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National Renal Pathology E.Q.A. Scheme

Circulation M

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

Cases included:

M 62
M 63
M 64
M 65
M 66
End

A click on the { Image} icon should provide an image from the material circulated. Some but not all cases will have two images.

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 a 'aide memoire' for participants who may no longer have the slides for review.

They are NOT intended as 'good examples' or as teaching material. In some instances the images (especially the second image) may be chosen to illustrate a feature which led some participants to a wrong diagnosis.

Case Response Analysis

Circulation: M

Case number: 62 .... {Image} .... {Image}


Number of responses:65 . Date of analysis: 10 DEC 95

Clinical:

40y.o. man. Renal failure (Urea 16.8, creat. 321, K 4.2, Bicarb. 23) and hypercalcaemia (corrected Ca 3.09). CXR unremarkable. Renal ultrasound no focal lesion, kidneys 10cm. Moderate diffuse increase in gamma globulins.

Specimen:

H&E, PAS, ZN. 
Diagnostic categories:                         Score:
 1  Granulomatous inflammation NOS                          1.09
 2  Granulomatous inflammation probably sarcoid             8.77
 3  Granulomatous inflammation ? TB                         0.05
 4  Granulomatous inflammation ? drug induced               0.03
 5  Granulomatous inflammation ? Wegener's                  0.03
 6  Myeloma kidney                                          0.03

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 2 with 8.77

Secondary diagnoses and comments (if any):

Exclude other causes of granulomatous nephritis*9. Exclude TB*7. CXR*1. Drug reaction?*6. ACE levels*9. ANCA*1. Hypertension*1. Calcification*4. Kveim test*5. Mantoux*1. Immunofluorescence *1. HIV status?*1.

Original report and further information (if any):

Parotid swelling developed after biopsy reported; Angiotensin converting enzyme found to be 68 (n.r. 7-21). Diagnosis of sarcoidosis made. Lost to follow up due to emigration.

Circulation: M

Case number: 63 .... {Image} .... {Image}


Number of responses:65 . Date of analysis: 10 DEC 95

Clinical:

34y.o. male. Few months of general malaise, nausea & vomiting. Admitted in renal failure, creatinine 1200. Kidneys normal size. No other history. Immuno. for IgG, A, M and C3 was negative. Electron microscopy not carried out.

Specimen:

H&E, SR 
Diagnostic categories:                         Score:
 1  Myeloma kidney / cast nephropathy                       9.51
 2  Lymphoma                                                0.15
 3  Interstitial nephritis with casts                       0.18
 4  Amyloidosis                                             0.15

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 9.51

Secondary diagnoses and comments (if any):

Stain for amyloid*1. Amyloid present too*2. E.M.*1. Serum/urine immunoelectrophoresis*14. Bone marrow *5. K and l immuno/in situ*5. Myeloma cells in intersitium?*6. Lymphoma markers?*2. Carcinoma(pancreatic?)?*1 Myeloma odd/impossible at this age *6. ATN too*1. Also eosinophilic interstitial nephritis*2.

Original report and further information (if any):

Myeloma kidney. Report surprised clinicians, but subsequently found urine protein 3.3g/l, lambda light chains; serum protein 62g/l, hypogammaglobulinaemia, two monoclonal lambda bands on IEP; excess plasma cells on bone marrow, including abnormal forms; trephine after therapy again showed atypical plasma cells.

Circulation: M

Case number: 64 .... {Image}


Number of responses:65 . Date of analysis: 10 DEC 95

Clinical:

55y.o. female. History of ischaemic heart disease. Admitted after one week of cough with haemoptysis. CXR: consolidation in right lung. Renla function initially normal. Developed abdominal pain and respiratory failure, then renal failure. Anti-GBM negative, ANCA positive. Immunohistology for IgG, A,

Specimen:

H&E, Meth Ag. 
Diagnostic categories:                         Score:
 1  Pauci-immune necrotising Gn. with crescents             9.54
 2  Focal segmental glomerulonephritis                      0.46

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 9.54

Secondary diagnoses and comments (if any):

Wegener's?*20. Polyarteritis?*10. MSB*1. c- or p- ANCA?*5. Viral inclusions in glomerular cells?*1. Lupus serology*1.

Original report and further information (if any):

Original report focal segmental necrotising glomerulonephritis. Clinical diagnosis of vasculitis, possibly Wegener's syndrome, but patient died a week after the biopsy, no p.m.

Circulation: M

Case number: 65 .... {Image} .... {Image}


Number of responses:65 . Date of analysis: 10 DEC 95

Clinical:

61 y.o. man presenting with vasculitic skin rash, cerebral thrombosis and renal impairment. Clinical diagnosis: rapidly progressive glomerulonephritis.

Specimen:

H&E, PAS, Sirius Red 
Diagnostic categories:                         Score:
 1  Amyloidosis                                             9.77
 2  Cryoglobulinaemia                                       0.12
 3  Immunotactoid glomeruloopathy                           0.08
 4  Light chain nephropathy                                 0.03

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 9.77

Secondary diagnoses and comments (if any):

Stain for amyloid type*12. Clinical info*2. Exclude UTI*1. Immunoelectrophoresis*4. Cryoglobulin?*1. Atherosclerosis*1. Vasculopathy*1. Pyelonephritis too?*2. Tubulo-interstitial nephritis too* 1. Rheumatoid?*2. Myeloma?*4. Light chain depsosition?*1. ANF?*1. Congo red*1. E.M.*1.

Original report and further information (if any):

Circulation: M

Case number: 66 .... {Image} .... {Image}


Number of responses:65 . Date of analysis: 10 DEC 95

Clinical:

Female age 3 years. Sister had renal transplant age 10 for ESRF of unknown cause. Patient has mild haematuria & proteinuria. IF: (see photo) very scanty granular deposits of IgM, IgA and C3. IgG negative.

Specimen:

H&E, PAS, PAMS, E.M. prints *4, IF print (IgM) *1. 
Diagnostic categories:                         Score:
 1  Alport's syndrome                                       8.91
 2  FSGS                                                    0.25
 3  Vesico-ureteric reflux                                  0.08
 4  IgA nephropathy                                         0.17
 5  Hereditary nephritis                                    0.43
 6  Thin membrane nephropathy                               0.03
 7  IgM nephropathy                                         0.03
 8  Proliferative glomerulonephritis NOS                    0.08
 9  Minimal change nephropathy                              0.03
 10 Is 5 acceptable as equal to 1?..PF                      0.00

Asterisks (if any) indicate dangerous diagnoses.
Highest scoring diagnosis was 1 with 8.91

Secondary diagnoses and comments (if any):

Immuno. for 'Goodpasture antigen'*5. Deafness / family history?*14. Odd in female*4. More e.m.*3.

Original report and further information (if any):

Alport's disease. Family subsequently found to have neural deafness. Patient has ? early cataract.

Links to cases in this document:
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M 62
M 63
M 64
M 65
M 66

[Leicester University] [] Pathology EQA
Last Updated: December 1995
Peter Furness BM, BCh, PhD, MRCPath, Department of Pathology, University of Leicester.