12 May 2010 – Case of the Week #178


This email is only sent to subscribers.  To subscribe or unsubscribe to this or our other email lists, click here.


All cases are archived on our website.  To view them sorted by number, diagnosis or category, visit our Home Page and click on the Case of the Week button on the left hand side.


Thanks to Dr. Billie Fyfe, Robert Wood Johnson Medical School, New Jersey (USA), for contributing this case and much of the discussion. To contribute a Case of the Week, follow the guidelines on our Case of the Week page.





Looking for high quality neuropathology antibodies?  As a leading provider of neuroscience antibodies, Covance offers a variety of neuropathology antibodies for immunohistochemistry on formalin fixed paraffin embedded tissues.


Covance’s neuropathology product line is highlighted by neuron specific enolase (NSE), synaptophysin and chromogranin.  In addition, Covance also offers antibodies and ELISA assays for neurodegenerative disease research featuring gold standard beta amyloid clones 4G8 and 6E10-offered exclusively from Covance.  Visit our website at www.store.crpinc.com to learn more or call 1.800.922.2226.




Website news:


(1) Thanks to the following contributors of images:

- Drs. Antonio Cubilla and Alcides Chaux for numerous images to the Penis/Scrotum chapter

- Dr. Asmaa Gaber Abdou: Chromophobe renal cell carcinoma for the Kidney - malignant chapter and intestinal actinomycosis for the Colon chapter

- Dr. Mark Rodacker: Low grade fibromyxoid sarcoma for the Soft Tissue chapter
- Dr. Elaine Alt: Low grade dysplasia in ulcerative colitis / pancolitis for the Colon chapter


(2) In April 2010, we had record traffic of 8,832 visits per day.  Thanks for your support.


(3) How can you tell what fellowship openings have recently been added?  We now have a link on the main fellowships page (sorted by Specialty) at the top that you can click to find out.


Case of the Week #178


Clinical History


A 69 year old obese woman with metastatic pancreatic carcinoma to the liver underwent a diagnostic renal core biopsy for work-up due to three to four months of nephrotic syndrome, with proteinuria increasing from 6 to 12 grams per 24 hours. Her urinary sediment was bland and she had negative serologic studies. The clinical differential diagnosis included membranous glomerulonephritis, minimal change disease, light chain deposition disease and amyloidosis. Her chemotherapeutic regimen included gemcitabine.


Micro images:


Low power



Medium power


High power


What is your diagnosis?




























Thrombotic microangiopathy due to gemcitabine therapy




The classic features of thrombotic microangiopathy are present, including fibrin thrombi in arterioles and capillaries, including glomerular capillaries. Immunofluorescence studies were negative for immunoglobulin deposition, and ultrastructural analysis revealed moderate effacement of foot processes and subendothelial fibrin deposition, as well as endothelial swelling. No immune complex type deposits were noted.


Gemcitabine, a nucleoside analog, is used to treat metastatic pancreatic carcinoma as well as many other malignancies. Thrombotic microangiopathy may occur, with rates varying from the manufacturer stated incidence of 0.015% to 1.4% (Expert Opin Drug Saf 2009;8:257, Cancer 2004;100:2664). Diagnosis is often difficult due to the underlying advanced malignancy, and often requires renal biopsy. 


Treatment includes cessation of gemcitabine therapy, which was effective in this case.  Antihypersensitive medications, plasma exchange therapy (Z Gastroenterol 2009;47:288), or immunoadsorption columns may also be helpful.


The current case is unusual in its presentation with nephrotic syndrome, as most patients present with increasing creatinine, hemolytic anemia, hypertension and thrombocytopenia.


Additional references: Nephrol Dial Transplant 2006;21:3038, Expert Opin Drug Saf 2008;7:703


Nat Pernick, M.D., President,

and Kara Hamilton, M.S., Associate Medical Editor

PathologyOutlines.com, Inc.

30100 Telegraph Road, Suite 408

Bingham Farms, Michigan (USA) 48025

Telephone: 248/646-0325

Email: NatPernick@Hotmail.com

Alternate email: NatPernick@gmail.com