Remarkable Past Medical History Research Articles

Father–Son COVID‐19‐associated mucormycosis: Important role of genetic susceptibility in combination with environmental factors

In this report, a father with a history of diabetes mellitus and his son without a remarkable past medical history, both got COVID‐19‐ associated mucormycosis (CAM) as evidenced by their clinical and radiological findings. This suggests the possible role of genetics in combination with the environment in susceptibility to CAM.

Robot-assisted Resection of a Wide-extending Abdominoperineal Angiomyofibroblastoma in a Male Patient

A 61-year-old man was referred for dysuria and management of a 6-months history of perineal swelling. Patient has no remarkable past medical history nor previous abdominal surgery. At physical examination, a bulging mass on the left half of the perineum was noted. Ultrasound (US) and magnetic resonance imaging (MRI) showed a 20 × 10 cm mass in the abdomen and pelvis, between the bladder and the rectum, developing toward the perineum, compressing the muscles,the prostate and the urethra (Fig. 1).

Intestinal Spirochetosis

A 49-year-old heterosexual man presented to our outpatient clinic after a positive fecal occult blood test result. He had no remarkable past medical history and reported neither weight loss nor bowel symptoms. Colonoscopy showed a small erosive lesion in the cecum (Figure A), and biopsies were performed. Light microscopy revealed a band of spirochetes resembling a “false brush border” that was adherent to the border of the epithelial layer (Figure B, arrows; hematoxylin-eosin staining). This was highlighted by immunostaining for Treponema pallidum (Figure C, arrows).

Asymptomatic Hyperpigmented Rash in a Healthy Adolescent Female.

Asymptomatic Hyperpigmented Rash in a Healthy Adolescent Female.

Case 295.

History A 57-year-old man with no remarkable past medical history presented to an outside institution with painless swelling in his right thigh of 6 months duration. He denied any trauma to the site. At that time, physical examination demonstrated swelling in his right upper thigh. All other work-up, including complete blood count and chest radiography, yielded negative results. The initial diagnosis was lymphangioma of the thigh. He continued to experience worsening swelling in his right upper thigh with no other symptoms over the next year. He was referred to our facility, where he underwent US evaluation of the thigh lesion (Fig 1), an MRI scan encompassing the entire extent of his thigh lesion (Fig 2), and a CT scan of his abdomen and pelvis (Fig 3).

Pseudopheochromocytoma as a Presentation of Amyotrophic Lateral Sclerosis

Introduction: Pseudopheochromocytoma presents as paroxysmal events of hypertension and other noradrenergic symptoms similar to pheochromocytoma (PCC) but do not meet tumoral diagnosis. Case Report: A 70-year-old Caucasian male with history of gastroesophageal reflux disease (GERD) and Barrett’s esophagus presented to the Emergency Department with fatigue, shortness of breath, palpitations, and fasciculations in the anterior chest wall. He reported recent diagnosis of PCC. Patient had episodes of non-exertional palpitations, diaphoresis, dizziness, facial flushing, and facial involuntary movement along with self-monitored average blood pressure (ABP) of 160/100 mmHg and heart rate (HR) of 90 beats per minute (bpm). Spells occurred 2 to 3 times per month at first, later increased. Between episodes self-monitored ABP was 120/70 mmHg and HR of 50 bpm and asymptomatic. He reported unintentional weight loss of 40 pounds in the same interval and newly muscle weakness that he attributed to weight loss and malnutrition. Patient had no remarkable past medical history. Medications included coq10 enzyme, glucosamine, flax seed oil, primrose oil and recently added doxazosin 1 mg tab per day. Evaluation revealed a cachectic patient (body mass index 17.46 k/m2) with normal vital signs, otherwise unremarkable physical exam except for diffuse fasciculations in chest and upper extremities. Outpatient work up included normal complete blood count, comprehensive metabolic panel, drug screening, thyroid function test. He had elevated free plasma metanephrine (FPM) of 73 pg/mL (< 57 pg/mL), free plasma normetanephrine (FPN) of 487 pg/mL (<148 pg/mL), before doxazosin. Repeated FPM of 55 pg/mL (< 57 pg/mL), FPN of 347 pg/mL (<148 pg/mL). The 24-hour urine for metanephrine was normal with total metanephrine of 157 ug/d (55-320 ug/d) and normetanephrine 432 ug/d (114-865 ug/d) with a creatinine of 900 mg/dL (800-2100 mg/d). He also had outpatient computed tomography (CT) scan of thorax, abdomen, and pelvis that was normal. Positron emission tomography CT scan did not reveal any tumors. Our initial suspicion, later confirmed with electromyography, was a neurodegenerative disease with motor neuron dysfunction. Patient was diagnosed with Amyotrophic Lateral Sclerosis (ALS) and started in riluzole with improvement of spells. Since, his muscle weakness progressed, he now requires noninvasive ventilation. Discussion: Pseudopheochromocytoma is an idiopathic disease that mimics catecholamine-secreting PCC and needs adequate and complete evaluation. Catecholamine levels can be affected by illness, stress, medications, and sample collection. In the case presented, the patient’s muscular weakness and fasciculations was caused by ALS. Neurodegenerative diseases such as ALS can cause a central nervous system stress response, consequently causing elevated norepinephrine levels.

