Nephrotic syndrome, mediastinal mass, and pulmonary embolus

Kevin P. Theleman, MD, Andrew G. Hickl, MD, and Stephen A. May, MD

From the Departments of Internal Medicine (Theleman and Hickl) and Pathology (May), Baylor University Medical Center, Dallas, Texas.

Corresponding author: Andrew G. Hickl, MD, 3434 Swiss Avenue, Suite 430, Dallas, Texas 75204.

A previously healthy 17-year-old white man in East Texas developed fever, cough, and malaise and was treated by his primary care physician for a presumed “walking pneumonia” that failed to resolve after treatment with azithromycin. Approximately 2 weeks after the onset of symptoms, edema appeared and progressed to anasarca. The patient was referred to a nephrologist. A kidney biopsy was recommended, but the patient's parents opted for an empiric trial of prednisone. A 24-hour urine collection yielded 17.9 g of protein. The edema worsened despite furosemide and metolazone therapy. The edema lessened, however, with intravenous torsemide, but within 24 hours of this therapy, the patient had acute pleuritic chest pain. His Po₂ level was 67 mm Hg, and a ventilation/perfusion scan was interpreted as high probability for pulmonary embolism. Chest radiography disclosed a probable mass. He had been taking prednisone, 25 mg twice daily, for approximately 2 weeks; omeprazole and heparin were added. He was referred to Baylor University Medical Center (BUMC) for further evaluation.

The patient denied using tobacco, alcohol, or illicit drugs and was not sexually active. Both parents were healthy. There was no family history of kidney disease, a hypercoagulable state, or a clotting disorder.

On physical examination at BUMC, the patient was breathing oxygen but was in no acute distress. No edema was apparent. He had no thyromegaly, venous distention, or palpable lymph nodes. The chest was clear. No precordial murmurs or abnormal heart sounds were heard. No abdominal abnormalities were noted, and no testicular masses were found. Neurologic examination disclosed no abnormalities. The skin was normal.

The laboratory findings are summarized in the Table. The serum total protein, albumin, globulin, and calcium levels were low, and the serum total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels were high. The 24-hour urine protein was 15.4 g. Creatinine clearance results were normal. There were 0 to 1 leukocytes and erythrocytes per high-power field in the urine. The partial thromboplastin time was increased, but the patient was receiving heparin. The fibrinogen level was normal. Tests for HIV, hepatitis B surface antigen, and hepatitis C antibody were negative; the rapid plasma reagin test was nonreactive. (BUMC Proceedings 2002;15:212-216)