NIV Congres

Introduction: Nephrotic syndrome is characterized by overt proteinuria, low serum albumin, peripheral oedema and hyperlipidaemia. Supportive treatment (protein, salt and water restriction, loop diuretics, ACE-inhibition, statins) and often steroids or immunosuppressants are mainstay therapy. However, when an underlying cause can be identified, this could simplify therapeutic management.

Case: A Caucasian man in his late 30s without any remarkable medical history, presented with symptoms of malaise/myalgia, headache, sore throat, lymphadenopathy and night sweating. He also gained weight (ten pounds since one week) and had noticed pedal oedema and swollen eyelids. About three weeks before presentation he had a non-itching and painless ‘rash’ on his glans penis, which had resolved spontaneously after unprotected intercourse. He smoked one package of cigarettes a day, his alcohol intake was modest (1 to 2 consumptions a day), and he denied recreational use of drugs, although six months ago he had used anabolic steroids as part of a fitness regime. At physical examination we observed a muscular man, not acutely ill, with a swollen face and bilateral peripheral oedema. The blood pressure was elevated (145/90 mmHg). Jugular venous pressure was normal. Cervical lymph nodes were tender but not enlarged, and there were multiple enlarged inguinal lymph nodes. The remaining physical examination was unremarkable. Initial investigations confirmed the clinical diagnosis of nephrotic syndrome. Blood testing revealed very low albumin levels (22 g/L), normal total cholesterol (6.0 mmol/L), highnormal creatinine levels (111 μmol/L, previously 92 μmol/L); complete blood count, CRP, glucose, liver function tests and creatinine kinase were unremarkable. Urine dipstick revealed 3+ proteinuria in absence of haematuria or leukocyturia. 24 h urine analysis confirmed the presence of severe proteinuria (16.8 g/24 h), his endogenous creatinine clearance was 108 ml/min/1.73m². Renal biopsy revealed membranous nephropathy. Because of the mentioned ‘rash’ on his glans penis he was tested for sexual transmitted diseases as a possible underlying cause of his nephrotic syndrome. Serology for syphilis was positive with high titers. After a single penicillin injection, there was fast and complete clinical recovery.

Conclusion: Always consider an underlying cause of glomerular nephropathy (preferably guided by a pathological diagnosis), as it could highly simplify and optimize treatment. Syphilis is a re-emerging infection in the western world; diagnosis is made by serologic testing and primary and secondary syphilis are easily treated with a single injection of penicillin.