Bilateral pulmonary embolism while receiving tranexamic acid: a case report

BackgroundWe present a case of a suspected tranexamic acid–related bilateral pulmonary embolism in a healthy and active middle-aged woman who was receiving tranexamic acid for menorrhagia with no other known significant risk factors for thromboembolism.Case presentationA 46-year-old Asian woman who was usually fit and well with no remarkable past medical history except for menorrhagia of 1-year duration for which she was receiving tranexamic acid presented to our accident and emergency department with a 2-week history of intermittent pleuritic central chest pain. She was reviewed and discharged to home with a diagnosis of musculoskeletal pain on two hospital visits because she had no significant risk factors for thromboembolism and her workup investigation results for pulmonary embolism and other differential diagnoses were largely unremarkable. On her third visit to the emergency ambulatory clinic with recurring symptoms of pleuritic chest pain, a pulmonary computed tomographic angiogram confirmed bilateral subsegmental pulmonary embolism.ConclusionThis case report reinforces the possible increased risk of thromboembolism in patients receiving tranexamic acid.

An autoimmune storm: A case based literature review of successful management of lupus-polymyositis overlap syndrome complicated by multiple organ failure

Overlap syndromes of Connective tissues diseases is a rare and under-studied disorder. This syndrome can be complicated by multiple life-threatening complications like hepatitis, pancreatitis, macrophage activation syndrome and Acute Respiratory Distress syndrome. We report a 22-year-old Hispanic male with no remarkable past medical history who presented to the hospital with abdominal pain, myalgia, arthralgia, and persistent fever for two weeks and was found to have tachycardia, pancytopenia, transaminitis and an elevated lipase. The patient was initially evaluated for acute pancreatitis and hepatitis due to binge drinking and presumptive viral infection. Infectious work up was unrevealing, and the patient continued to deteriorate. The autoimmune panel came back significant for highly elevated Antinuclear Antibody (ANA) and Anti Double Stranded DNA antibody (dsDNA), low complement, high inflammatory markers, ferritin, elevated Creatine Kinase (CK), positive Anti Mi 2 antibody, low Natural Killer (NK) cell activity and elevated CD25. Patient was subsequently diagnosed with Lupus- Polymyositis overlap syndrome. Acute lupus flare was considered as the trigger for pancreatitis and hepatitis. The hospital course was complicated by Acute Respiratory Distress Syndrome (ARDS) due to Lupus pneumonitis, encephalopathy, and Macrophage Activation Syndrome (MAS). Patient was treated successfully with steroid pulse therapy, Cyclophosphamide, plasmapheresis, artificial ventilation, and extracorporeal membrane oxygenation (ECMO). We believe that this case is unique as it represented a diagnostic challenge as the Lupus-Polymyositis overlap syndrome is a rare entity, and it initially manifested in an extensively complicated pattern which is unusual. Moreover, this case was not only a diagnostic challenge but also a treatment conundrum due to multiple life-threatening complications the patient had during this hospitalization. In this review, we intend to discuss the management of this challenging and rarely reported connective tissue disease overlap syndrome.

Young female patient with bilateral periorbital edema

A 19-year-old female patient presented to the emergency department with a one-week history of fever, malaise, and progressive eyelid swelling. She had no remarkable past medical history and seemed at ease during her consultation. A physical examination showed the following: blood pressure, 139/82 mm Hg; heart rate, 81/min; temperature, 37.9 °C (100.2 °F); respiratory rate, 16/min; and oxygen saturation, 98% on room air. Marked bilateral periorbital edema (Fig. 1A) and posterior cervical lymphadenopathy were observed.

