Clinical Chemistry - Case Study
https://doi.org/10.1093/clinchem/hvae092
A 72-year-old female with a long-standing history of poorly controlled type 2 diabetes mellitus (T2DM), hypertension, high cholesterol, and recent onset proteinuria (<6 months) presented to her primary care provider (PCP) with increased urinary frequency and vaginal discharge that she had experienced for 7 to 10 days.
Student Discussion Document (pdf)
William Butler, Christina C. Pierre, Bruce E. King, and Brian Young
A 72-year-old female with a long-standing history of poorly controlled type 2 diabetes mellitus (T2DM), hypertension, high cholesterol, and recent onset proteinuria (<6 months) presented to her primary care provider (PCP) with increased urinary frequency and vaginal discharge that she had experienced for 7 to 10 days. Her urine was cloudy in appearance, and urinalysis (UA) revealed glucosuria (>1000 mg/dL; >56 mmol/L), moderate hematuria, and proteinuria (>300 mg/dL). Her estimated glomerular filtration rate (eGFR) was >60 mL/min/m2. Nitrites were negative with only trace leukocyte esterase. The patient was treated with ketoconazole for a presumptive yeast infection and advised to return if her symptoms persisted or worsened.
Three days later, the patient presented to the emergency department with dark, foamy urine. The results of a comprehensive metabolic panel and complete blood count tests were within normal limits, with the exception of an elevated random plasma glucose result of 173 mg/dL (9.6 mmol/L). UA was negative for nitrites and leukocyte esterase. A computed tomography (CT) scan of the abdominal and pelvic regions was unremarkable, with no anatomical signs of infection, abnormal growths, or obstructing calculi. Given the persistence of her symptoms, the patient was treated for a presumptive bacterial infection with cephalexin while awaiting culture results, which ultimately returned negative with no signs of bacterial growth after 24 h.
Her symptoms persisted for 2 months after initial onset, and the patient returned to her PCP to discuss her ongoing dysuria and the abnormal appearance of her urine. She described the appearance of the urine as clear in the morning but noted that it became increasingly “skimmed milk-like” in appearance throughout the day. UA findings and eGFR remained similar to those obtained at her previous visit. She had experienced significant weight loss. The patient reported that her symptoms would temporarily improve when treated with ketoconazole in the past. She was treated with oral fluconazole for 1 week but returned 1 month later reporting no significant improvement in symptoms. Clinical pathology was consulted to review and advise on the next steps for further workup.