PMC4376932_01
Schematic presentation of therapies administered and changes in key clinical indices during the 119 days of hospitalization. mPSL = Methylprednisolone; PSL = prednisolone; PE = plasma exchange; HD = hemodialysis; Plt = platelets; LDH = lactate dehydrogenase; BP = blood pressure.
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F1
Changes in platelet counts, lactate dehydrogenase levels, and mean blood pressure over time during the 119-day hospital stay are schematically represented in figure 1, along with major therapeutic interventions.
Renal biopsy specimens examined on hospital day 22 using light microscopy. a Hematoxylin and eosin staining. Original magnification x20. b Periodic acid methenamine silver staining. Original magnification x40. c Metallothionein staining. Original magnification x20. d Electron microscopy. All 17 glomeruli examined under light microscopy show a loss of normal architecture. Renal arterioles, including afferent and efferent arterioles, show endothelial cell edema and proliferative changes, and atrophy of renal tubules. Electron microscopy demonstrates extensive, dense extracellular fibril deposits (arrow).
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F2
After this, platelet counts rose to 197 x 109 cells/l, and kidney biopsy was conducted on hospital day 22 (fig. 2).
Axial head magnetic resonance and computed tomography scans. a Fluid-attenuated inversion recovery scans taken on hospital day 48, when the patient complained of hand numbness. Magnetic resonance imaging shows multiple high-intensity areas in the cerebellum, occipital lobe, and parietal lobe. Magnetic resonance angiography reveals no significant stenosis of the major cerebral arteries. b Computed tomography scans taken after the onset of a generalized seizure on hospital day 61. Images demonstrate multiple hemorrhagic foci in the right hemisphere. Scans also depict an extension of the hemorrhage into the right lateral ventricle. c Computed tomography scans on hospital day 115 showing nearly complete absorption of the intracranial hematoma. Scale bars = 200 mm.
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F3
T2-weighted fluid-attenuated inversion recovery (FLAIR) magnetic resonance scans of the bilateral cerebellum, occipital lobe, and parietal lobe showed multiple high-intensity areas, suggesting a diagnosis of reversible posterior leukoencephalopathy syndrome (fig. 3a). On hospital day 61, generalized convulsions recurred, and head CT images showed multiple hemorrhagic lesions in the right temporal, right parietal, and right frontal lobes (fig. 3b). The patient recovered enough to walk with a cane (fig. 3c).