Nephrotic syndrome induced by gold therapy.

The patient, a 44-year-old bus conductor, developed seropositive rheumatoid arthritis in the summer of 1966. The first metatarsophalangeal joints were affected initially, and over the next five months the arthritis became generalized. Treatment with indomethacin gave little relief and a course of weekly injections of sodium aurothiomalate was started on 15 December 1966. The dose was gradually increased from 10 to 50 mg. over three weeks, and thereafter kept at this level, the urine being examined before each injection. A total dose of 500 mg. had been given before therapy was stopped at the end of February 1967, when the patient developed heavy proteinuria (Albustix 300 mg./100 ml.). He was then treated with plaquenil for three months. Proteinuria persisted and minimal ankle oedema developed in June. This became more pronounced in July and was beginning to resolve when he was referred to the renal unit in September. At that time his hands showed the classical changes of active rheumatoid arthritis and most of the large joints were also involved. He had slight oedema of both ankles without raised jugular venous pressure or other evidence of heart disease. Blood pressure was 130/80. Investigation Results.-24-hour urinary protein excretion 3.4 g. Urine microscopy-occasional granular casts. Blood urea 27 mg./100 ml., sodium 142 mEq/1., potassium 4 mEq/1., chloride 98 mEq/1., C02 content 26 mEq/1. Serum total protein 6-15 g./100 ml. (albumin 40%, globulin 60%). Serum electrophoresis showed an increase in alpha-2 globulin. Creatinine clearance 114 ml./min. L.E. cell test negative. Immunofluorescent test for antinuclear factor negative. Modified Rose-Waaler test positive 1/128. Left renal biopsy: the specimen contained 11 glomeruli, one of which was hyalinized, the remainder being histologically normal; the proximal convoluted tubules showed some hyaline droplet change; there was no evidence of damage to the basement membrane. Immunological protein clearances: IgG/siderophilin= 025 (Cameron and Blandford, 1966), alpha-2/siderophilin=0 016 (MacLean and Robson, 1967). His oederria was controlled on treatment with 40 mg. of frusemide daily. By February 1968 proteinuria had cleared, plasma proteins returned to normal (total 6-5 g./100 ml. with normal electrophoresis), and diuretic treatment was withdrawn. There has been no recurrence of proteinuria to date.