Rupture of the esophagus due to carbonate use - a case report

Background: Rupture of the esophagus which is not iatrogenic or due to carcinoma, Mallory Weiss syndrome, or foreign body is called a spontaneous rupture of esophagus or Boerhaave syndrome. Symptoms are not specific and include back or retrosternal chest pain, crepitus on chest wall palpation, or mediastinal crackle. Esophagus rupture could have dyspnea, tachypnea, tachycardia, and dullness in the chest exam due to pleural effusion beside the pain. Case presentation: In this report, we had two cases with rupture of the esophagus due to soda (bicarbonate) use with no remarkable past medical history. Both patients had stable vitals when they came to the Emergency Department. Diagnosis was confirmed by chest CT scan. One of the patients did not take any invasive treatment and there was no need for operation. The other patient underwent thoracotomy and esophageal repair. Both of them had good general condition after some days. Conclusion: We recommend not englutting excessive amounts of soda why it can cause rupture of the esophagus in patients with unknown esophageal wall weakness or healthy esophagus.

1639 Chronic Diarrhea Due to Pancolitis Caused by Trichuris trichiura

INTRODUCTION: Indonesia as one of the largest tropical countries in the world, shared the particularly high burden cases of parasitic colitis especially due to worm infections; Therefore patient with chronic diarrhea in tropical country should be evaluated for parasitic infections such as Trichiasis. CASE DESCRIPTION/METHODS: 22-year-old woman presented with prolonged diarrhea with mucus and no blood since one month ago. She had two to four times bowel movements once a day. She also complained for having recurrent diffuse periumbilical pain and nausea every day. She also reported for having weight loss of 3 kg. She had no remarkable past medical history. She admitted for having poor hygiene lifestyle and using non purified ground water as drinking water. She previously had visited nearest hospital for consultation, the blood test showed hemoglobin of 12.8 g/dl, white blood cell of 28,000/mL; stool analysis showed positive microscopic erythrocyte and leukocyte without worm eggs or other parasites. Other laboratory value was normal. She was admitted and treated with Levofloxacin, attaplugite, and probiotic. After five days of hospitalization, no improvement was seen, therefore she was referred to our hospital endoscopy unit for colonoscopy. Colonoscopy examination showed inflammation of the entire colon with erosion and ulceration, also multiple Trichuris trichiura were found. She was treated with mebendazole. She had clinical improvement and re-colonoscopy was done after two weeks. Re-colonoscopy examination showed no inflammation and no worms were found. DISCUSSION: Patients with Chronic diarrhea in tropical countries should always be evaluated for parasitic infections. Stool examination and colonoscopy may be helpful to establish the diagnosis. Trichuris trichiura infections may manifest as asymptomatic infection or chronic diarrhea or dysentery which may mimic inflammatory bowel disease.

A rare cause of small bowel diaphragm disease presenting with palpated abdominal mass

Small bowel diaphragm disease is a rare complication related to non-steroidal anti-inflammatory drug (NSAID) use. It presents with non-specific symptoms such as vomiting, abdominal pain, subacute bowel obstruction and occasionally as an acute abdominal condition. We report a case of diaphragm disease in a 33-year-old female who presented with vomiting, constipation and abdominal pain started 5 days earlier. Physical examination revealed palpated abdominal mass. The patient’s past medical history was remarkable for NSAID use. The patient was managed by surgical resection of involved intestine and diagnosis was confirmed by histological examination. Although there are few published cases of diaphragm disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing patients presenting with non-specific abdominal symptoms with remarkable past medical history of NSAID use.

