presentasi jurnal diverticullum Meckel

8/13/2019 presentasi jurnal diverticullum Meckel

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Case Report

Acute Renal Failure Secondary toTuberculosis:

A Diagnostic Challenge

Oktaviani Halim

030.09.178

Nefrologi


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INTRODUCTION

Tuberculosis (TB)

:

Disease ofthe past

Disease patterns and clinical presentations:

Acquired Immunodeficiency Syndrome (AIDS)

Globalization with immigration from TB endemic countries

Reemergingin recent

times


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INTRODUCTION

Unusual case of acute renal failure secondary

to renal tuberculosis : The initial clinical and serological

picture was highly suggestive of lupus nephritis.

The challenges in the diagnosis and

management of this clinical presentation.


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CASE PRESENTATION

A 45-YEAR-OLD FEMALE resident in Ireland,originally from the Philippines, wastransferred for further management of acute

renal failure.

MALAISEand FATIGUEover the precedingmonth associated with a SMALL, PAINLESS

SWELLING ON THE LEFT SIDE OF THE NECK.


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CASE PRESENTATION

Fevers

Chills

Rigors

night sweats photosensitive rash

joint pains

weight loss

urinary tract symptoms..

Upper respiratory tractsymptoms, sinusitis, or

rash.

Taking any medicationsor herbal remedies

NEGATIVE


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CASE PRESENTATION

Past medical history was unremarkable except

for LUMPECTOMY FOR A BENIGN BREAST

CYST several years ago.

Menstrualcycles :normal

No history of miscarriages in the past.

SERUM CREATININE on admission was205

mol/L with an active urine sediment


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CASE PRESENTATION

On examination, she appeared UNWELL, was

afebrile, with a BLOOD PRESSURE

130/80MMHG, and weighed 57 kgs.

A bedside urine dipstick was positive for

BLOOD (+) AND PROTEIN (+++).

Oral ulceration, rashes, or joint swelling:

Negative


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CASE PRESENTATION

Neck:

Supple to palpation except for a SOLITARY 1

CM NONTENDER, MOBILE LYMPH NODE IN

THE LEFT ANTERIOR TRIANGLE OF NECK.

The thyroid gland was not enlarged.

Cardiovascular, respiratory, and abdominal

examination was unremarkable.


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CASE PRESENTATION

Biochemical investigations revealed A SERUM

CREATININE WHICH HAD RISEN TO 568

MOL/L AND UREA OF 23.4 MMOL/L.

Haemoglobin level of 13 g/dL ; SERUM C-

REACTIVE PROTEIN OF 74 MG/L (normal


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CASE PRESENTATION

A full vasculitic screen :

Antinuclear factor (ANF) was positive with a

homogenous pattern

Antidouble-stranded DNA antibodies were raised

(anti-dsDNA titre 59, >30 positive)

Antineutrophil cytoplasmic (ANCA) and

antiglomerular basement membrane antibodieswere negative.

Antistreptolysin O titres were also within

normal limits.


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CASE PRESENTATION

Serum complement levels showed depletion

of C4 and normal C3 levels.

Serology was negative for human

immunodeficiency virus (HIV), toxoplasmosis,

and brucellosis.

A 24-hour urine collection quantified the

PROTEINURIA AT 1.2 G/24 HRS.


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CASE PRESENTATION

Chest radiograph was normal.

Renal ultrasonography : Normal sized kidneys withgood corticomedullary differentiation and no evidenceof hydronephrosis.

Fine needle aspiration biopsy of the neck lump :mature lymphocytes admixed with neutrophils, with90% of the cells showing positivity for CD45stronglysuggestive of nonspecific inflammatory changes.

In view of the presentation of acute renal failure,haematuria, and proteinuria with serological evidencesuggestive of lupus, a renal biopsy was performed toclarify the diagnosis.


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CASE PRESENTATION

Histopathology results, however, showed

WIDESPREAD CASEATING GRANULOMATA

WITH LANGERHANS CELLSconsistent with

renal tuberculosis.

No acid fast bacilli (AFB) were seen on light

microscopy.


