Adam
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277. A 68-year-old female with stable coronary artery disease undergoes angiography of the right lower extremity for peripheral vascular disease. The patient is on warfarin for recurrent deep vein thrombosis, aspirin, lisinopril, metoprolol, and atorvastatin. Preangiography, she received a course of dicloxacillin for cellulitis 1 week ago. Three weeks after angiography the patient is evaluated for general malaise. Physical examination reveals a petechial rash and livedo reticularis on both lower extremities.
Laboratory evaluation reveals that her creatinine has risen from 1.5 to 3.7 mg/dL. Other laboratory abnormalities include an ESR of 96 mm/h, leukocytosis, eosinophiluria, and a reduced third component of complement (C3). Urine sodium is 40 meq/L. Urinalysis reveals 1+ protein, 10 to 20 WBC/HPF, and 5 to 10 RBC/HPF with no casts. What is the most likely diagnosis?
a. Prerenal azotemia
b. Radiocontrast-induced acute renal failure
c. Drug-induced acute interstitial nephritis
d. Atheroembolic renal failure
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| vanshita
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D
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| sprint123
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A and B--->Urine sodium is less than 20....Ruled out
I will go for C based on significant history..
Acute intersititial nephritis - WBC casts +,Mild proteinuria +,eosinophiluria + ,urine sodium -40, petechial rash.Increased ESR,Patient on aspirin..All these are given in the quetsion..
I am not too sure to rule out D...
Bit confused....Any comments please?
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| Justice
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I think it is (C)
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| Adam
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vanshita, please explain why it's D
sprint123, your analysis is very good, I'm gonna write the answer and explanation later.
Thanks
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| vanshita
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urine sodium 40
rule out pre renal cause
i choose D because pt has livedo reticularis on both lower extremities which is present in embolic episode
what"s answer?
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| NE
Forum Guru
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I will highlight the key words for embolization syndrome in this case:
A 68-year-old female with stable coronary artery disease undergoes angiography of the right lower extremity for peripheral vascular disease. The patient is on warfarin for recurrent deep vein thrombosis, aspirin, lisinopril, metoprolol, and atorvastatin. Preangiography, she received a course of dicloxacillin for cellulitis 1 week ago. Three weeks after angiography the patient is evaluated for general malaise. Physical examination reveals a petechial rash and livedo reticularis on both lower extremities.
Laboratory evaluation reveals that her creatinine has risen from 1.5 to 3.7 mg/dL. Other laboratory abnormalities include an ESR of 96 mm/h, leukocytosis, eosinophiluria, and a reduced third component of complement (C3). Urine sodium is 40 meq/L. Urinalysis reveals 1+ protein, 10 to 20 WBC/HPF, and 5 to 10 RBC/HPF with no casts.
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| dr.wad
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I GUESS IT IS ( C ) DRUG INDUCRD INTERSTITIAL NEPHRITIS.
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| Adam
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dear NE, thank you .. I intend to write the explanation but you did it by your "highlights"..
The correct answer is (D) Atheroembolic renal failure
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| AAAAA
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D ??
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| sprint123
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hello adam,..excellent question...Can u explain why is there a decreased C3 in athero-embolic occlusion...Will decreased c3 be a finding of AIN?
livedo reticularis and decreased c3 are the only two findings which does not fit into AIN in this question....Can these occur in AIN also?
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| r_albayunen
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ill go with C
eosinophils ! and if ypu think about an emboli occluding the renal artery will give a pre renal azotemia with a Na < 20 ... but then you have he livido reticularis .. i hate this overlap .. suggestions?
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| Adam
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dear r_albayunen
Atheroembolic renal failure doesn't casue pre-renal azotemia, It's INTRARENAL. the cholesterol showers do not occlude the major arteries, just micro ones.
another thing, drug-induced AIN, will not decrease C3.
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| r_albayunen
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thanx adam .. you are right answer is D. post angio chances of an atheroma disruption and a emboli with the livido reticularis on legs ...
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