Triple Thrombotic Threats—A Master of Disguise

A thromboembolic event in nephrotic syndrome often develops over time. Cerebral venous thrombosis is a rare initial complication in adults with membranous nephropathy. Our 39-year-old male patient had prior cerebral and renal vein thrombosis and presented with right heart failure, hypotension, and tachycardia. He was found to have bilateral pulmonary artery thromboses and right ventricular dysfunction. After alteplase thrombolysis failed, a catheter thrombectomy was performed. Further testing, due to recurrent thrombosis and leg swelling, showed nephrotic proteinuria and positive anti-phospholipase A2 receptor antibodies, diagnosing primary membranous nephropathy. Treated with steroids and anticoagulants, he responded well, with reduced proteinuria, improved serum protein C and S, and no further thromboembolic events.