National Renal Pathology E.Q.A. Scheme
Circulation A
This document gives information on individual cases in
circulation A of this scheme. It contains no personal details
of participants.
Cases included:
A 284
A 285
A 286
A 287
A 288
A 289
End
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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
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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: A
Case number: 284
....
Number of responses:78 . Date of analysis: 10 JAN 08
Clinical:
Male, 75 years old. Purpuric rash on legs, ?secondary to drugs. Blood +++,
protein ++++, protein:creatinine 257, protein concentration urine 2213.
Immunoflurescence - IgA and C3 in mesangium. Electron microscopy - deposits
in mesangium and some deposits in subendothelial zone.
Specimen:
H&E, Silver
Diagnostic categories: Score:
1 Henoch Schonlein purpura 3.08
2 IgA nephropathy 2.56
3 IgA nephropathy / HSP 4.36
Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 3 with 4.36
Secondary diagnoses and comments (if any):
ATN too*1. Could rash be 2ry to drugs?*1. PAS*1. Discrepancy between
severity of clinical information and biopsy appearance?*4.
Original report and further information (if any):
Henoch-Schonlein purpura. Skin biopsy showed changes consistent with a
leukocytoclastic vasculitis.
Circulation: A
Case number: 285
....
Number of responses:78 . Date of analysis: 10 JAN 08
Clinical:
Male, 47 years old. Six months cough and blood nasal discharge.
Microscopic haematuria. Immunofluorescence showed no immunoreactants.
Specimen:
H&E
Diagnostic categories: Score:
1 Crescentic Gn c/w Wegener's 7.69
2 Pauci-immune / vasculitic crescentic Gn 2.18
3 Necrotising glomerulonephritis 0.13
Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 7.69
Secondary diagnoses and comments (if any):
ANCA?*40. CXR*4. EM*2. Nasal biopsy*1. Silver*3. PAS*2. Congo red*1. Z-N*
1. Grocott*1. Exclude cryo*2. Anti-GBM?*4. Exclude thrombotic
microangiopathy*1. Renal function?*1. Inadequate information*1.
Original report and further information (if any):
MPO-ANCA positive, segmental necrotising GN with crescents (pauci-immune).
Circulation: A
Case number: 286
....
Number of responses:78 . Date of analysis: 10 JAN 08
Clinical:
Female, 24 years old. SLE 1998. Class III biopsy 1999. Class IV Jan 2005.
On MMF > Creatinine 120 - 140. BP 145/80. Haematuria ++. Proteinuria ++.
Immunos: Glomerular as well as tubular basement membrane showed IgG (3+/4+)
IgM (2+/4+), C1q (2+/4+), C3 (4+/4+) and segmental fibrinogen (3+/4+).
Specimen:
H&E and PAS
Diagnostic categories: Score:
1 SLE class IV A/C 4.10
2 SLE class IV 2.18
3 SLE class IV A 2.31
4 SLE class IV G(A) 1.28
5 SLE class III 0.13
Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 4.10
Secondary diagnoses and comments (if any):
Haematoxyphil bodies noted*2. Lupus serology*2. EM*4. Silver*4.
Insufficient glomeruli for classification*8.
Original report and further information (if any):
Class IV lupus nephritis (acute segmental necrotising glomerulonephritis).
Activity index 15/24, chronicity 8/12.
Circulation: A
Case number: 287
....
Number of responses:78 . Date of analysis: 10 JAN 08
Clinical:
Male, 61 years old. Inoperable adenocarcinoma of the pancreas, treated with
Gemcitabine. Presented with acute renal failure.
Specimen:
H&E, Photo's of silver and EM x 2
Diagnostic categories: Score:
1 HUS / thrombotic microangiopathy 6.47
2 ATN ?toxic ?HUS 0.71
3 ATN NOS 0.90
4 Oxalate nephropathy (2ry to chemo) 0.26
5 Acute tubulointerstitial nephritis 0.19
6 Mesangiocapillary Gn 0.85
7 FSGS 0.24
8 ATN and ?minimal change 0.13
9 MCGN 0.13
10 Crystal nephropathy 0.13
Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 6.47
Secondary diagnoses and comments (if any):
Oxalate crystals noted *6. Presumably gemcitabine-related?*28. IF*2. More
clinical info.*5. Immuno. results?*7. Iscahemic changes too*1. Diabetic
changes too*1. Haematological investigation for HUS*11. Exclude tumour
lysis syndrome*1. Exclude antiphospholipid antibodies*1. Insufficient for
EQA*2.
Original report and further information (if any):
Thrombotic microangiopathy / haemolytic uraemic syndrome, probably as a
complication of gemcitabine therapy. Patient now on haemodialysis.
Circulation: A
Case number: 288
....
Number of responses:78 . Date of analysis: 10 JAN 08
Clinical:
Female, 67 years old. Nephrotic syndrome. Normal creatinine. Urine
dipstick blood + protein +++ Background - breast cancer and hypothyroid.
Specimen:
H&E, Photo's of PAS, Meth Silver and Congo Red x 2
Diagnostic categories: Score:
1 Amyloidosis 10.00
Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 10.00
Secondary diagnoses and comments (if any):
Exclude myeloma*13. Investigation for amyloid type*20. EM*3. Also ATN*1.
Original report and further information (if any):
Myeloma, confirmed by monoclonal band on electrophoresis, light chains in
urine, free lambda light chains of 363mg/l and kappa:lambda ratio of 0.03.
Bone marrow trephine confirmed yeloma. paraprotein reduced with treatment,
but still nephrotic.
Circulation: A
Case number: 289
....
Number of responses:77 . Date of analysis: 10 JAN 08
Clinical:
Sex not stated. Aged 44 years. Blood and protein in urine. Proteinuria
2.0g/day. IgA 4.3. Creatinine 80 umol/L. ANCA negative. ANA negative.
C3 and C4 normal. BP 144/85 mmHg.
Specimen:
H&E, PAAg, Photo's of IgA x 2, EM x 2
Diagnostic categories: Score:
1 IgA nephropathy 10.00
Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 10.00
Secondary diagnoses and comments (if any):
Secondary FSGS*1. Hypertension too*1. Exclude HSP*1. Assume other IF is
negative?*4. Also chronic thrombotic microangiopathy*1.
Original report and further information (if any):
IgA mesangial proliferative glomerulonephritis, with features of focal and
segmental glomerulosclerosis.
Links to cases in this document:
Top
A 284
A 285
A 286
A 287
A 288
A 289
Last updated: 10 JAN 08
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