Brain Abscesses Associated with Asymptomatic Pulmonary Arteriovenous Fistulas

Brain abscess commonly occurs secondary to an adjacent infection (mostly in the middle ear or paranasal sinuses) or due to hematogenous spread from a distant infection or trauma. Pulmonary arteriovenous fistulas (AVFs) are abnormal direct communications between the pulmonary artery and vein. We present two cases of brain abscess associated with asymptomatic pulmonary AVF. A 65-year-old woman was admitted with a headache and cognitive impairment that aggravated 10 days prior. An magnetic resonance (MR) imaging revealed a brain abscess with severe edema in the right frontal lobe. We performed a craniotomy and abscess removal. Bacteriological culture proved negative. Her chest computed tomography (CT) showed multiple AVFs. Therapeutic embolization of multiple pulmonary AVFs was performed and antibiotics were administered for 8 weeks. A 45-year-old woman presented with a 7-day history of progressive left hemiparesis. She had no remarkable past medical history or family history. On admission, blood examination showed a white blood cell count of 6290 cells/uL and a high sensitive C-reactive protein of 2.62 mg/L. CT and MR imaging with MR spectroscopy revealed an enhancing lesion involving the right motor and sensory cortex with marked perilesional edema that suggested a brain abscess. A chest CT revealed a pulmonary AVF in the right upper lung. The pulmonary AVF was obliterated with embolization. There needs to consider pulmonary AVF as an etiology of cerebral abscess when routine investigations fail to detect a source.

Crystalline cast nephropathy in a patient with IgD lambda myeloma

A 72-year-old woman was admitted at our department for renal dysfunction with general fatigue and loss of appetite for 2 months. She had no remarkable past medical history except hypertension, which was treated with angiotensin-converting enzyme inhibitor and a calcium channel blocker. Physical examination was unremarkable, except for pale conjunctivae. Urinary protein to creatinine ratio was 9.5 g/gCr, revealing a large discrepancy from the result of mild proteinuria by urinary dipstick (2?; indicating 100–300 mg/L). No hematuria was found. Serum creatinine level was increased to 1.90 mg/ dL associated with anemia (hemoglobin 7.3 g/dL). Other findings were total protein 6.8 g/dL, serum albumin 4.67 g/ dL, serum IgG 516 mg/dL (normal 870–1700 mg/dL), serum IgA 17 mg/dL (normal 110–410 mg/dL), serum IgM 5 mg/ dL (normal 34–220 mg/dL), and serum IgD 306 mg/dL (normal 0–9 mg/dL). Serum and urine electrophoresis revealed a monoclonal spike and an IgD-type monoclonal k band, respectively. The free k light chain level was 3720 mg/ L; serum j/k ratio was 0.0017. On the 5th day after admission, kidney biopsy was performed (Fig. 1). On light microscopy, minor glomerular abnormalities were observed; furthermore, diffuse mononuclear cell infiltration in the interstitium and crystalline casts in the proximal tubules were observed. These crystalline casts were hematoxylin and eosin positive but periodic acid-Schiff (PAS) negative. Moreover, only k light chain staining was positive. On electron microscopy, crystalline casts were found to form gigantic plate-shaped crystalline structures. Bone marrow aspiration cytology confirmed the diagnosis of multiple myeloma. She received bortezomib–dexamethasone therapy and achieved complete remission with normal renal function for 2 years. Cast nephropathy is the most common renal complication [1]. In rare cases, the casts exclusively comprise crystals. Myeloma-free light chains (MFLCs) are usually absorbed by proximal tubular cells, leading to acute proximal tubular damage associated with needle-shaped crystals in epithelial cells. This condition is well known as acquired light chain-related Fanconi syndrome [2]. Conversely, MFLCs that are not absorbed by the proximal tubules are distributed to the distal tubules and the ascending loop of Henle, where Tamm–Horsfall protein (THP) casts are exclusively synthesized [3]. These casts usually comprise needle-shaped or rhomboid crystals. THP is one of the glycoproteins, which is invariably PAS positive. The crystalline casts that were observed in this case were PAS negative and were distributed in the proximal tubule lumen. This is understandable, considering the site of THP synthesis. Some reports described crystal formation in organs except the kidneys. In these organs, crystal formation occurred in microvasculature due to low tissue temperature and/or blood circulation stasis; however, the precise mechanism is uncertain [4]. The characteristics of this case emphasized that MFLCs may form crystals independently or at least, without THP participation. Some have reported factors that may contribute to explain MFLC precipitation for crystal formation: a large MFLC amount & Satoshi Kumakura satoshi.kuma.714@gmail.com

EARLY ONSET PERIPARTUM CARDIOMYOPATHY FOLLOWING DILATION AND EVACUATION FOR COMPLETE HYDATIDIFORM MOLE COEXISTENT WITH LIVE FETUS

