pulse rate is 72/min, and respiration rate is 16/min. BMI is 25. Estimated central venous pressure is 7 cm H2O. The lungs are clear. There are no murmurs or extra heart sounds. Abdominal examination is unremarkable. There is no edema.

Laboratory studies:

Blood urea nitrogen 56 mg/dL (20 mmol/L)
Creatinine 5.2 mg/dL (459.7 µmol/L)
Serum free light chain ratio Normal
Urinalysis pH 5.0; 1+ protein; 3-5 erythrocytes/hpf; 5-10 leukocytes/hpf; occasional leukocyte casts

Chest radiograph is normal. Kidney ultrasound shows slightly enlarged kidneys without evidence of obstruction.

Which of the following is the most likely diagnosis?

A: ANCA-associated vasculitis
B: Anti–glomerular basement membrane antibody disease
C: IgG4-related interstitial nephritis
D: Lupus nephritis

MKSAP Answer and Critique

The correct answer is C: IgG4-related interstitial nephritis.

The most likely diagnosis is IgG4-related interstitial nephritis. This patient has a history of autoimmune pancreatitis and now presents with acute kidney injury. Her urinalysis is most consistent with a tubulointerstitial pattern, with mild proteinuria and the presence of inflammatory cells. This history and clinical presentation suggest the possibility of IgG4-related interstitial nephritis. Systemic IgG4-related disease is an uncommon disorder characterized by infiltration of different organs by lymphoplasmacytic infiltrates of IgG4-positive plasma cells with resultant fibrosis associated with elevated serum IgG4 levels. Autoimmune pancreatitis is one form of IgG-related disease, although other organs such as the kidney may be affected, most commonly as interstitial nephritis. IgG4-related interstitial nephritis may present with acute or chronic kidney failure as well as renal mass–like lesions on imaging. As with other IgG4-related diseases, almost all patients with IgG4-related kidney disease will have elevated serum IgG4 levels, and the kidneys may be diffusely enlarged on imaging due to cellular infiltration. Definitive diagnosis requires kidney biopsy with staining for IgG4-positive plasma cells. Treatment is similar to other IgG4-related diseases using immunosuppression with glucocorticoids.

ANCA-associated vasculitis and anti–glomerular basement membrane antibody disease typically cause rapidly progressive glomerulonephritis with significant proteinuria and hematuria in the sediment, occasionally with erythrocyte casts, none of which is present in this patient.

Lupus nephritis is primarily a glomerular lesion with significant proteinuria in the context of other clinical findings suggestive of systemic lupus erythematosus. This patient’s clinical presentation is therefore less consistent with this diagnosis.

Key Point

  • IgG4-related disease is characterized by infiltration of different organs by lymphoplasmacytic infiltrates of IgG4-positive plasma cells with resultant fibrosis associated with elevated serum IgG4 levels.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Don't let these 5 reasons prevent you from becoming a doctor

July 29, 2016 Kevin 7
…
Next

The ER physician approach to the crying baby

July 30, 2016 Kevin 1
…

Tagged as: Nephrology

Post navigation

< Previous Post
Don't let these 5 reasons prevent you from becoming a doctor
Next Post >
The ER physician approach to the crying baby

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap

More in Conditions

  • How molecular discoveries are transforming preeclampsia prediction and care

    Thomas McElrath, MD, PhD and Kara Rood, MD
  • How neuroplasticity offers hope for complex PTSD

    Hannah Holmes
  • New treatments for enlarged prostate offer faster relief with fewer side effects

    Martina Ambardjieva, MD, PhD
  • How value-based care transforms chronic kidney disease management

    Timothy Pflederer, MD
  • Why telling kids to eat less and move more fails to address obesity

    Callia Georgoulis
  • Clinical ghosts and why they haunt our exam rooms

    Kara Wada, MD
  • Most Popular

  • Past Week

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Why so many doctors secretly feel like imposters

      Ryan Nadelson, MD | Physician
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Why rigorous training is vital for today’s surgeons

      Philip Alford, MD | Physician
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician
    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
  • Recent Posts

    • From rejection to resilience: a doctor’s rise through the Caribbean route

      Ryan Nadelson, MD | Education
    • Rethinking medical gatekeeping in the age of AI

      Justin Schrager, MD, MPH | Tech
    • Why physicians struggle with caregiving and how to cope with grace

      Jessie Mahoney, MD | Physician
    • How molecular discoveries are transforming preeclampsia prediction and care

      Thomas McElrath, MD, PhD and Kara Rood, MD | Conditions
    • Why agency and partnership are vital in modern health care

      Alan P. Feren, MD | Physician
    • How neuroplasticity offers hope for complex PTSD

      Hannah Holmes | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Why so many doctors secretly feel like imposters

      Ryan Nadelson, MD | Physician
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Why rigorous training is vital for today’s surgeons

      Philip Alford, MD | Physician
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician
    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
  • Recent Posts

    • From rejection to resilience: a doctor’s rise through the Caribbean route

      Ryan Nadelson, MD | Education
    • Rethinking medical gatekeeping in the age of AI

      Justin Schrager, MD, MPH | Tech
    • Why physicians struggle with caregiving and how to cope with grace

      Jessie Mahoney, MD | Physician
    • How molecular discoveries are transforming preeclampsia prediction and care

      Thomas McElrath, MD, PhD and Kara Rood, MD | Conditions
    • Why agency and partnership are vital in modern health care

      Alan P. Feren, MD | Physician
    • How neuroplasticity offers hope for complex PTSD

      Hannah Holmes | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...