A Case with Membranous Glomerulonephritis and Myelodysplastic Syndrome

Dr. Saime Paydas, Cukurova University Medical Faculty, Department of Internal Medicine, Balcali Hospital, 01330 Adana (Turkey) Dear Sir, We described a case of membranous glomerulonephritis (MGN) and anemia-thrombocytopenia in a male who was subsequently diagnosed as hypoplastic-type myelodysplastic syndrome (MDS). A 65-year old man was admitted for uremia and anemia. He has had history of edema and lumbal pain for 8 months. Ten days before admission, he complained of melena. On physical examination, pallor and splenomegaly were detected. Investigations were as follows: hematocrit 15%, hemoglobin 4.9 g/dl, WBC 10, 100/mm3, platelet count 75,000/mm3, peripheral blood smear disclosed anisocytosis, poikilocytosis, polychro-masia, WBC were normal, BUN 90 mg/dl, creatinine 8.7 mg/dl, phosphorus 8.1 mg/dl, total protein 6.6 g/dl, albumin 4.1 g/dl, total iron 140 μg/dl, unsaturated iron-binding capacity 230 μg/dl, total ironbinding capacity 37 μg/dl, acid phosphatase 10.8 mg/dl, pros-tatic acid phosphatase normal, prostate-specific antigen normal, vitamin B12 465 pg/ml, folic acid 4.20 ng/ml, erythrocyte sedimentation rate 115 mm/h. Antinuclear antibody, rheumatoid factor, HBsAg, anti-HCV and an-ti-HAV were negative. Urine protein excretion was 3.75 g/day and creatinine clearance 10.8 ml/min. There was no Bence Jones pro-teinuria. Urine microscopy showed granular and cellular casts but no organisms. Ultrasonographic and computerized to-mographic exam of the abdomen and pelvis were negative except for prostatic hypertrophy (38 × 22 × 27 mm). Chest x-ray showed a dilated aorta. Upper and lower gastrointestinal endoscopy were negative. Dry tap was found in bone marrow aspiration. Bone marrow biopsy was consistent Fig. 1. Biopsy No. 1339/91: diffuse thickening of the glomerular capillary walls (membranous glomerulonephritis). HE. × 600. phosphamide (100 mg/day), dipyridamole (225 mg/day) and famotidine (20 mg/day). Three months later, urea level and urine protein excretion were 30 mg/dl and < 0.3 g/day respectively; but anemia persisted (Hct 14-16%). A second bone marrow biopsy was performed. It was found that the bone marrow was infiltrated by monocytic cells (fig. 2),