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NBME 21 Answers

nbme21/Block 3/Question#34 (39.3 difficulty score)
A 39-year-old woman with rheumatoid arthritis ...
Membranous glomerulonephritisπŸ”
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 +9 
submitted by mcl(586),
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Mnsboeuram riomrotllpgiepehus k(aa arbsomeunm phorhnteapy, p 485 AF 912)0 may uorcc rcnadoeys to gsdru hcsu sa lipenainmciel. fIuucmeeomsneonrlc hossw alugranr ssptedoi due to mnmieu ecxpoml epin.odotis lliW laso ees dsiueff ialcprayl dan MBG h,kegniitnc dan SME wlil owsh sekpi dna doem encpeapara deu to ephiluibeltas io.stdpes




 +6 
submitted by deannosancuck(6),
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oeuramMsnb ernrlestiiuGomlohp is poitrhceN; LYON RRPEOAUTNII is ni the tgnetive

tI ant'c eb GNMP escebau PGNM si iictperhN tiwh sbleoips rpcNeioht

rOhet eohsicc ear aitdimenel yb elnRa isoypB

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +4  
cooldudeboy1  could someone explain why the other choices are ruled out by biopsy? +  
arlenieeweenie  @cooldudeboy1 PSGN does have a granular immunofluorescence, but there is no previous illness or hematuria mentioned so you can rule that out. Goodpasture is classically linear IF since they're antibodies against the GBM. IgA nephropathy is mesangial IF so it would deposit more in the middle. Minimal change wouldn't show anything on IF +2  
qball  I know First Aid states MPGN as a nephritic disease but I think it can present as nephritic or nephrotic syndrome. https://emedicine.medscape.com/article/240056-clinical. Of course, the renal biopsy helps give it away but I wouldn't be so quick as to rule out MPGN +1  
taediggity  Totally agree w/ you Qball... I thought MPGN too, but I think Penicillamine makes it Membranous Nephropathy +  



 +2 
submitted by stefanmil(2),

Why we have deposits in the glomerular membrane. It supposed to be subepithelial - spike and dome - granulations, right?

lovebug  @stefanmil Yap. you're right. I think "Spike and dome" @ EM. and Diffuse capillary and GBM thickening in @ LM. +  



 -1 
submitted by sahusema(138),
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It osnuds a lto like NG,SP but PSGN is ntchepiri nda ew ouwld ese pndcrnoeou ethuraami hwit liainmm oanie.urtirp