ABSTRACT
A 45-year-old woman was referred to hospital by her general practitioner after presenting with bleeding gums, epistaxis and a feeling of general malaise. She described a week-long history of epistaxis occurring three to four times daily. Her gums had started to bleed for several minutes after brushing her teeth for the past few days. She described feeling very fatigued and nauseated. She had vomited earlier that morning and described a dull ache around her umbilical region. The general practitioner performed some routine blood tests and found that her urea level was very elevated at 57 mmol/L and her creatinine level was 189 μmol/L. A baseline test from 6 years earlier showed a creatinine level of 56 μmol/L. The doctor called the patient and advised her to present to the emergency department urgently for further assessment. Over the past few months, the patient had been reviewed with worsening right leg pain and fatigue. X-rays of her hip, femur and knee had been unremarkable. Her past medical history included two first-trimester miscarriages. She had been using 400 mg ibuprofen TDS for the past 6 weeks but took no other regular medications. Her family history was significant for both her mother and sister having systemic lupus erythematosus (SLE). She worked as a baker, was an ex-smoker with a 10 pack year history and did not drink alcohol. She lived with her husband and two young children. She had been born in the United Kingdom and had last travelled abroad to Belgium 8 months ago.
