Spot the Diagnosis! The case of the Woman and the Flask

In Arts PRN, Featured, Medical Concepts by Leah Zhao1 Comment

As part of the Arts PRN series, we will intermittently be featuring pieces of historic art that hint at an underlying medical condition. They say a picture is worth 1000 words… can you Spot the Diagnosis after examining only a painting? Read on to learn not only about the art, but about these fascinating medical conditions. Who knows, maybe they’ll help you make a diagnosis some day (or at least help you out on Jeopardy)! After you read, consider submitting your own art to the Arts PRN Project.

This week’s Spot the Diagnosis features Gerrit Lou’s 1663 painting of “The Dropsical Woman.” Based on the scene depicted, can you guess what the woman’s diagnosis is?

What disease does this woman have?

The woman depicted in this painting is suffering from dropsy, an old term for edema, most likely secondary to glomerulonephritis. The woman appears to be quite edematous: her foot is too large to fit properly in her shoe, her face is puffy, and the skin around her eyes is especially swollen, suggesting periorbital edema. Although it is difficult to tell whether she is also experiencing swelling in any other body regions since she is fully clothed, she appears to have generalized edema, otherwise known as anasarca.1

The matula, a transparent glass flask usedby medieval physicians to inspect patients’ urine.

Furthermore, the man to her left is a physician who is examining her urine in a transparent glass flask called a matula. Visual examination of a patient’s urine, known as uroscopy, was a common practice at the time used by physicians to aid diagnosis of many diseases.2 Her urine appears to have a pink hue, likely due to gross hematuria, with sediment material on the bottom on the flask.

Dropsy, or edema, can be due to many diseases that cause failure of the kidneys, liver, or heart. In this woman’s case, the hematuria, periorbital edema, and pedal edema are highly suggestive of glomerulonephritis, a form of glomerular disease. In general, glomerular diseases affect the glomerulus, the basic filtration unit of the kidney. These diseases can be broadly categorized into two prototypical presentations: nephrotic syndrome and glomerulonephritis, i.e. nephritic syndrome.3

What is the pathophysiology and clinical presentation?

Periorbital edema, one of the first clinical signs of nephrotic syndrome.

In nephrotic syndrome, leakage of plasma proteins from glomeruli is the primary pathogenic mechanism. This leakage can result in proteinuria and hypoalbuminemia. Because albumin is a major contributor to oncotic pressure in the vasculature, loss of albumin in nephrotic syndrome results in “underfill edema,” which presents as periorbital edema (often the first sign of nephrotic syndrome) and anasarca (generalized edema). To compensate for the loss of albumin, the liver will ramp up synthesis of proteins, including lipoproteins, resulting in hypercholesterolemia as well.4

In glomerulonephritis, also known as nephritic syndrome, inflammation causes damage to the glomerular capillary walls, resulting in increased permeability to proteins, red blood cells, and white blood cells. As such, glomerulonephritis presents with gross hematuria, proteinuria (which may also cause edema), and leukocyturia. Inflammation also reduces blood flow through the glomerular capillaries, leading to acute kidney injury (oliguria, elevated serum creatinine), and hypertension (due to activation of the RAAS system).5

What are causes of this disease?

Nephrotic syndrome can be due to primary or secondary disease processes that injure the glomerulus, with diabetes mellitus being the most common cause. Meanwhile, glomerulonephritis is often caused by conditions that result in immune complex deposition in the glomeruli.

Table 1: Etiology of glomerular diseases5

Nephrotic syndrome Glomerulonephritis
Primary

  • Minimal change disease
  • Focal segmental glomerulosclerosis
  • Membranous glomerulonephritis
  • Membranoproliferative glomerulonephritis

Secondary

  • Diabetic nephropathy (most common)
  • Amyloid nephropathy
  • Lupus nephritis
  • Post-streptococcal glomerulonephritis
  • Subacute bacterial endocarditis
  • Lupus nephritis
  • Anti-glomerular basement membrane disease
  • IgA nephropathy (most common)
  • ANCA small-vessel vasculitis
  • Membranoproliferative glomerulonephritis

What are the emergent complications?

