Case Archive
 
Nephrology
Ref. # 78618

A 41 year old New York woman with a history of hypertension, seizure disorder, arthritis, hepatic cirrhosis, anemia, cholelithiasis and alcoholism was referred to a hematologist. A positive direct Coombs test led to a possible diagnosis of lupus. No further testing for lupus was ordered. Six months later the patient developed a facial depigmentary rash and arthropathy of the left ankle and right shoulder. She was admitted to the hospital for auto-immune hemolytic anemia associated with liver disease, which was treated with prednisone. Over the next four years the patient developed progressive renal failure and ultimately required hemodialysis. One year later she suffered gastrointestinal bleeding and pericarditis and subsequently died. A medQuest nephrologist opined there was a negligent failure to follow up on the diagnosis of lupus, such as ordering a kidney biopsy, which led to the patient's renal failure. No mention of the diagnosis was ever made to any of the patient's treating physicians, nor was a rheumatologist ever consulted. With timely diagnosis and treatment, the patient's kidney disease may have improved.

Nephrology
Ref. # 55318

A 31 year old Massachusetts woman was seen by an internist for complaints of arthralgias in both hands. Treatment included Voltaren and wrist splints. X-rays showed only soft tissue swelling. Ten months later, she was seen again for arthralgias and diagnosed with probable rheumatoid arthritis. Treatment included prednisone 10 mg. qd for one week and Motrin. A rheumatoid factor was negative; X-rays were normal. The arthralgias improved in one week. Ten months later the woman was seen for periorbital edema, which was interpreted as probable allergic reaction, and a cough, which was treated with Bactrim-DS. She returned two days later with an urticarial rash, interpreted as due to Bactrim allergy. She was placed on Benadryl, which was ineffective for one month, after which she was placed on Seldane. Seven weeks later she presented to the ER with chest pain and urticaria. She was treated with Atarax for hives and diagnosed with probable chronic idiopathic urticaria by a dermatologist. Seven months later she returned to the internist with bilateral periorbital edema and bilateral ankle effusions. An empirical trial of prednisone for probable rheumatoid arthritis flare was ineffective. The woman was referred to a rheumatologist, who diagnosed lupus nephritis. She required hospitalization for three months for a retroperitoneal hematoma and diffuse lupus nephritis. She subsequently suffered an inferior wall MI, and required biweekly transfusions. A medQuest nephrologist opined the internist negligently failed to order blood work, urinalysis or lupus testing. The two and a half year delay in making the correct diagnosis made the patient's course more protracted and serious. With early, aggressive immunosuppressive therapy, there was an opportunity for the woman's renal function to have been preserved.




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