05-09-2007, 10:01 AM
A 56-year-old man presents to your office complaining of fatigue and persistent joint pain for three months. His past medical history is significant for hypercholesterolemia, hypertension, and hepatitis C from injection drug use in the distant past. He has not been treated for hepatitis. He has no drug allergies.
His physical examination is remarkable for a right ventricular heave and a soft holosystolic murmur at the right sternal border. His abdomen is soft, with a liver edge palpable three centimeters below the costal margin and splenomegaly. There are purpuric lesions on his skin. There is no joint deformity or muscle atrophy. Laboratory studies reveal the following:
Hemoglobin 12 g/dL; platelets 410,000/mm3; BUN 47 mg/dL; creatinine 3.2 mg/dL; glucose 130 mg/dL, serum bicarbonate 20 mEq/L; total bilirubin 1.2 mg/dL; AST 88 U/L; ALT 110 U/L.
C3 and C4 levels are low. Rheumatoid factor is positive at a high titer.
Urinalysis -- protein 3+, hemoglobin 1+, with 50 red cells and no white cells or casts.
Immunofluorescence of the renal biopsy shows large glomerular intracapillary deposits, with granular subendothelial deposits outlining the glomerular capillary walls.
What would be the next appropriate step in the management of this patient?
(A) Kidney transplant
(B) Hemodialysis
© Prednisone
(D) Interferon and ribavirin
(E) Cyclophosphamide
His physical examination is remarkable for a right ventricular heave and a soft holosystolic murmur at the right sternal border. His abdomen is soft, with a liver edge palpable three centimeters below the costal margin and splenomegaly. There are purpuric lesions on his skin. There is no joint deformity or muscle atrophy. Laboratory studies reveal the following:
Hemoglobin 12 g/dL; platelets 410,000/mm3; BUN 47 mg/dL; creatinine 3.2 mg/dL; glucose 130 mg/dL, serum bicarbonate 20 mEq/L; total bilirubin 1.2 mg/dL; AST 88 U/L; ALT 110 U/L.
C3 and C4 levels are low. Rheumatoid factor is positive at a high titer.
Urinalysis -- protein 3+, hemoglobin 1+, with 50 red cells and no white cells or casts.
Immunofluorescence of the renal biopsy shows large glomerular intracapillary deposits, with granular subendothelial deposits outlining the glomerular capillary walls.
What would be the next appropriate step in the management of this patient?
(A) Kidney transplant
(B) Hemodialysis
© Prednisone
(D) Interferon and ribavirin
(E) Cyclophosphamide