Any disease affecting the kidney, including glomerulonephritis, can progress to kidney failure, which has many potentially life-threatening complications. Once the patient reaches the late stages, the kidneys are unable to eliminate accumulating toxins, fluids and electrolytes, resulting in uremic syndrome. In uremic syndrome, toxins accumulate in the systemic circulation. Urea and creatinine levels are used as surrogate markers for these toxic compounds.

Patients with uremic syndrome may suffer from any of the following complications:6

  • Volume overload – activation of the RAAS system causes retention of sodium and fluid.
  • Hyperkalemia – kidney damage leads to reduced potassium excretion.
  • Metabolic acidosis – reduced acid excretion leads to metabolic acidosis.
  • Uremic pericarditis – pathogenesis is not well understood.
  • Other non-specific uremic symptoms: nausea, vomiting, anorexia, malnutrition, fatigue, and more.

What are the treatment for these complications?

Uremic syndrome should be treated based on patient presentation. For example, patients with volume overload should be treated with diuretics, sodium restriction, and anti-hypertensives, while those with metabolic acidosis should be given sodium bicarbonate with close monitoring of sodium levels.

If the patient develops uremic pericarditis, or has refractory hyperkalemia, metabolic acidosis or fluid overload, then renal replacement therapy is indicated. The options for renal replacement therapy include dialysis (hemo or peritoneal) and kidney transplant from a living or deceased donor.

Why was the physician inspecting the woman’s urine?

In this 1663 painting, the physician was inspecting the patient’s urine through a transparent glass flask known as a matula. The visual inspection of urine, known as uroscopy, was a common assessment method used in medieval medicine to aid diagnosis and management. In fact, the matula became the symbol for physicians, much like the stethoscope today.2

The contents and appearance of urine continued to be studied by physicians and scientists throughout the 17th and 18th century. By the 19th century, the advent of better microscopes allowed rapid progression in urinalysis, or the microscopic evaluation of urine. Today, urinalysis remains an integral diagnostic tool to medical professionals.1

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Spot the Diagnosis

Hidden stories

References:

1.
Bardales R H. From Urine Contemplation to Urine Evaluation: Historical Overview. In: Practical Urologic Cytopathology. Oxford University Press, USA; 2002:1-10.
2.
Connor H. Medieval uroscopy and its representation on misericords–part 1: Uroscopy. Clin Med (Lond). 2001;1(6):507-509. [PubMed]
3.
Radhakrishnan J. Glomerular disease: Evaluation and differential diagnosis in adults. UpToDate. https://www.uptodate.com/contents/glomerular-disease-evaluation-and-differential-diagnosis-in-adults. Accessed November 4, 2017.
4.
Nephrotic Syndrome: Pathogenesis and Clinical Findings. The Calgary Guide. http://calgaryguide.ucalgary.ca/nephrotic-syndrome-pathogenesis-and-clinical-findings/. Accessed November 4, 2017.
5.
Kasper D L, Jameson J Larry, Hauser S, Loscalzo J, Fauci A S, Longo D. Glomerular Diseases . In: Harrison’s Principles of Internal Medicine 19/E (Vol.1 & Vol.2). McGraw-Hill Education / Medical; 2015:338.
6.
Rosenberg M. Overview of the management of chronic kidney disease in adults. UpToDate. https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in-adults. Accessed November 4, 2017.
Leah Zhao

Leah Zhao

Leah Zhao is a second year medical student at McMaster University. She spends most of her free time enjoying good food, going on outdoor adventures, and being a couch potato in front of her laptop.
Tetyana Maniuk

Tetyana Maniuk

Tetyana is a medical student at uOttawa with a passion for the arts. She is the Editor of CanadiEM's Arts PRN Section.
Tetyana Maniuk
- 1 day ago