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CASE PRESENTATION

Granuloma with caseating central necrosis (white arrow).


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CASE PRESENTATION

Patient had been vaccinated with BCG in herchildhood, Didnt have any contact with tuberculosis

carriers nor was there any history of recent travelabroad.

Mantoux test : Positive at 12 mm.

Sputum microscopy : Negative for AFB.

Serial early morning urine samples : Negative for AFB.

CT of the thorax, abdomen, and pelvis : ENLARGEDRETROGASTRIC LYMPH NODES MEASURING UP TO 2.8 1.2 CMand further SUBCENTIMETRE MEDIASTINALAND RETROPERITONEAL LYMPH NODES.


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CASE PRESENTATION

She was commenced on standardcombination antituberculous chemotherapyconsisting of isoniazid, rifampicin, ethambutol,

and pyrazinamide. She subsequentlydeveloped deranged liver enzymes whichnormalized following withdrawal of rifampicin.

Completed 18 months of treatment for renaltuberculosis, butfailed to recover renalfunctionand is now Dialysis Dependent,Awaiting Renal Transplantation.


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CASE PRESENTATION

A repeat renal biopsy was performed :

following completion of anti-tuberculous

therapy.

This confirmed significant tubulointerstitial

fibrosis in the absence of any caseating

granulomas.

A follow-up CT scan showed resolution of the

previously detected lymphadenopathy.


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CASE PRESENTATION

Tubulointerstitial fibrosis in the absence of caseating granulomas


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DISCUSSION

The case above illustrates the presentation ofacute renal failure in a patient with an activeurinary sediment and serological evidence oflupus as suggested by anti-dsDNA positivity and

complement consumption. These biochemicalfeatures strongly raised the clinical suspicion oflupus nephritis.

However, other causes of rapidly progressiverenal failure including post infectiousglomerulonephritis as well as vasculitic andinterstitial glomerulonephritis were also

considered in the differential diagnosis.


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DISCUSSION

Our patient also presented with painless cervicallymphadenopathy, and other conditions such as

lymphoma, sarcoidosis, toxoplasmosis,

brucellosis, HIV, local salivary gland neoplasia andparagangliomas were also considered.

However, a renal biopsy was critical in securing

the correct diagnosis of renal tuberculosis to

guide appropriate treatment in our patient.

The presence of caseous necrosis on renal biopsy

made sarcoidosis unlikely in this setting.


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DISCUSSION

This case highlights the importance ofpostprimary tuberculosis as a reemerging

clinical problem, particularly withthe trend of

widespread immigration and globalisation. Renal tuberculosis usually presents as gross

haematuria, insidious pyuria, or obstructive

uropathy but can also present rarely withacute renal failure in HIV patients with

tuberculosis treated with rifampicin.


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DISCUSSION

This case is unique in that it combined acompatible clinical and serological picturesuggestive of lupus nephritis, while renalhistopathology confirmed the cause of acuterenal failure as tuberculosis.

Although highly specific for systemic lupuserythematosus, false positive antidsDNA

antibodies have been described in a healthysubset of an elderly population but are veryunusual in younger individuals such as ourpatient.


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DISCUSSION

The mechanism of this finding remainsunclear. The degree of proteinuria in our case

is also unusual in renal tuberculosis, however,

there were no other clinical symptoms or signsto support lupus at diagnosis and these did

not manifest in her later followup as well.


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DISCUSSION

To our knowledge, acute renal failure secondaryto renal tuberculosis presenting in this mannerhas not been reported previously in theliterature.

This case highlights the importance of clarifyingthe diagnosis of acute renal failure through renalbiopsy where possible, prior to thecommencement of treatment.

It also illustrates the need to be aware of atypicalclinical presentations of tuberculosis which maybe more common in the contemporary setting.


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CONCLUCION

The diagnosis of tuberculosis and systemic lupus

erythematosus can be clinically challenging as

highlighted by this case.

It is also important to consider tuberculosis in the

differential diagnosis of unusual presentations,particularly in immigrant populations and

immunosuppressed individuals.


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