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National Renal Pathology E.Q.A. Scheme

Circulation Y

This document gives information on individual cases in circulation Y of this scheme. It contains no personal details of participants.


Cases included:

Y 272
Y 273
Y 274
Y 275
Y 276
Y 277
End


A click on the {Image} icon should provide an image from the material circulated. Some of the images are composites - remember to scroll the image to see parts beyond the bottom of your screen.

WARNING The image files associated with this document are selected by the Organiser in an attempt to illustrate the relevant features of the material which was circulated in the EQA scheme. They are intended as an 'aide memoire' for participants who may no longer have the slides for review.

They are NOT intended as 'good examples' or as teaching material. Some of the images may be chosen to illustrate a feature which led some participants to a wrong diagnosis.


Case Response Analysis

Circulation: Y

Case number: 272 .... {Image}


Number of responses:83 . Date of analysis: 7 JUL 07

Clinical:

Male, 64 y.o. Known hypertension & ischaemic heart disease. Acute on chronic renal failure, creatinine inc from 140 - 1066. Haematuria, arthralgia. ANCA +, PR3. ?vasculitis. On ACE inhibitors & NSAIDS. IF showed small amount of IgA within paramesangium. Small amount of granular IgG in a peripheral location. C3 shows non-specific staining. No other immune reactants.

Specimen:

H&E
Diagnostic categories:                         Score:
 1  Pauci-immune crescentic Gn / vasculitis                 8.59
 2  Henoch Schonlein nephritis / IgA nephropathy            0.54
 3  Granulomatous interstitial nephritis                    0.12
 4  Crescentic Gn / IgA nephropathy                         0.27
 5  Wegener's glomerulonephritis                            0.12
 6  Crescentic glomerulonephritis NOS                       0.24
 7  Extracapillary proliferative glomerulonephritis         0.12

Asterisks (if any) indicate dangerous diagnoses.     
Highest scoring diagnosis was 1 with 8.59

Secondary diagnoses and comments (if any):

Exclude ascending infection*1. EM*16. Silver stain*4. PAS*2. Need to see IgA to judge significance *15. ATN too*7. Anti-GBM antibody?*1. Insufficient material / not suitable for EQA*12.

Original report and further information (if any):

Necrotising glomerulonephritis consistent with ANCA-positive vasculitis. Also acute tubular damage and haemorrhage. Choroic damage probably due to longstanding hypertensive vascular damage.


Circulation: Y

Case number: 273 .... {Image}


Number of responses:83 . Date of analysis: 7 JUL 07

Clinical:

Female, 44 years old. Arthralgia and rash. Creatinine 150, MPO >100, ANA+, pANCA+. Immunofluorescence: IgA/M/G, C1q, C3 all positive. EM not performed.

Specimen:

H&E
Diagnostic categories:                         Score:
 1  SLE class III                                           5.30
 2  SLE Class II                                            2.05
 3  SLE class IV                                            1.33
 4  SLE NOS                                                 0.60
 5  Mesangial proliferative Gn (SLE not mentioned)          0.12
 6  Henoch Schonlein purpura                                0.12
 7  Gn ?SLE                                                 0.12
 10 Specific diagnosis not possible, ?SLE                   0.36

Asterisks (if any) indicate dangerous diagnoses.     
Highest scoring diagnosis was 1 with 5.30

Secondary diagnoses and comments (if any):

Further lupus serology (e.g. anti-dsDNA)*11. Silver stain (for subclassification*6)*14. PAS*4. EM*14. More details/pictures of IF*12. More clinical info*5. Drug history?*2. Oxalate crystals noted*1. Unsuitable for EQA*5.

Original report and further information (if any):


Circulation: Y

Case number: 274 .... {Image}


Number of responses:83 . Date of analysis: 7 JUL 07

Clinical:

Male, 27 years old. "Coryzal" symptoms for one month. Creatinine on presentation 608. No other significant haematological or immunological findings. IP: Negative. EM: No glomeruli.

Specimen:

H&E,
Diagnostic categories:                         Score:
 1  Acute tubular necrosis                                  5.59
 2  Normal (by light microscopy)                            1.20
 3  Sickle cell disease                                     0.22
 4  HUS                                                     0.02
 5  Tubulo-interstitial nephritis                           0.43
 6  Not diagnostic                                          1.45
 7  FSGS                                                    0.26
 8  Minimal change nephropathy                              0.22
 9  Hereditary nephropathy                                  0.09
 10 Others- post-infectious, HIVAN...                       0.52

Asterisks (if any) indicate dangerous diagnoses.     
Highest scoring diagnosis was 1 with 5.59

Secondary diagnoses and comments (if any):

Unsuitable for EQA*39. EM on material from paraffin block*5. Silver*5. PAS*2. More clinical info.*7. Proteinuria?*2. Exclude myoglobinuria*1. TIN too*1. Tubular damage insufficient to explain ARF*6. Drug related?*4.