Peripartum cardiomyopathy (PPCM) is a rare disorder (1 case per 1,000 to 4,000 live births). Complete hydatidiform mole and coexistent fetus (CMCF) is even less common (1 in 22,000 to 100,000 pregnancies). A 33 year old primigravida with no remarkable past medical history was admitted at 12 weeks

Primary tuberculosis of the breast: A rare case

Introduction: Tuberculosis (TB) is a very common entity that is predominant in the developing countries. However, coming across TB of the breast is a rare, exceptional and an exciting experience. Primary breast TB incidence is reported to range between 0.025 and 0.1% in the developed countries compared to the incidence of breast TB in the developing countries which is approximated at 3–4.5% of TB cases. The breast is generally labeled as the body organ which is structured in such a manner that its environment is not conducive for the multiplication of the bacilli. Case Report: A case of a 32-year-old female presented with an occasionally painful left breast and left axillary lumps over a period of two months duration. She had been well with no remarkable past medical history. There is no history of previous trauma and she was not exposed to people with TB at home and at work. There are no respiratory system signs of TB. Biopsies of the left breast lump as well as that of the left axillary lump were performed and the diagnosis of TB breast and the left axillary was clinched. The patient was then put on anti-TB treatment. Conclusion: There are no specific clinical or radiological features of TB of breast. The final diagnosis of breast TB is made though histopathological findings. The radiological investigations help with the characterization of the extent of the lesions.

Pleural Effusion, Ascites, and Periportal Edema in the Absence of Fulminant Hepatic Failure Secondary to Nimesulide

Introduction: Nimesulide is a non-steroidal antinflammatory drug that has been associated with hepatoxicity leading to acute hepatitis, as well as fulminant hepatic failure. The mechanisms have been studied, but are still poorly understood. We hereby report the first case of nimesulide leading to ascites in the presence of bilateral pleural effusions in the absence of fulminate hepatic failure. Case Report: A 44-year-old Brazilian woman with no remarkable past medical history presented with sharp right upper quadrant epigastric pain following a recent 2-week trip to Brazil. She was visiting her family, who lived in a mountainous region and owned a farm that housed cows and pigs, but she did not have any direct contact with animals during her visit. However, she did drink local, unfiltered tap water. Prior to travel, she had sustained an ankle sprain and in Brazil; she was prescribed nimesulide 200 mg 3 tablets a day for 5 days. On presentation, she reported nausea with episodes of non-bloody emesis with body aches, chills, and weakness. On exam, she was afebrile with no scleral icterus. Abdomen was tender to palpation in the right upper quadrant, with positive Murphy’s sign. Her lungs exhibited absent to decreased breath sounds in the bilateral bases. Her white blood cell count was 7,600 per μL. Liver tests showed an AST 327 U/L and ALT 518 U/L. CT abdomen revealed large-volume ascites, periportal edema, and bilateral pleural effusions. Hepatitis A IgM antibody, hepatitis B core IgM antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis C, and hepatitis E antibodies were all negative. Anti-smooth muscle antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, and antimitochondrial antibodies were also negative. She subsequently underwent a transjugular liver biopsy, which was noted for acute lobular hepatitis with prominent zone 3 necrosis and a trans-sinusoidal gradient of 5 mm Hg. Additionally, a simultaneous diagnostic paracentesis was also obtained, which was significant for a SAAG gradient of 1.1. Further infectious work-up revealed a negative HIV, HSV, EBV, and CMV. Yellow fever, Strongyloides, Dengue fever, Leptospira, Schistosoma, and Brucella antibodies were also negative. Conclusion: There have been reports associating nimuselide with fulminant hepatic failure, but none involving nimuselide with pleural effusions and ascites without frank hepatic failure. Although the exact mechanism remains unclear, a clinician still needs to be aware of nimesulide as a possible cause of ascites and pleural effusion in spite of the absence of fulminant liver failure, as documented in our patient, and a thorough drug history is very pivotal.

