presentasi jurnal diverticullum meckel
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Case Report
Acute Renal Failure Secondary toTuberculosis:
A Diagnostic Challenge
Oktaviani Halim
030.09.178
Nefrologi
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INTRODUCTION
Tuberculosis (TB)
:
Disease ofthe past
Disease patterns and clinical presentations:
Acquired Immunodeficiency Syndrome (AIDS)
Globalization with immigration from TB endemic countries
Reemergingin recent
times
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INTRODUCTION
Unusual case of acute renal failure secondary
to renal tuberculosis : The initial clinical and serological
picture was highly suggestive of lupus nephritis.
The challenges in the diagnosis and
management of this clinical presentation.
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CASE PRESENTATION
A 45-YEAR-OLD FEMALE resident in Ireland,originally from the Philippines, wastransferred for further management of acute
renal failure.
MALAISEand FATIGUEover the precedingmonth associated with a SMALL, PAINLESS
SWELLING ON THE LEFT SIDE OF THE NECK.
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CASE PRESENTATION
Fevers
Chills
Rigors
night sweats photosensitive rash
joint pains
weight loss
urinary tract symptoms..
Upper respiratory tractsymptoms, sinusitis, or
rash.
Taking any medicationsor herbal remedies
NEGATIVE
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CASE PRESENTATION
Past medical history was unremarkable except
for LUMPECTOMY FOR A BENIGN BREAST
CYST several years ago.
Menstrualcycles :normal
No history of miscarriages in the past.
SERUM CREATININE on admission was205
mol/L with an active urine sediment
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CASE PRESENTATION
On examination, she appeared UNWELL, was
afebrile, with a BLOOD PRESSURE
130/80MMHG, and weighed 57 kgs.
A bedside urine dipstick was positive for
BLOOD (+) AND PROTEIN (+++).
Oral ulceration, rashes, or joint swelling:
Negative
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CASE PRESENTATION
Neck:
Supple to palpation except for a SOLITARY 1
CM NONTENDER, MOBILE LYMPH NODE IN
THE LEFT ANTERIOR TRIANGLE OF NECK.
The thyroid gland was not enlarged.
Cardiovascular, respiratory, and abdominal
examination was unremarkable.
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CASE PRESENTATION
Biochemical investigations revealed A SERUM
CREATININE WHICH HAD RISEN TO 568
MOL/L AND UREA OF 23.4 MMOL/L.
Haemoglobin level of 13 g/dL ; SERUM C-
REACTIVE PROTEIN OF 74 MG/L (normal
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CASE PRESENTATION
A full vasculitic screen :
Antinuclear factor (ANF) was positive with a
homogenous pattern
Antidouble-stranded DNA antibodies were raised
(anti-dsDNA titre 59, >30 positive)
Antineutrophil cytoplasmic (ANCA) and
antiglomerular basement membrane antibodieswere negative.
Antistreptolysin O titres were also within
normal limits.
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CASE PRESENTATION
Serum complement levels showed depletion
of C4 and normal C3 levels.
Serology was negative for human
immunodeficiency virus (HIV), toxoplasmosis,
and brucellosis.
A 24-hour urine collection quantified the
PROTEINURIA AT 1.2 G/24 HRS.
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CASE PRESENTATION
Chest radiograph was normal.
Renal ultrasonography : Normal sized kidneys withgood corticomedullary differentiation and no evidenceof hydronephrosis.
Fine needle aspiration biopsy of the neck lump :mature lymphocytes admixed with neutrophils, with90% of the cells showing positivity for CD45stronglysuggestive of nonspecific inflammatory changes.
In view of the presentation of acute renal failure,haematuria, and proteinuria with serological evidencesuggestive of lupus, a renal biopsy was performed toclarify the diagnosis.
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CASE PRESENTATION
Histopathology results, however, showed
WIDESPREAD CASEATING GRANULOMATA
WITH LANGERHANS CELLSconsistent with
renal tuberculosis.
No acid fast bacilli (AFB) were seen on light
microscopy.
