Delayed Diagnosis of Cast Nephropathy

      A 64-year-old woman presented to our hospital with a 1-month history of progressive dyspnea and generalized edema. Her past medical history comprised only multiple intracranial meningioma, and she was not on any regular medication. She was a current smoker of 15 pack-years and did not consume alcohol. She did not have a family history significant for cardiac, pulmonary, liver, or kidney diseases. On physical examination, mild tachycardia and tachypnea, pallor conjunctiva, elevated jugular venous pressure, and bilateral edema of the lower legs were noted. There was no evidence of jaundice, heart murmur, respiratory crackles, or hepatomegaly. Laboratory investigation revealed low hemoglobin (8.5 g/dL), elevated blood urea nitrogen (17.1 mg/dL) and serum creatinine (1.62 mg/dL), and proteinuria (1.79 g/g creatinine) with microscopic hematuria. Chest X-ray study showed mild cardiomegaly with bilateral pleural effusion; and transthoracic echocardiography revealed only mild pericardial effusion with normal left ventricular size and function. She was diagnosed with suspected congestive heart failure with renal insufficiency, and diuretics mildly improved her symptoms; however, her serum creatinine level progressively worsened. Antinuclear antibody, antineutrophil cytoplasmic antibody, and antiglomerular basement membrane antibody tests were negative. Tests for hepatitis B surface antigen and core and surface antibodies, hepatitis C virus, and Treponema pallidum were also negative. Serum protein electrophoresis showed no typical M-peak, and a qualitative test for urinary Bence Jones protein was negative. Because the cause of renal failure remained unknown, renal biopsy was undertaken for definitive diagnosis. The histological pattern was consistent with cast nephropathy. Therefore, serum and urinary protein electrophoresis were repeated, and Bence Jones protein of the lambda light chain type was detected. Bone marrow aspiration revealed 19.8% plasma cells, which have nucleus with abnormal mitosis or malformation. She was finally diagnosed with renal failure due to multiple myeloma and was transferred to the tertiary hospital.
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