A 38-year-old woman presents with swelling of her feet for the past 1 month. The swelling is more in the early mornings while she gets up from bed. The swelling subsides as the day progresses. On evaluation she has a high blood pressure of 160/96 mmHg. Labs reveal blood urea nitrogen of 40 mg/dL and a serum creatinine of 1.8 mg/dL. Her urine dipstick is positive for proteinuria.

1. Which of the following statements about her condition is false?
1. About 5% cases of all intrinsic renal failure are caused due to her condition.
2. Her urine microscopy is likely to demonstrate hematuria.
3. Her condition responds well to steroids
4. Her likelihood of progressing to chronic renal disease is about 30%.

Answer: The answer is (c). 

The condition she most likely has is acute glomerulonephritis probably membranous nephropathy. In adults this conditions is not very much responsive to steroids. As a component of the glomerulonephritis she is likely to demonstrate microscopic hematuria. Her likelihood of progressing to chronic kidney disease is about 30%.

2. Which of the following statements about her lab investigations is true?
1. The complement levels are a good marker of the severity of the disease
2. Creatinine clearance is the gold standard marker of glomerular filtration.
3. Fractional excretion of sodium is high in these patients
4. Presence of p-ANCA indicates Wegener’s granulomatosis

Answer: The answer is (b). 

Complement levels give an indication to the involvement of the complement system in the pathogenesis of the glomerulonephritis. Fractional excretion of sodium in patients with glomerulonephritis is not much elevated. P-ANCA indicates microscopic polyangitis. C-ANCA usually is a marker for Wegener’s granulomatosis.

3. Relapsing crops of skin bullae, preceded by mucosal membrane bullae, erosions and ulcerations is typical of:
1. Erythema nodosum
2. Bullous pemphigoid
3. Pemphigus vulgaris
4. Chicken pox

Answer: The answer is (c). 

Relapsing crops of skin bullae characterize pemphigus vulgaris. Mucous membrane bullae, erosions and ulcerations often precede the bullae. Superficial detachment of skin after pressure or trauma is usually present and it is referred to as Nikolsky’s sign.

4. The following statements about Pemphigus are all true except:
1. Pemphigus is an uncommon intradermal blistering disease occurring on skin and mucous membranes.
2. It is caused due to an autoimmune process against the adhesion molecules in the desmosomal complex of the skin and mucous membrane.
3. The disease is probably viral in etiology
4. Drugs such as penicillamine can cause pemphigus.

            Answer: The answer is (c). 

Pemphigus is an uncommon intradermal lesion, which is blistering in nature, occurring on skin and mucous membranes. It is an autoimmune disease caused due to antibodies against the adhesion molecules on the desmosomal complex on the skin and mucous membrane. Drug induced pemphigus is caused due to penicillamine and captopril.