Diagnostic dilemmaA Red Herring in the Green Grass: Syphilitic Membranous Glomerulonephritis
Section snippets
Presentation
Physical discomfort attributed to a routine chore was actually an unusual presentation of an insidious infection. A 51-year-old man presented to the emergency department and reported 1 week of persistent, localized lower back pain that began after he had spent the day mowing his lawn. He denied any trauma, rash, dysuria, discoloration of urine, or other constitutional symptoms. His past medical history included hypertension and a seizure disorder. Approximately 2 days before presentation, he
Assessment
On physical examination, the patient was not in any distress. His blood pressure was 141/86 mm Hg, his pulse was 68 beats per minute, and his weight was 310 lb (140.6 kg). His cardiovascular, respiratory, neurologic, and musculoskeletal findings were all normal. He had no hepatosplenomegaly or lymphadenopathy. However, he had red lesions on the mucous membrane of his soft palate, and dark, pigmented, maculopapular rashes on the palms of his hands and the soles of his feet (Figure 1). In
Diagnosis
The patient underwent a renal biopsy after confirmation of syphilis. Light microscopy demonstrated mild chronic kidney injury with approximately 15% tubular atrophy and signs of interstitial fibrosis. No evidence of acute vasculitis was present. Of 22 glomeruli, 1 was globally sclerotic, and generally the glomeruli were congested with mild ischemic changes. A slight increase in the mesangial matrix and thickening of the peripheral capillary loops was apparent (Figure 2A). Crescents, necrosis,
Management
The patient admitted that, 2 months earlier, he had sexual contact with a person other than his usual partner. He was treated with penicillin G, 2.4 × 106 U intramuscularly, in a single dose on day 3 of his hospitalization. His partner was treated at an outpatient clinic. Clinical and laboratory response to therapy are shown in the Table.
Penicillin generates a striking improvement in renal function and a sustained response, as confirmed by reductions in proteinuria, in patients with syphilitic
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The case: a 23-year-old Asian man with HIV infection and leg pitting edema
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Cited by (8)
Membranous Nephropathy in Syphilis is Associated with Neuron-Derived Neurotrophic Factor
2023, Journal of the American Society of NephrologySyphilis-associated membranous nephropathy successfully treated with amoxicillin
2021, Clinical NephrologyRenal manifestations of syphilis
2021, Internal Medicine JournalMembranous Glomerulonephritis as an Uncommon Presentation of Secondary Syphilis: A Reminder on Therapeutic Decision-Making in Clinical Practice
2020, Journal of Investigative Medicine High Impact Case Reports
Funding: None.
Conflict of interest: None.
Authorship: All authors had access to the data. SAN prepared the draft; VC and KFA collected the data; AAE critically reviewed and revised the manuscript; AK collected data and designed and wrote the manuscript. All authors approved the final submission.