A 50 year old male presents a 4 weeks history of exertional shortness of breath. He a long history of depression which he originally took Lithium Carbonate but stopped this medication over 5 years ago since then taking Paroxetine. He was also diagnosed asthma 2 years ago by his general practitioner which he was prescribed salbutamol inhalers taking ibuprofen over last six months Osteoarthritis of hips. The only other relevant information two weeks ago he returned from a 6 week holiday in Australia where he spent a week in outback. He had frequently been bitten by mosquitoes. Examination reveals a rather ill and tanned individual a temperature of 37oC, a pressure of 146/86 mmHg a pulse of 106 beats per minute. No specific abnormalities were noted except scattered bibasal fine crackles occasional wheeze on chest examination. Investigations reveal: Haemoglobin 14g/dL White cell count 6 x 109/L Neutrophil count 3.5x109/L Lymphocyte coun 2 x 109/L Monocyte count normal Eosinophils 1 x 109/L ESR (Westergren) 65 mm/1st hour Serum sodium 136 mmol/L Serum potassium 7.0 mmol/L Serum chloride 106 mmol/L Serum bicarbonate 15 mmol/L Serum creatinine 600 umol/L Ultrasound of kidneys: Right kidney 12cm, left kidney 13cm. No obstruction seen What is the likely diagnosis?
1 ) Amyloid
2 ) Analgesic nephropathy
3 ) Churg Strauss syndrome
4 ) Membranous glomerulonephritis
5 ) Rapidly progressive glomerulonephritis
Comments: This patient may have an inflammatory pathology as indicated by ESR. He developed asthma in presence of a raised peripheral eosinophil count. The presence of above renal impairment lends a possible diagnosis of Churg Strauss syndrome, which can cause a pauci immune small vessel vasculitis, glomerulonephritis. ANCA titres should be checked.3 )