NEPHROLOGY – CASE REPORT Renal cocktail: too hard for a diabetic Ankur Gupta • Mohan Biyani • Susan J. Robertson Received: 17 June 2011 / Accepted: 6 July 2011 / Published online: 22 July 2011 Ó Springer Science+Business Media, B.V. 2011 Abstract We herein report a case of a 67-year-old diabetic woman who presented with a history of fatigue for 1 month. Her investigations showed proteinuria, active urine sediment, p-ANCA positivity and worsened renal functions. A diagnosis of rapidly progressive glomerulonephritis was made. Renal biopsy revealed class V (membranous) lupus nephritis with superim- posed ANCA-associated crescentic glomerulonephritis. She was treated with steroids and cyclophosphamide. Two months later, she presented with cytomegalovirus colitis and deep vein thrombosis of right leg. The case reflects an interesting renal pathology, and complica- tions of the disease per se and its treatment. Keywords Membranous lupus nephritis Á ANCA Á Crescentic glomerulonephritis Á CMV colitis Á Deep vein thrombosis Introduction and case Glomerular diseases masquerading diabetes are often an unrecognized clinical scenario. However, to have a combination of secondary glomerular diseases with unprecedented complications is quite rare. We herein present such an interesting case of a 67-year-old African-American woman who came to our emer- gency room with a history of fatigue for last 1 month. Her past medical history was significant for type 2 diabetes mellitus and hypertension. She did not have any history suggestive of secondary complications of diabetes and a baseline serum creatinine of 83 lmol/l and a normal urinalysis. She denied any history of gross hematuria, weight loss, hemoptysis, nasal bleed, visual, neurological or gastrointestinal symptoms, rash, photosensitivity, joint pains, Raynaud’s phenomenon or skin tightness. Her medications included metformin 500 mg/day and hydrochlorthiazide 12.5 mg/day. On examination, she looked pale, afebrile, blood pressure 126/78 mmHg, heart rate 73 min and had mild pedal edema. Fundus examination showed grade 1 hypertensive retinopathy with no evidence of diabetic changes. Systemic examination was normal. Investigations revealed a hemoglobin of 91 g/l, white counts (WBC) 4.1 9 10 9 /l, blood urea 16 mmol/l, serum creatinine 232 lmol/l, albumin 31 g/l and glycated hemoglobin 6%. Urine routine showed 2? protein. Urine microscopy showed red cells 30/high power field (HPF), white cells 5–10/HPF and one red cell cast. Twenty-four-hour urine protein was 1.18 g. Antinuclear antibody (ANA) was strongly positive with 1:2560 titers and had nucleolar pattern. Anti-double stranded (Anti-DS) A. Gupta (&) Á M. Biyani Department of Nephrology, The Ottawa Hospital (University of Ottawa), Riverside Campus 1967 prom. Riverside Drive, Ottawa, ON K1H 7W9, Canada e-mail: parthankur@yahoo.com S. J. Robertson Department of Pathology, University of Ottawa, Ottawa, Canada 123 Int Urol Nephrol (2012) 44:1289–1292 DOI 10.1007/s11255-011-0037-4