Original report and further information (if any):

Acute tubular insult. No true necrosis. No significant glomerular changes. Creatinine peaked at 608, then completely normal 2-3 months later, with supportive therapy only.


Circulation: Y

Case number: 275 .... {Image}


Number of responses:83 . Date of analysis: 7 JUL 07

Clinical:

Female, 17 years of age. Six weeks haemoptysis. Anti GBM positive in the blood test. Raised creatinine - 114. Immunofluorescence - IgG 3+ linear GBM staining with some C3.

Specimen:

H&E
Diagnostic categories:                         Score:
 1  Anti-GBM antibody disease / Goodpasture                 9.76
 2  Probable vasculitis, not diagnostic                     0.12
 3  Diffuse endocapuillary glomerulonephritis               0.12

Asterisks (if any) indicate dangerous diagnoses.     
Highest scoring diagnosis was 1 with 9.76

Secondary diagnoses and comments (if any):

ANCA*2. Silver*4. MSB*2. PAS*1. ANCA?*4. Prominent interstitial eosinophils ?TIN*2. Light micro. not typical of anti-GBM disease*3. Early / mild disease*6.

Original report and further information (if any):

Anti-GBM glomerulonephritis with clinical features of Goodpastures syndrome. Treatment (immunosuppression and plasma exchange) was successful.


Circulation: Y

Case number: 276 .... {Image}


Number of responses:81 . Date of analysis: 7 JUL 07

Clinical:

Male, 62 years old. Alcoholic liver disease and nephrotic syndrome with a urinary protein of 5g/24hrs. EM shows patchy effacement of podocyte foot processes and focal areas show wrinkling of basement membranes. No electron dense deposits seen.

Specimen:

H&E, PAS, Photo's of C1q and IgM
Diagnostic categories:                         Score:
 1  Primary FSGS                                            7.70
 2  FSGS (collapsing / cellular form)                       0.56
 3  C1q nephropathy                                         0.07
 4  FSGS (Tip variant)                                      0.48
 5  Diffuse mesangial proliferative Gn                      0.37
 6  Diabetic glomerulopathy                                 0.12
 7  Minimal change nephropathy                              0.17
 8  Focal Segmental Glomerulonephritis                      0.25
 9  Mesangiocapillary Gn 2ry to cryo.                       0.12
 10 Focal proliferative glomerulonephritis                  0.15

Asterisks (if any) indicate dangerous diagnoses.     
Highest scoring diagnosis was 1 with 7.70

Secondary diagnoses and comments (if any):

Secondary to liver disease?*3. Was IgA negative?*3. Not diagnostic / unsuitable for EQA*4. Clinical info.*1. Silver stain*3. PAS*1. . Exclude SLE*1. Exclude diabetes*2. Slides missing*3.

Original report and further information (if any):

Focal segmental glomerular sclerosis.


Circulation: Y

Case number: 277 .... {Image}


Number of responses:74 . Date of analysis: 7 JUL 07

Clinical:

FOR EDUCATION AND INTEREST ONLY. Male, 65 years old. Acute Renal Failure. Creatinine 124 in May, now 837. All immunology negative. Urine blood +++ protein +++ Initial presentation before ARF was nephrotic. IF for IgA and IgM negative.

Specimen:

H&E, Silver: EM, IF of IgG, C3, Kappa & Lambda
Diagnostic categories:                         Score:
 1  Monoclonal immunoglobulin deposition disease            1.62
 2  Mesangiocap./ prolif. Gn with monoclonal deposits       2.91
 3  Light chain deposition disease                          3.04
 4  Myeloma kidney and proliferative Gn                     0.14
 5  Membranous Gn and monoclonal protein deposition         0.41
 6  Crescentic change in membranous Gn                      0.41
 7  Non-amyloid immunoglobulin deposition disease           0.27
 8  Post-infectious Gn                                      0.41
 9  Mesangiocapillary Gn                                    0.68
 10 Immunotactoid / Fibrillary Gn                           0.14

Asterisks (if any) indicate dangerous diagnoses.     
Highest scoring diagnosis was 3 with 3.04

Secondary diagnoses and comments (if any):

Also ? post-infective?*1. ATN too*4. Cryoglobulinaemia?*3. Amyloidosis?* 2. Urine/serum IEP*2. Skeletal survey*1. See KI 2004;65:85-96*1. Any deposit on TBMs?*1. ANCA?*1. Anti-GBM?*1. Higher mag. /more EM*3.

Original report and further information (if any):

Monoclonal immunoglobulin deposition disease, light and heavy chains, causing a mesangiocapillary pattern of glomerulonephritis. Subsequent investigation confirmed monoclonal IgG kappa paraprotein.


Links to cases in this document:
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Y 272
Y 273
Y 274
Y 275
Y 276
Y 277



Last updated: 7 JUL 07
Organiser: Professor Peter Furness, PhD, FRCPath. Department of Pathology
Leicester General Hospital
Gwendolen Road
Leicester
LE5 4PW, U.K.
Tel: (0116)2584582
Fax: (0116) 2584582

Email: peter.furness@le.ac.uk