Mr. HV is a 67 year old man
- Presents with fatigue, general weakness, productive cough and a gradually rising serum creatinine.
- Past history significant for lupus nephritis diagnosed in 1996 initially controlled on azathioprine and prednisone and off all immunosuppression roughly one year ago
- Lupus flare in 1 year ago (elevated creatinine to 2.5 from baseline of 1.6 mg/dL and Uprot 2.4 g/24 hours) treated with MMF (switched to Myfortic because of GI intolerance with CellCept) and steroids (not biopsy-confirmed because of thrombocytopenia and uncontrolled HTN)
- Scr gradual increases to 3.1 mg/dL, complements have been persistently low, anti-dsDNA antibody level is 142 IU/L.
- Worsening fatigue and generalized weakness since July. He also reports 1 month of cough productive of yellow sputum.
- Has stopped Myfortic completely because of diarrhea, which is now resolved.
Past Medical History:
1. CKD secondary to immune complex GN likely due to Class
IV/V lupus nephritis and possibly TMA
2. SLE/scleroderma overlap syndrome - stiff hands, skin
tightening, esophageal dysmotility, and Raynaud’s.
3. Hypertension
4. Mitral regurgitation: 1998 transthoracic echo (TTE) 55% ejection
fraction, cardiac catheterization with no evidence of coronary artery disease –
episodic congestive heart failure (CHF).
5. Granulomatous disease noted on chest CT
What's the differential diagnosis?