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CASE PRESENTATION
Granuloma with caseating central necrosis (white arrow).
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CASE PRESENTATION
Patient had been vaccinated with BCG in herchildhood, Didnt have any contact with tuberculosis
carriers nor was there any history of recent travelabroad.
Mantoux test : Positive at 12 mm.
Sputum microscopy : Negative for AFB.
Serial early morning urine samples : Negative for AFB.
CT of the thorax, abdomen, and pelvis : ENLARGEDRETROGASTRIC LYMPH NODES MEASURING UP TO 2.8 1.2 CMand further SUBCENTIMETRE MEDIASTINALAND RETROPERITONEAL LYMPH NODES.
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CASE PRESENTATION
She was commenced on standardcombination antituberculous chemotherapyconsisting of isoniazid, rifampicin, ethambutol,
and pyrazinamide. She subsequentlydeveloped deranged liver enzymes whichnormalized following withdrawal of rifampicin.
Completed 18 months of treatment for renaltuberculosis, butfailed to recover renalfunctionand is now Dialysis Dependent,Awaiting Renal Transplantation.
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CASE PRESENTATION
A repeat renal biopsy was performed :
following completion of anti-tuberculous
therapy.
This confirmed significant tubulointerstitial
fibrosis in the absence of any caseating
granulomas.
A follow-up CT scan showed resolution of the
previously detected lymphadenopathy.
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CASE PRESENTATION
Tubulointerstitial fibrosis in the absence of caseating granulomas
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DISCUSSION
The case above illustrates the presentation ofacute renal failure in a patient with an activeurinary sediment and serological evidence oflupus as suggested by anti-dsDNA positivity and
complement consumption. These biochemicalfeatures strongly raised the clinical suspicion oflupus nephritis.
However, other causes of rapidly progressiverenal failure including post infectiousglomerulonephritis as well as vasculitic andinterstitial glomerulonephritis were also
considered in the differential diagnosis.
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DISCUSSION
Our patient also presented with painless cervicallymphadenopathy, and other conditions such as
lymphoma, sarcoidosis, toxoplasmosis,
brucellosis, HIV, local salivary gland neoplasia andparagangliomas were also considered.
However, a renal biopsy was critical in securing
the correct diagnosis of renal tuberculosis to
guide appropriate treatment in our patient.
The presence of caseous necrosis on renal biopsy
made sarcoidosis unlikely in this setting.
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DISCUSSION
This case highlights the importance ofpostprimary tuberculosis as a reemerging
clinical problem, particularly withthe trend of
widespread immigration and globalisation. Renal tuberculosis usually presents as gross
haematuria, insidious pyuria, or obstructive
uropathy but can also present rarely withacute renal failure in HIV patients with
tuberculosis treated with rifampicin.
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DISCUSSION
This case is unique in that it combined acompatible clinical and serological picturesuggestive of lupus nephritis, while renalhistopathology confirmed the cause of acuterenal failure as tuberculosis.
Although highly specific for systemic lupuserythematosus, false positive antidsDNA
antibodies have been described in a healthysubset of an elderly population but are veryunusual in younger individuals such as ourpatient.
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DISCUSSION
The mechanism of this finding remainsunclear. The degree of proteinuria in our case
is also unusual in renal tuberculosis, however,
there were no other clinical symptoms or signsto support lupus at diagnosis and these did
not manifest in her later followup as well.
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DISCUSSION
To our knowledge, acute renal failure secondaryto renal tuberculosis presenting in this mannerhas not been reported previously in theliterature.
This case highlights the importance of clarifyingthe diagnosis of acute renal failure through renalbiopsy where possible, prior to thecommencement of treatment.
It also illustrates the need to be aware of atypicalclinical presentations of tuberculosis which maybe more common in the contemporary setting.
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CONCLUCION
The diagnosis of tuberculosis and systemic lupus
erythematosus can be clinically challenging as
highlighted by this case.
It is also important to consider tuberculosis in the
differential diagnosis of unusual presentations,particularly in immigrant populations and
immunosuppressed individuals.
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THANK YOU
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