Fatal broncho-pneumonia of an infant with arthrogryposis multiplex congenita (AMC)

Arthrogryposis multiplex congenita (AMC) is a heterogenous group of disorders characterized by multiple joint contractures with an estimated frequency of 1 in 3000-5100 livebirths. The authors present a case of an 11-month-old infant with AMC who died due to severe pneumonia. The deceased had no significant anomaly except for the stated orthpaediatric deformities, and the long-term outcome was expected to be positive. The only remarkable past medical history was respiratory syncytial virus (RS) infection at 6-months old which had taken a few days for a complete recovery. Onset of high fever was observed 3 days prior to her death and she was found in a state of cardiopulmonary arrest in bed by her father in an early morning. Forensic autopsy confirmed the pathohistological diagnosis of severe broncho-pneumonia. The presence of scoliosis and funnel chest was considered to be attributable to the disability to turn herself over and excrete sputum sufficiently, leading to a fatal respiratory complication. This paper stresses the possibility of distal arthrogryposis type of AMC becoming contributory to death despite the initial optimistic prognosis, as well as the importance of postmortem investigation in unexpected fatal cases.

Xanthogranuloma in Adolescence

Xanthogranuloma in Adolescence

Transformation of membranous nephropathy into antiglomerular-basement membrane glomerluonephritis.

Sir, Further to the recently published case of membranous nephropathy with superimposed anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis [1], we report a case of membranous nephropathy (MN) with crescentic transformation secondary to antiglomerular basement membrane (antiGBM) antibodies. AntiGBM disease is associated with ANCA-positive vasculitis in one-third of the cases but very rarely seen in association with MN. Individual cases or small series have been reported with the occurrence of antiGBM disease preceding, coexistent with or following MN [2–5]. A 63-year-old Caucasian male was referred to the renal services following detection of proteinuria on routine testing by the primary care physician. He was hypertensive for 11 years, well controlled with atenolol and bendroflumethazide. Other remarkable past medical history included open ureterolithotomy for renal stone disease. Initial laboratory tests showed serum urea 6.1 mmol/L, creatinine 105 μmol/L, albumin 31 g/L and proteinuria (4 g/24 h). Ultrasound showed a large left renal cyst and normal right kidney. ANA was weakly positive; serum immunoglobulins and complement levels were normal. HbsAg and antiHCV were negative. Renal biopsy was performed and revealed 21 glomeruli, all of which showed marked thickening of the capillary walls. There was minimal tubular atrophy with normal blood vessels. Silver staining revealed spikes on the glomerular basement membrane and immunohistochemistry showed granular IgG, IgM and C1q positivity. Subepithelial deposits were seen on electron microscopy (Figures 1 and ​and2)2) anti-neutrophil cytoplasmic antibody (ANCA) (Figures 3 and 4). A diagnosis of idiopathic membranous nephropathy was made and he was commenced on ramipril and simvastatin. Fig. 1. (A) Renal biopsy (silver stain ×10), (B) silver stain shows spikes (×40), (C) immunohistochemistry reveals granular IgG deposition in glomerular basement membrane (×40) and (D) immunohistochemistry reveals granular C1q deposition ... Fig. 2. (A) Haemotoxylin and eosin stain reveals crescents in the glomeruli (×1.6), (B) silver stain shows crescents in the glomeruli (×10), (C) silver stain shows crescent in the glomerulus (×40) and (D) immunohistochemistry shows IgG ... Three months later, he presented non-specifically unwell with anorexia, dark urine and loin pain. Laboratory investigations revealed severe renal failure with urea 32.9 mmol/L, serum creatinine 503 μmol/L with low albumin 22 g/L. Magnetic resonance angiography performed on suspicion of renovascular disease revealed patent renal vessels with no evidence of thrombosis or stenosis. Serologic tests came back strongly positive for antiGBM antibodies (>100 ELISA units, 0–2.5 normal) and negative for ANCA. Chest X-ray was normal with no evidence of pulmonary haemorrhage. Repeat renal biopsy revealed four glomeruli and all showed segmental necrosis with active crescents (Figure 2). Silver staining revealed typical spikes on the glomerular basement membrane, with granular IgG, IgM, C3 and C1q on immunohistochemistry and subepithelial deposits on electron microscopy. Immunofluoroscence was not performed. The biopsy picture was consistent with coexistent membranous nephropathy and antiGBM disease. He was treated with haemodialysis, intravenous pulse cyclophosphamide, steroids and plasma exchange. With advanced renal injury on biopsy and dialysis dependency at presentation, he did not recover renal function. Serial antiGBM titres became undetectable and immunosuppression was tapered to stop by 2 months of discharge. The patient remained on CAPD for 2 years and received a successful living related renal transplant from his daughter.