Images In...

Acute renal failure followed by low back ache

Mahesh Prasad¹, Arjun Maitra², Nimish Sethiya³, V K Bharadwaj⁴, Virendra Chowdhury¹, Jyoti Valecha⁵, Rakesh Biswas³

¹ People’s College of Medical Sciences, Medicine, Bhanpur Bypass Road, Bhopal, 462037, India
² People’s College of Medical Sciences, Physiology, Bhanpur Bypass Road, Bhopal, 462037, India
³ People’s College of Medical Sciences, Medicine, People’s College of Medical Sciences, Bhopal, 462010, India
⁴ People’s College Of Medical Sciences, Pathology, Bhanpur Bypass Road, Bhopal, 462037, India
⁵ Jawaharlal Nehru Cancer Hospital and Research Centre, Radiology, Idgah Hills, Bhopal, Bhopal, 462001, India

Correspondence to:
Rakesh Biswas, rakesh7biswas{at}gmail.com

A 47-year-old man presented with a history of oliguria and uraemic symptoms such as anorexia, nausea and vomiting. His serum creatinine on admission was 8.5 mg/dl and his arterial blood gas revealed metabolic acidosis. He was enrolled for regular sessions of haemodialysis following which his symptoms improved remarkably and his serum creatinine returned to normal. A renal biopsy done at this time showed a moderate tubulo-interstitial nephritis with mild global glomerular sclerosis.

The patient returned 1 month later with severe back ache and a computed tomography (CT) scan of the lumbosacral spine was undertaken (fig 1).

View this figure (97K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Computed tomography (CT) scan of the lumbosacral spine.

 

A week later he developed sudden altered sensorium along with restless twitching of the limbs. Repeated serum creatinine showed a high value and arterial blood gas again showed metabolic acidosis.

A CT scan of the head was done as a work up for his altered sensorium (fig 2). Finally the diagnosis was established following a bone marrow examination (fig 3).

View this figure (67K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Cranial CT scan.

 

View this figure (113K): in this window | in a new window | PowerPoint for Teaching   Figure 3 Bone marrow histology.

 

The CT of the spine taken for low back ache and of the cranium taken for altered sensorium revealed multiple punched out osteolytic lesions (evident on figs 1 and 2). This was immediately suggestive of myeloma-like plasma cell dyscrasia.

The bone marrow showed a severely depressed erythroid element, and the myeloid elements replaced with lymphoid cells showed reactive lymphocytes with moderate basophilic cytoplasm suggestive of a lymphoplasmacytic monoclonal proliferation.

These bone marrow findings are suggestive of Waldenstrom’s macroglobulinaemia (WM). A serum protein agarose gel electrophoresis revealed an M spike in the globulin region.

WM is less common than multiple myeloma, and must be differentiated on predominantly clinical grounds from other entities presenting with monoclonal spikes of IgM. A diagnosis of WM can be made irrespective of IgM concentration if there is evidence of bone marrow infiltration by lymphoplasmacytoid lymphoma.¹ Lytic bone disease is very uncommon in WM but well described in the literature.² Although renal complications of plasma cell dyscrasias with IgM proliferations such as WM are rare, a wide spectrum of kidney lesions has been reported in patients, many of whom have presented with acute renal failure.³ The second hospital admission of our patient was with altered sensorium which was thought to be due to uraemic encephalopathy (along with twitching of the limbs that could again be a part of the uraemic encephalopathy).

Our patient received one cycle of chemotherapy with standard alkylating agents and steroids, following which he developed a severe bout of diarrhoea and fever. He was treated for the gastrointestinal sepsis but he could not recover and succumbed to the infection 4 weeks after.

To all professionals in People’s College and patient’s relatives involved in the care of this patient.

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

1. Dimopoulos, MA, Kyle, RA, Anagnostopoulos, A, et al. Diagnosis and management of Waldenstrom’s macroglobulinemia. J Clin Oncol 2005; 23: 1564–77.[Abstract/Free Full Text]
2. Krausz, Y, & Slotnick, A. Macroglobulinemia of Waldenstrom associated with severe osteolytic lesions. Acta Haemat 1977; 58: 307–11.[CrossRef][Medline]
3. Audard, V, Georges, B, Vanhille, P, et al. Renal lesions associated with IgM-secreting monoclonal proliferations: revisiting the disease spectrum. Clin J Am Soc Nephrol 2008; 3: 1339–49.[Abstract/Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?