入院检查，尿蛋白24小时蛋白定量2.98g，BUN3.98，Scr61，血浆白蛋白28.1，乙肝全阴，丙肝阴性，自身抗体阴性。

免疫荧光“

IgG+++，IgM++，IgA++，C3++，C1q++

 这个病例从荧光及光镜检查诊断膜性肾病应该没有问题，有疑问的是：

    1.年轻患者，免疫荧光呈现满堂亮，首先考虑为继发性膜性肾病，但经询问临床，目前没有明确的继发因素

    2.患者毛细血管襻管腔内可见大量血栓样物堵塞，但临床肾功能还挺好，抗磷脂抗体的结果还没有反馈回来。

同意不典型膜性肾病（继发性肾病待排），有无做油红O染色？apo组化或荧光？

It seems that everybody agrees with the diagnosis of membranous glomerulopathy. The last photo (immunofluorescence stain) is classic.  The immunofluorescence is full house, especially with C1q ++ , which is often seen in patient with lupus. If patient's serology for ANA, anti-DNA antibody and anti-Smith antibody is negative, or clinically not lupus, electron microscopy is helpful to differentiate idiopathic from secondary. Please show us the EM photos. 

The capillary "thrombi" may be just congested RBCs or some sort of artifact.  The silver stains do not demosntrate thrombi.  EM is also helpful to recognize the true thrombi and corresponding endothelial changes.  Thank you again for this challenging case.

Based on the EM photos, I should admit it is not a clear cut case. But I still feel these subepithelial deposits vary in size and shape, and are not evenly distributed along capillary wall.  These features are suggestive of secondary form of MGN.  I am waiting for Dr. Geng's interpretation.

This case of membranous GN should be probably staged as II-III/IV. Let us know your thought.

 这个病例电镜可以看到多部位的免疫复合物沉积，且是年轻患者，免疫荧光呈现满堂亮，所以还是倾向于继发性膜性肾病，建议临床再随访、观察。

毛细血管腔内的血栓样物可能是一些血浆的成分，在第二张电镜图上可以看到管腔内有些丝网状的物质。