Stroke in a Young Woman as a Presenting Manifestation of Membranous Nephropathy

Stroke is one of the most severe complications of nephrotic syndrome (NS), only a few cases have been reported in previous literature. Some of those cases are not clear about whether the stroke was purely caused by NS because they also had other risk factors for stroke, such as old age, hypertension. A recent study showed that serum albumin less than 2.8 g/dL is a risk factor for thromboembolic events (venous thromboembolic events). Anticoagulation is suggested for patients with NS with low albumin by KIDIGO guideline 2012. Here, we describe a case in which a young patient presented with stroke as an initial symptom of membranous nephropathy (MN). A 36-year-old woman with no medical history came to the emergency room for left side weakness. Computed tomography of head showed right middle cerebral artery infarct. She was healthy and had no history of hypertension or peripheral vascular disease. She was not taking any medication before admission and did not have any toxic habits. She had nephrotic range of proteinuria with no active sediment in urine analysis, serum albumin of 1.7 g/dL, normal renal function, elevated blood pressure on admission, and no signs of left ventricular hypertrophy. All coagulopathy workup was negative. The renal biopsy showed MN. She was started on Coumadin and treated with steroids and cyclophosphamide. Four months after the stroke, she still could not perform daily activity independently. This case illustrates that stroke can be an initial symptom of MN, and it is important we detect and anticoagulate this high-risk group of patients before their developing stroke. Urine analysis is an inexpensive screening tool for NS and should be considered as an initial workup for a young patient who presents with stroke.