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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 140
A 141
A 142
A 143
A 144
A 145
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: A

Case number: 140 .... {Image}


Number of responses:75 . Date of analysis: 10 JAN 00

Clinical:

55y.o. with polycystic kidney disease. Tumour mass 4x3x3cm, homogenous cut surface with areas of haemorrhage. Patient also had proteinuria 8g/24h

Specimen:

H&E, PAS 
Diagnostic categories:                         Score:
 1  Renal cell carcinoma (+/- 'granular cell' or 'oncocytic'1.91
 2  Renal cell carcinoma and minimal change/FSGS/other Gn   1.51
 3  Oncocytoma                                              3.20
 4  RCC and segmental glomerulosclerosis ? overload         0.13
 5  Collecting duct carcinoma                               0.23
 6  Oncocytoma and minimal change/FSGS/other Gn             2.75
 7  FSGS (tumour not mentioned)                             0.13
 8  Oncocytoma + myeloma / cast nephropathy                 0.13

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 3 with 3.20

Secondary diagnoses and comments (if any):

Cause of 8g proteinuria needs immuno + EM to sort out*15. Better gross description*6. More blocks to exclude RCC*11. Cytogenetics*1. Silver stain*1. Congo red*4. Hale's colloidal iron*5. Hypertension/scarring too*12. Seg. sclerosis-1ry or 2ry to hypertension?*4. Exclude diabetes*2. Separate tiny papillary adenoma*2. Why so few cysts?*3. Renal vein thrombosis?*1. Unsuitable for EQA*1.

Original report and further information (if any):

Circulation: A

Case number: 141 .... {Image}


Number of responses:75 . Date of analysis: 10 JAN 00

Clinical:

66y.o female, 6/12 hx joint pains & vague symptoms. On Didronel for osteoporosis. Intermittent Voltarol. Elevated rheumatoid factor, negative ANCA, deteriorating renal function (urea 25, creat. 397). Calcium low normal. IF negative. EM not done.

Specimen:

H&E only 
Diagnostic categories:                         Score:
 1  Interstitial nephritis                                  10.00

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 10.00

Secondary diagnoses and comments (if any):

Drug related?*36. Allergic?*3. Auto-immune/RhA?*2. EM*1. Lymphoma??*1. Storage disorder??*1. Whipple's??*1. ATN too*1. Eaten wild mushrooms?*1. Congo red*1. Exclude myeloma*1. Pale H&E*7.

Original report and further information (if any):

Circulation: A

Case number: 142 .... {Image}


Number of responses:75 . Date of analysis: 10 JAN 00

Clinical:

57y.o. female. Presented with nephrotic syndrome. Urinary protein 10g/day. Rheumatoid arthritis, recent penicillamine treatment. IF showed strong capillary loop staining for IgG and C3.

Specimen:

H&E, EM x2 
Diagnostic categories:                         Score:
 1  Membranous Gn, penicillamine related                    4.67
 2  Membranous Gn, penicillamine not mentioned              5.33

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 2 with 5.33

Secondary diagnoses and comments (if any):

Silver stain*3. How long on penicillamine?*1.

Original report and further information (if any):

Circulation: A

Case number: 143 .... {Image}


Number of responses:75 . Date of analysis: 10 JAN 00

Clinical:

Male, 29. At age 17, clinical diagnosis Henoch Schonlein purpura, no biopsy. Age 25; purpuric rash, haematuria, proteinuria. On treatment for hypertension since then. Now well, but haematuria & proteinuria 2.33g/24h. No immunological abnormality in serum. No IgG on IPx.

Specimen:

H&E, IPx for IgA 
Diagnostic categories:                         Score:
 1  IgA nephropathy / HSP                                   9.87

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 9.87

Secondary diagnoses and comments (if any):

Hypertension too*3. Silver*1. Thick H&E*2.

Original report and further information (if any):

Circulation: A

Case number: 144 .... {Image}


Number of responses:75 . Date of analysis: 10 JAN 00

Clinical:

40 y.o. Maltese female, creatinine 161, recent E coli UTI, proteinuria 0. 4g/day, normal BP, negative ANF, ESR 140, CRP 105 IF: IgM and C3 in small vessels; glomeruli negative.

Specimen:

H&E, silver 
Diagnostic categories:                         Score:
 1  Granulomatous T - I  nephritis NOS                      1.33
 2  Granulomatous TIN  differential given                   4.67
 3  Granulomatous TIN probably sarcoid                      0.27
 4  Granulomatous TIN probably TB                           1.73
 5  Granulomatous TIN probably Wegener's                    1.33
 6  Granulomatous TIN probably drug induced                 0.53
 7  Granulomatous TIN, probably chronic UTI                 0.13

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 2 with 4.67

Secondary diagnoses and comments (if any):

?TB*50, ?drug reaction*23, ?fungi?13, ?sarcoid*19, ?Wegener's*18, ?Churg Strauss*4, ?Brucella*6, ?viral*1, ?E coli*5, ?parasites*1. ?Crohn's*1. EVG*1. PAS-D*4. MSB*1. EM*1. Von Kossa*1. Urine culture*4.

Original report and further information (if any):

Granulomatous vasculitis and necrotising glomerulitis; differential includes Wegener's, necrotising sarcoid and Churg-Strauss syndrome. Not TB. Subsequently, ANCA found positive and patient revealed URT symptoms; diagnosis Wegener's.

Circulation: A

Case number: 145 .... {Image}


Number of responses:73 . Date of analysis: 10 JAN 00

Clinical:

12 year old boy. Cryptogenic cirrhosis. Liver transplant 5 years ago. Cyclosporin treatment for 3 years >5mg/kg then switched to microphenalin. Declining renal function.

Specimen:

PAS, MSB (H&E not submitted) 
Diagnostic categories:                         Score:
 1  Cyclosporin toxicity                                    6.60
 2  Interstitial & glomerular  fibrosis ? cause             0.32
 3  Focal glomerulonephritis/glomerulosclerosis NOS         0.81
 4  Nodular glomerulosclerosis                              0.07
 5  TTP/HUS                                                 0.42
 6  Transplant glomerulopathy                               0.00
 7  FSGS                                                    1.64
 10 Transplant case so diagnosis not offered                0.14

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 6.60

Secondary diagnoses and comments (if any):

Immuno.*3. EM*2. Silver*1. Fibrosis related to cirrhosis?*2. IgA?*1. HIV status?*1. Microangiopathy due to CyA?*3. CyA levels?*1. Unsuitable for EQA*2. What is microphenelin*many? - (Presumably means mycophenolate mofetil . I just copied the spelling! - PF)

Original report and further information (if any):

Links to cases in this document:
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A 140
A 141
A 142
A 143
A 144
A 145

Last updated: 10 JAN 00
Organiser: Dr Peter Furness, PhD, FRCPath. Department of Pathology,
Clinical Sciences Building,
Leicester Royal Infirmary,
P. O. Box 65,
Leicester, U.K.
Tel: (0116)2584582
Fax: (0116) 2584573

Email: pnf1@le.ac.uk