PMC6689923_01
Renal biopsy slides showing secondary glomerulonephritis: (a) light microscopy showed glomerulus with normal size and cellularity. Basement membrane spikes are not observed, consistent with early stage membranous nephropathy (Jones methenamine silver stain; original magnification 600x). (b) Immunofluorescence showed granular capillary wall staining for IgG at 2+ intensity (IgG direct immunofluorescence stain; original magnification 400x). (c) Electron microscopy demonstrated glomerular capillary with numerous small subepithelial electron-dense immune complex deposits (arrows) adjacent to occasional, very small, spikes of basement membrane material (Electron microscopy study; original magnification 5000x). (d) Electron microscopy demonstrating mesangial deposits (white arrow) (Electron microscopy study; original magnification 5000x).
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See Figure 1 for summary of slides and findings suggesting secondary MGN.
Graph of urine protein to creatinine ratio trend (g protein/g creatinine): black arrow shows start of symptoms of weakness and diplopia in September 2016 near initial diagnosis of nephrotic syndrome. Red arrow and line represent the initiation and duration of corticosteroid therapy (high dose 1 g/kg), and therapy end is denoted by end of red line. Green arrow and line indicate the start of adrenocorticotropic hormone therapy (ACTHAR ), 80 units twice a week dose, and therapy end is denoted by end of green line. Blue arrow and line indicate start of 0.375 g/m2 of body surface area (BSA) rituximab infusions weekly for a total of four infusions.
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See Figure 2 for graph of urine protein to creatinine ratio and onset of symptoms, start and stop of corticosteroid treatment, trend of proteinuria in response to ACTH treatment, and start date of rituximab (4 April 2018).