A normally healthy 67‐year‐old African American male presented with 2 weeks of worsening shortness of breath, orthopnea, and lower‐extremity edema as well as some chest pains and joint aches. One week prior to presentation he was evaluated by his primary care physician and noted to have a 25‐pound weight gain and started on diuretics, and an echocardiogram was ordered. However, several days later he presented to the emergency room because of worsening dyspnea and edema. On physical examination the BP was 211/100 mmHg. The examination of the head, eyes, ears, nose, and throat showed mild periorbital puffiness. His lungs were clear to percussion and auscultation; his heart exam revealed no jugular venous distention, a normal first and second heart sound with a regular rhythm and a soft S4 and bilateral 2+ pitting lower extremity edema. Abdominal exam, joint exam, and neurological exam were normal. Significant diagnostic studies showed a hemoglobin was 11.4 g/dL and hematocrit was 36%, Creatinine was 2.1 mg/dL up from a baseline 1.2 mg/dL. Urinalysis showed 2+ blood. 3+ protein, and a few hyaline casts. Chest x‐ray showed possible pulmonary venous congestion and small bilateral pleural effusions. Additional diagnostic studies revealed normal renal ultrasound, normal lower‐extremity Dopplers, and a negative chest CT angiogram for pulmonary embolism. Thoracentesis revealed a transudate fluid. Serological testing revealed a borderline low C3 and normal C4, and rheumatoid factor was negative. Hepatitis B and C serologies were negative, and antinuclear antibody returned 1:2560. Renal biopsy showed class IV diffuse segmental lupus nephritis, with 30% active crescents.
Lupus is a systemic illness that is often complicated by nephritis and acute renal failure. The symptoms are often not dramatic and vary from person to person making diagnosis challenging and often more common diagnosis are sought first. In this case the patient's symptoms were relatively acute in onset, but he presented with a classic triad of new‐onset severe hypertension, edema, and renal failure. However, the initial workup was directed at cardiac and pulmonary causes. Acute renal disease was of lower suspicion perhaps because of to its milder level of renal failure and nonprogressive nature in This case. Eventually the borderline low C3 and positive ANA indicated possible renal involvement, leading to a biopsy and diagnosis.
The purpose of this report is to highlight the necessity for aggressively evaluating mild cases of renal failure, especially when patients present with more systemic unexplainable findings.
L. Verma, none.