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March 22, 2017

Pushing Glass (March 22, 2017)

A 71-year-old woman with a history of multiple myeloma, hypertension and vitamin D deficiency presented with decreased renal function. Investigations show serum creatinine increased to 3.36 mg/dL. Serum albumin is 2.6 gm/dL. Twenty-four hour urinary protein is 2.8 gm/day.

These images show characteristic findings of which of the following diseases:

A) Thrombotic microangiopathy
B) Cast nephropathy
C) Light chain deposition disease
D) Cryoglobulinemic glomerulonephritis
E) Amyloidosis
F) Fibrillary glomerulopathy

Answer: D
The images show intracapillary hyaline, thrombi which are weakly PAS-positive, and stain red on silver and trichrome stains. These showed positive staining only for IgG1 and kappa light chain. The capillary loops are substantially thickened by predominantly subendothelial and para-mesangial electron dense deposits. Congo red stain is negative. The features are indicative of type I cryoglobulinemic glomerulonephritis, as can be seen in patients with a monoclonal immunoglobulin precipitation or an underlying B cell lymphoproliferative disease. For further reading: https://www.ncbi.nlm.nih.gov/pubmed/23429354