Quiz Page June 2007

Brief Clinical Presentation 

A 29-year-old man developed nephrotic syndrome with normal kidney function and a diffuse papulosquamous eruption involving the trunk, arms, palms, and soles. A kidney biopsy was performed.

■ What do you see in the glomeruli by light microscopy?

■ What is your interpretation of the electron microscopy?

■ What is your description of the skin changes on the arms?

■ What is your diagnosis?

Full Clinical Presentation 

A 29-year-old man presented with heavy proteinuria and edema of acute onset. Five weeks earlier, he noticed a papule on the glans penis that later turned into an ulcer. The initial treatment with acyclovir was switched to ciprofloxacin. Ten days later, the patient showed an induration of the foreskin and bilaterally enlarged inguinal lymph nodes. He then was started on cefaclor therapy. Three days later, he developed papulosquamous eruption on his right elbow. Shortly before hospital admission, his doctor noticed peripheral edema and proteinuria with protein of 12 g/d.

Laboratory findings on admission included the following values: creatinine, 0.9 mg/dL (79.6 μmol/L); blood urea nitrogen, 15.9 mg/dL (5.7 mmol/L); hemoglobin, 12.3 g/dL (7.3 mmol/L); aspartate aminotransferase, 59 U/L; alanine aminotransferase, 104 U/L; alkaline phosphatase, 236 U/L; γ-glutamyltransferase, 678 U/L; and albumin, 2.1 g/dL (21 g/L). Proteinuria showed 7.5 g/d of protein, urine dipstick showed (+++) protein, and sediment was negative for cells and cellular casts.

Discussion 

■ What do you see in the glomeruli by light microscopy?

As seen in Fig 1, glomeruli look unremarkable and have regular thin basement membranes. There is no mesangial hypercellularity or increase in mesangial matrix.

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Figure 1. Kidney biopsy specimen. (A) Periodic acid–Schiff stain and (B) methenamine silver stain (original magnification ×200).

■ What is your interpretation of the electron microscopy?

As seen in Fig 2, the glomerulus shows extensive foot-process effacement of podocytes and slightly swollen endothelial cells. The basement membrane is unremarkable. This picture is characteristic of minimal change glomerulonephritis.

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Figure 2. Transmission electron microscopy (original magnification ×4,900).

■ What is your description of the skin changes on the arms?

As shown in Fig 3, there are several monomorphous 3- to 5-mm erythematous coin-shaped papules with peripheral scale. The differential diagnosis of a papulosquamous eruption includes atopic dermatitis, photosensitivity reaction after intake of certain drugs, psoriasis, cutaneous manifestations of systemic lupus erythematosus, drug eruption, and syphilis. In this location, drug eruption or skin rash in secondary syphilis would be most likely.

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Figure 3. Right arm and elbow.

■ What is your diagnosis?

Our patient had an infection caused by Treponema pallidum, confirmed serologically (T pallidum particle agglutination titer, 1:2,560 [<1:80], venereal disease research laboratory test result, 1:64 [<1], fluorescent treponemal antibody absorption immunoglobulin G, 1:640 [<1:5], fluorescent treponemal antibody absorption immunoglobulin M, >1:384 [<1:12]). The initial skin lesion probably was a classic chancre of primary syphilis. After systemic spread of the organism, the patient developed secondary syphilis with renal and possibly hepatic involvement.

Nephrotic syndrome is a rare complication of secondary syphilis, characterized clinically by an acute onset, association with the skin rash, and resolution within weeks after treatment. As in our patient, renal involvement usually occurs early in the course of the disease and often is accompanied by syphilitic liver involvement.

Minimal change disease, epimembranous glomerulonephritis, proliferative glomerulonephritis, and renal gumma and amyloid renal disease have been reported in the course of syphilis. In our patient, infection with hepatitis B, hepatitis C, human immunodeficiency virus, and Neisseria gonorrhoeae were ruled out, and treatment with benzathine penicillin was initiated. Proteinuria decreased to 500 mg/d of protein within a week, and excretory renal function remained stable.

Final Diagnosis 

Minimal change glomerulonephritis associated with secondary syphilis.