MED-3. A pleural effusion in a healthy patient manifesting as nephrotic syndrome.

Patients with the nephrotic syndrome have an increased incidence of arterial and venous thromboemboli. Studies evaluating measures of hemostasis activation, such as the plasma level of fibrinopeptide A, which is cleaved from fibrinogen by thrombin, suggest that even asymptomatic nephrotic patients have evidence of ongoing coagulation. A 31-year-old male, current smoker presented with the complaints of cough and pleurisy like symptoms for two weeks. Chest x-ray was consistent with left sided pleural effusion, which was sanguineous and culture negative. Due to persistence of symptoms and to rule out empyema CT of chest was done revealing pulmonary embolism with the extension of the thrombus from inferior vena cava to the left renal veins. His urine analysis showed 4+ proteinuria, microscopic hematuria. Renal biopsy showed membranous glomerulopathy with segmental sclerosis interstitial fibrosis and tubular atrophy consistent with nephrotic syndrome, which improved with steroids. Nephrotic syndrome is associated with a hypercoagulable state, which may induce hyperaggregability of platelets and profound clotting factor abnormalities. Although the causal relationship between the hypercoagulable state and development of thrombosis has not been established, nephrotic patients frequently suffer from thromboembolic events. A high index of suspicion is needed to make the diagnosis because clinical signs may obscure, as in our patient who was other wise healthy with a pleural effusion but had extensive thrombosis as well as nephrotic syndrome.

Fawzia Salahuddin, MD, and Rashid Rahman, MD. Emergency Medicine and Internal Medicine and Pulmonary and Critical Care Medicine, University of Illinois College of Medicine, Peoria, IL.