A 43-year-old male patient with hypercholesterolaemia treated with statins, non-hypertensive or diabetic.
Smoker and occasional drinker.
The nephrological history began in April 2003, when she presented a clinical and analytical nephrotic syndrome, in the context of a mild illness treated with amoxicillin-clavulanic acid.
Due to spontaneous partial remission of the condition, with residual proteinuria around 1 g/24 h, and since it maintained normal renal function at all times, it was decided not to biopsy and follow-up in the nephrology outpatient clinic.
Thereafter, proteinuria increased progressively up to 14 g/24 h, selective, with no changes in urinary sediments.
The immunological study did not detect the presence of autoantibodies and maintained normal complement levels in repeated studies during follow-up.
Serology for hepatitis C, B and human immunodeficiency virus were negative.
With normal renal function, in October 2003, a renal biopsy showed a stage II NMG.
Immunofluorescence showed intense granular parietal deposits of IgG, C3 and C1q.
Treatment was initiated with prednisone at a dose of 1 mg/kg/day and partial remission of proteinuria was achieved up to 1.3-0.5 g/24 h.
The treatment was continued for 8 months, with progressive decrease of steroids.
At that time, enalapril and candesart were started, with proteinuria persisting around 0.5 g/24 h.
In December 2006, the patient presented with erythematous, scaly lesions on hands, feet and elbows.
Psoriatic arthritis was diagnosed.
Given the failure of treatment with acitretin, in April 2009 it was decided to use an anti-TNF-a (etanercept) for 9 months, significantly improving skin lesions until their disappearance.
At the same time, proteinuria decreased to complete remission 6 months after starting this treatment.
She remained in complete remission of her glomerular condition for 11 months, with total absence of skin lesions, and in December 2010, psoriatic skin manifestations returned slowly and progressively.
At that time, proteinuria of 0.5 g/24 h was detected again.
Figure 1 shows a summary of the evolution of the case.
