Clinical History:

A 15-year-old girl was seen by her family physician because of increasing lethargy. She had a recent history of the "flu". The child's condition does not improve after several weeks, so a renal biopsy is then done.

Images 4.1 and 4.2:

What does the light microscopy show (image 4.2 is stained with a trichrome stain)?

Sclerosis in a segmental pattern in some glomeruli

What diagnosis would you consider if the patient had been a 1 year old child with a history of failure to thrive and edema, urinalysis showing hyaline casts and oval fat bodies, proteinuria of 3.7 gm/day, hypoalbuminemia and increased serum cholesterol?

Minimal change disease

Image 4.3:

What does the H&E appearance of the glomerulus show?

The glomerulus is normal by light microscopy.

Image 4.4:

What is the essential feature seen in the electron micrograph?

Effacement of foot processes of podocytes.

Questions:

1. What additional history should be obtained?

There is no family history of congenital diseases, including sickle cell disease. The child is being fed well.

2. What laboratory tests should be ordered?

Urinalysis - 3+ protein, everything else negative; it is a "selective proteinuria" with just albumin present; 24 hr urine protein is 1.5 gm.

3. What is the differential diagnosis?
• Minimal change disease
• Focal segmental glomerulosclerosis
• Membranoproliferative glomerulonephritis
• SLE (rare)
4. What additional laboratory tests could be ordered?
• C3 is normal
• C1q is negative
• ANA is negative
5. What do you do next?

Treat with corticosteroids and see if the child improves.