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NBME 21 Answers

nbme21/Block 3/Question#34 (40.6 difficulty score)
A 39-year-old woman with rheumatoid arthritis ...
Membranous glomerulonephritisπŸ”

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submitted by mcl(596),
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suaMnmorbe hroemorupsigplitel aak( osrmuenmba t,ohrpayhnep p 845 FA 90)12 aym crcuo acnresdyo ot gsudr shuc as eincpnllieima. rIucnmoelnemosfcue oswhs ngarrula isdpeost eud to nmieum xmolecp toinoepsd.i Wlil aols ese fudsefi clyapailr and GMB hg,nienktci dna MSE lilw owhs epiks dna dome aeaenarppc deu to abelhilspteui ipdsstoe.

submitted by deannosancuck(6),
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euonmraMbs Goltoliirehusnmerp is oetp;hriNc NLOY TEIOIRPNRUA is ni hte geientvt

It ta'cn be NMGP eecbaus GNPM is repNctiih tihw sbieposl rcpthNoie

Oreth oicesch rae atneiimlde yb nRela spiByo

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. 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 +  

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. +  

submitted by sahusema(143),
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tI nsusod a tlo kiel P,NSG tub NGPS is rcieinhpt and we lwodu ese oucednropn uheimarta ithw imalmni aniruetr.oip