Patient is a 45-year-old man who has been feeling tired with decreased energy level for almost 1 year.
Elevated TSH was noted 3-months ago, and patient started on thyroid replacement, and statin for hyperlipidemia.
Patient continued to feel tired, experiencing decreased exercise tolerance and noted some ankle swelling for past few months. Rural clinic working diagnosis – “CHF”. At the time of consult noted 1-2+ lower extremity edema. On further questioning admits to ‘foamy urine’ for 5-6 months. No history of joint pains, stiffness, skin rashes, weight loss, fever, chills or night sweats. No history of gross hematuria or NSAID use
Gastro-esophageal reflux disease
History of squamous cell cancer
Bilateral carpal tunnel release
Laboratory and other data:
Normal white and red blood cell count
Serum creatinine 70 umol/L (eGFR 75),
Serum albumin 33 g/L.
HbA1C, ANA, C3, IgG, anti-HCV, HBsAg requested.
Uric acid Normal at 229 (149-369 umol/L),
Serum calcium 2.30 (2.10-2.55 mmol/L)
ANA – Negative, C3 1.41, APLA- Negative
Anti-HCV – Negative, HBsAg – Negative
Serum immuno-electrophoresis: monoclonal IgG lambda band
Low Total IgG 1.4 (6.00- 16.00 g/L)
ESR 40 cm
Urinalysis showed 3+ protein, trace of blood,
24-hr Urine protein 12.4 g/day
Echocardiogram: Normal myocardial function
Stress test: negative for ischemia