CASE 20
A 38-year-old female, MM, is seen in your office complaining of malaise for the past several months, a chronic cough, and pain in the left flank with hematuria (red blood cells in the urine). There is no medical history of note. There is no recent travel; she is afebrile, a nonsmoker, and not on any medication (either over-the-counter or prescribed). There is a family history of kidney stones, but her diet is not particularly rich in proteins, oxalates, or dairy products.
QUESTIONS FOR GROUP DISCUSSION
1. Hematuria and pain in the left flank, combined with the family history, is suggestive of renal colic. Explain why this does not account for all of this patient’s symptoms.
2. What diseases might affect both the lungs and kidney, as well as contributing to this patient’s feeling unwell? Review Case 17.
3. The laboratory studies showed normal serum/urinary urate levels. Explain why this would rule out kidney stones as an explanation for this patient’s symptoms described in question 1. Why might drug-induced allergies cause a similar presentation?
4. The laboratory report also indicated that this patient had an increase in serum calcium concentration. Discuss some of the causes of this finding.
5. Explain how you would rule out (a) lytic bone disease (e.g., myeloma with osteolytic lesions) and (b) parathyroid adenoma (tumor of the parathyroid gland).
6. The chest radiograph indicated bilateral adenopathy (enlargement of glandular tissue, particularly of the lymph glands). Given the results of the chest radiograph, it is likely that infection with Mycobacterium tuberculosis would be high on the list of probabilities. What test could you administer to your patient to indicate whether this patient had been exposed to this infectious agent? What antigen would you use as a positive control? Explain why a positive control would be necessary.
7. Having ruled out tuberculosis as a consideration to explain this patient’s symptoms, a computed tomographic (CT) scan was performed for more definition of the lungs. Results suggest granulomatous lesions in the peripheral lung fields with confirmation of hilar adenopathy, which is suggestive of sarcoidosis. What would you expect a biopsy of the lung tissue to show?
9. Patients with sarcoidosis have elevated levels of angiotensin-converting enzyme (ACE). Although a positive result supports a diagnosis of sarcoidosis, it is not confirmatory. Explain.
