Caso clinico nejm 2010

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The

n e w e ng l a n d j o u r na l

of

m e dic i n e

case records of the massachusetts general hospital
Founded by Richard C. Cabot Nancy Lee Harris, m.d., Editor Eric S. Rosenberg, m.d., Associate Editor Jo-Anne O. Shepard, m.d., Associate Editor Alice M. Cort, m.d., Associate Editor Sally H. Ebeling, Assistant Editor Christine C. Peters, Assistant Editor

Case 5-2010: A51-Year-Old Man with HIV Infection, Proteinuria, and Edema
Jai Radhakrishnan, M.D., M.R.C.P., Raul N. Uppot, M.D., and Robert B. Colvin, M.D.

Pr e sen tat ion of C a se
From the Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York (J.R.); and the Departments of Radiology (R.N.U.) and Pathology (R.B.C.), Massachusetts General Hospital; and the Departments ofRadiology (R.N.U.) and Pathology (R.B.C.), Harvard Medical School — both in Boston. N Engl J Med 2010;362:636-46.
Copyright © 2010 Massachusetts Medical Society.

A 51-year-old man with a history of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection was seen in the nephrology clinic of this hospital because of proteinuria, edema, and hypertension. The patient had been in hisusual state of health until approximately 4 weeks earlier, in early spring, when headache, nasal congestion, pressure behind his eyes, and a nonproductive cough developed, which he attributed to seasonal allergies. His primary care provider prescribed loratadine. At follow-up 1 week later, he reported headache, nasal congestion, and intermittent blurred vision. The blood pressure was 154/100 mm Hg,the pulse 100 beats per minute, the weight 106.8 kg, and the height 170.2 cm. There was fat accumulation on the neck posteriorly and a mild right ventricular heave, and the abdomen was obese; the remainder of the examination was normal. Laboratory-test results, obtained when the patient was not fasting, revealed a normal complete blood count and normal levels of serum electrolytes, calcium,phosphorus, alkaline phosphatase, and lipase; the CD4 T-cell count was 279 per cubic millimeter, and the HIV viral load less than 50 copies per milliliter; other results are shown in Table 1. The dosage of lisinopril, which he was taking for hypertension, was increased. Two weeks later, he reported persistent blurred vision. The blood pressure was 140/100 mm Hg in the right arm and 142/98 mm Hg in theleft; the pulse was 100 beats per minute. The patient saw an ophthalmologist. Levels of glycated hemoglobin and serum bilirubin were normal; additional results of laboratory tests of the blood and urine are reported in Table 1. He was referred to the nephrology clinic. The patient reported increased urinary frequency without dysuria, as well as foamy urine. He had had two episodes ofnephrolithiasis (once associated with the administration of indinavir); on two occasions, 10 and 11 years earlier, separated by 18 months, proteinuria was present on urinalysis (2+ and 3+, respectively). Two years earlier, ultrasonography of the kidneys was reportedly normal. He had had hypertension for 5 to 10 years. Diagnoses of HIV and HCV genotype 1a infections had been made 12 years earlier, during anadmission for endocarditis of the tricuspid valve caused by Staphylococcus aureus, associated with intravenous drug abuse.

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n engl j med 362;7

nejm.org

february 18, 2010

Downloaded from cme.nejm.org by JOSE L. GUILLEN on February 23, 2010 . Copyright © 2010 Massachusetts Medical Society. All rights reserved.

case records of the massachusetts gener al hospital

A liver biopsy,performed 3.5 years before this evaluation, had revealed mildly active chronic hepatitis, with a fibrosis score of 2 on a scale of 0 to 6, with a higher score indicating a greater degree of fibrosis; the level of HCV RNA was greater than 700,000 IU per milliliter. Magnetic resonance imaging (MRI) of the liver 2 years before this evaluation revealed diffuse fatty infiltration. The patient snored...
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