Pathology images pending
Biopsy #1: Mesangial and focal endocapillary proliferative glomerulonephritis (lobular accentuation), with a small cellular crescent, peripheral and perihilar FSGS, tubule-interstitial without significant changes. IF and EM findings suggestive of resolving or evolving immune complex mediated process.
IF: Diffuse and focal granular staining of GBM with IgG (3+), kappa and lambda (1-2+), IgA (mild), segmental peripheral and para-mesangial granular and focal confluent IgM (1-2+), C3 and C1q with rare segmental granular staining (trace-1+).
EM: Segmental double contours, and pale subepithelial, intramembranous sub-endothelial, and para-mesangial areas, suggesting immune deposits. Fine granular and fibrillary deposits in lamina densa, sub-endothelial, and mesangial locations. Scant sub-epithelial and intramembranous electron dense deposits are seen. No hump-like deposits, and no TBM deposits. No tubule-reticular inclusions. There is sub-endothelial cell interposition, and focal sub-endothelial lucency.
Biopsy #2: Approximately 50% of glomeruli are globally sclerosed. Thickened GBM with spike-like projections, as well as double contours. No acute endocapillary inflammation, fibrinoid necrosis, or cellular crescents. IF: Sparse granular staining for IgG (2+), IgA (trace), IgM(trace) and C3(2+) along the capillary loops and GBM. some at mesangial area. There is also diffuse linear staining for IgG (3+), IgA (2+), IgM (1+) along the GBM. Polyclonal and all IgG classes stained. Arteriolar walls with some C3 staining. EM: Capillary loops markedly distorted by the presence of numerous sub-epithelial, several subendothelial, and intramembranous electron-dense deposits. Double contours due to sub-endothelial deposits with prominent cellular interposition. Deposits are finely granular. No tubuloreticular inclusions.
Biopsy #3: A pattern of membranoproliferative glomerulonephritis with focal endocapillary proliferation. Immune complexes are present in both linear, and granular pattern and localize to capillary loops. Segmental sclerosis in ~50% of glomeruli. IFTA of ~20%. Finding similar to those in the previous biopsies. Current biopsy with a slight different pattern of electron dense deposits, with subepithelial and intramembranous deposits that are IgG dominant. DD: autoimmune, post-infectious, membranous LN (potentially class V with mesangial alterations), lupus-like process, drug induced, or viral hepatitis.