Crescentic Glomerulonephritis with Tubercular Lymphadenitis

Abstract

A 65-year-old lady presented with history of fever of three weeks duration and gradually developed puffiness of face and limbs, since a week. She had reduced appetite and decreasing urine output since one week as well. Fever was moderate grade; not associated with any chills, rigors or showed any diurnal variation. There was no history of cough, breathlessness, haemoptysis, skin rash, joint pains, mouth ulcers, pain abdomen, haemeturia, ocular complaints. On clinical evaluation, she had oedema, temperature of 101 deg F, BP was 160/90 mm of Hg. Right arm was supine. She had a two cm firm and on tender lymph node palpable in the right axillary region of the medial group. Systemic examination was unremarkable. Initial investigations revealed Hb 10.4 gm/dl, TLC: 12,200/cumm, DLC: (Neutrophils 79%, Lymphocytes 18%, Monocytes 2% and Eosinophils 1%), Platelets 4, 00,000 per cubic mm, ESR: 68 mm, CRP: 9.0 mg/L, BUN 30 mg/dl, serum creatinine of 2.4 mg/dl. Urine showed numerous dysmorphic RBCs per high power field, and urine dipstick showed 2+ proteins. Twenty four hour urinary protein excretion was 1.3 gm per day. She had rapidly worsening renal function with reduced urine output and her serum creatinine increased to 5.8 mg/dl over the next one week. Ultrasound of the abdomen revealed multiple retroperitoneal Lymph Nodes along with mesenteric lymph nodes forming a lymph node mass. The size of the lymph node mass was 2.2 × 1.7 cm. Her sputum for both acid fast bacilli (AFB) and Gene expert for Mycobacterium tuberculosis was negative. A non-contrast CT scan of the chest and abdomen revealed multiple lymph nodes; Preaotric, Paraortic, Precaval and Peripancreatic region, along with mesenteric lymph nodes