Brain and Lung Abscesses in a 48-year-old Man with Focal and Segmental Glomerulosclerosis

Abstract

Case RepoRtWe report a case of FSGS (tip lesion) with nephrotic syndrome and acute renal failure that complicated with pulmonary and brain abscesses and was under immunosuppressive therapy. The patient was a 48-year-old man who was admitted for evaluation of azotemia. There was a history of decreased urine volume in recent days. He presented with BP=160/100 and 3+ leg edema on physical examination. He did not have any history of recent sore throat, hypertension (HTN), oral ulcer, arthralgia, photophobia, skin rash or family history of renal disease. Urinlysis showed 3 + proteinuria and 2+hematuria. Serum creatinine was 2.3 mg/dl, blood urea nitrogen=32mg/dl, serum albumin=2.4g/dl, triglyceride=295mg/ dl, cholesterol=320mg/dl, Hb=13g/dl and 24 h urine protein was 6580 mg/day. Other laboratory findings were unremarkable. He was oliguric and the serum creatinine gradually increased to 6.8 mg/ dl during the next few days. Microscopic urine sediment showed many muddy brown coarse granular cast, dysmorphic RBC and fatty cast. Because of elevated serum creatinine and uncontrolled hypertension and volume overloading, hemodialysis was started and after blood-pressure control (by amlodipine 10mg/day, prazocine 5mg/bid, metoprolol 50mg/bid), renal biopsy was done. The results of serologic examination including ANA, anti-ds DNA, C3, C4, CH50, HBS Ag, HCV Ab, HIV Ab, Cryoglobulin, Anti GBM Ab and ASO were normal. Renal biopsy showed focal segmental glomerulosclerosis (tip lesion type) as well as acute tubular necrosis. Corticosteroid pulse (methyl prednisolone 1000 mg/day) was prescribed for three days and continued with 60 mg prednisolone/day. Conservative management of metabolic acidosis, hyperlipidemia, anemia and hypocalcemia was continued. after hemodialysis three times daily (HD), urine output increased and serum creatinine decreased gradually to 1.5 mg/dl and his oedema decreased to 1+ after two weeks of admission, so he was discharged and prednisolone was tapered gradually to 20 mg/day during 4 months. Because serum creatinine was increased, cyclosporine 100 mg/bid was started and after four weeks, serum creatinine reached to 0.8 mg/dl and urine protein was 740 mg/day. Six weeks later, he suffered from productive cough and shaking chill and fever. Chest x ray and chest CT scan revealed right side pulmonary abscess [Table/ Fig-1]. BK (Bacille de Koch) smear of sputum was negative. Treatment with ceftriaxone 1g/bid/IV infusion and clindamycin 600mg/tds/IV infusion was prescribed and after four days, fever disappeared. After two weeks of parenteral treatment, he was discharged and oral antibiotics with Amoxicillin-clavulanate 625mg/TDS continued for four additional weeks, and the, second lung CT scan was near normal [Table/ Fig-2]. Cyclosporine dose was reduced to 100 mg/day and serum creatinine remained 1.5 mg/dl. After three months he was again referred to clinic with dysarthria and right side face deviation and hence was admitted. A large round mass like lesion was detected in his right side brain CT scan and MRI [Ta...