Diagnostic dilemma
A Red Herring in the Green Grass: Syphilitic Membranous Glomerulonephritis

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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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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.

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