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    Im CPC

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    Deepak Ghimire
    This document presents a case study of a 19-year-old Filipino female admitted for fever and abdominal pain. Her lab results show pancytopenia, low complement levels, proteinuria and a positive direct Coombs test. Differential diagnoses considered include SLE, drug-induced lupus, parvovirus infection and dengue. SLE is determined to be the most likely diagnosis based on her presentation meeting several SLE criteria. She is experiencing a flare of her SLE that involves lupus nephritis.

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    Im CPC

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    Deepak Ghimire
    79 views52 pages
    This document presents a case study of a 19-year-old Filipino female admitted for fever and abdominal pain. Her lab results show pancytopenia, low complement levels, proteinuria and a positive direct Coombs test. Differential diagnoses considered include SLE, drug-induced lupus, parvovirus infection and dengue. SLE is determined to be the most likely diagnosis based on her presentation meeting several SLE criteria. She is experiencing a flare of her SLE that involves lupus nephritis.

    Original Description:

    A CASE PRESENTED ON MARCH 09 2016 (INTERNAL MEDICINE)

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    This document presents a case study of a 19-year-old Filipino female admitted for fever and abdominal pain. Her lab results show pancytopenia, low complement levels, proteinuria and a positive direct Coombs test. Differential diagnoses considered include SLE, drug-induced lupus, parvovirus infection and dengue. SLE is determined to be the most likely diagnosis based on her presentation meeting several SLE criteria. She is experiencing a flare of her SLE that involves lupus nephritis.

    Copyright:

    © All Rights Reserved
    Download as PPSX, PDF, TXT or read online from Scribd
    Download as ppsx, pdf, or txt
    79 views52 pages

    Im CPC

    Uploaded by

    Deepak Ghimire
    This document presents a case study of a 19-year-old Filipino female admitted for fever and abdominal pain. Her lab results show pancytopenia, low complement levels, proteinuria and a positive direct Coombs test. Differential diagnoses considered include SLE, drug-induced lupus, parvovirus infection and dengue. SLE is determined to be the most likely diagnosis based on her presentation meeting several SLE criteria. She is experiencing a flare of her SLE that involves lupus nephritis.

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    ADISCUSSANTS:

    CASE
    Romero,
    Jiesta Anna Monica
    PRESENTATION
    SOUTHWESTERN UNIVERSITY
    School of Medicine

    Department of Internal Medicine

    Ongayo, Stephanie Kristie


    Campugan, Harjarra Kate
    Salazar, Bea Caressa
    Abraham, Leonard
    Ghimire, Deepak
    Artiaga, Narlou

    GENERAL DATA

    A case of V.C.

    19 y.o

    Female

    Single

    Filipino

    Cebu City

    Admitted for 2nd time


    at SHH

    CHIEF COMPLAINT

    On and off fever

    HISTORY OF PRESENT ILLNESS

    3 days PTA

    Intermittent fever (undocumented)

    Epigastric pain

    Rash on face and lower extremities

    Self-medicated with Paracetamol 500mg


    tab every 4 hrs

    HISTORY OF PRESENT
    ILLNESS

    2 days PTA

    Intermittent fever

    Paracetamol 500mg tab every 4 hrs was


    continued

    HISTORY OF PRESENT
    ILLNESS

    Hours PTA

    Sought consultation in SHH-OPD

    CBC and U/A were requested

    CBC

    CBC

    RESULT

    WBC

    REF.

    2.9 x 103/mm3

    4.4-11.0

    NEU

    61.1% x 103/mm3

    37-80

    LYM

    29.3% x 103/mm3

    10-50

    MON

    6.8% x 103/mm3

    0-12

    EOS

    2.0% x 103/mm3

    0-7

    BAS

    0.4% x 103/mm3

    0-2.5

    RBC

    3.78 x 109/mm3

    4.5-5.10

    HGB

    9.3 g/dl

    12.3-15.3

    HCT

    30.0 %

    35.9-44.6

    MCV

    79 pg

    80-96

    MCHC

    31.1 g/dl

    27.5- 33.2

    RDW

    13.0 %

    11.6- 14.8

    PLT

    94 x 103/mm3

    150-450

    MPV

    8.3 um3

    6.0-11.0

    URINALYSIS
    URINALYSIS

    RESULT

    REFERENCE VALUE

    MACROSCOPIC EXAMINATION
    COLOR

    YELLOW

    TRANSPARENCY

    TURBID

    PH
    SPECIFIC GRAVITY

    6.5
    1.015

    1.003 1.035

    CHEMICAL PROPERTIES:
    PROTEIN (albumin)

    3+

    NEGATIVE

    LEUKOCYTES

    NOT DONE

    NEGATIVE

    BLOOD / Hb

    4+

    NEGATIVE

    MICROSCOPIC PROPERTIES:
    WBC

    5-8 / HPF

    0-5/HPF

    RBC

    25-30/ HPF

    0-2/HPF

    BACTERIA

    FEW

    PAST MEDICAL HISTORY


    Has a history of Bronchial Asthma (1999)

    No maintenance medications

    Has no known drug or food allergy

    No previous surgical history

    PERSONAL & SOCIAL


    HISTORY
    Non-smoker

    Non-alcoholic beverage drinker

    No history of illicit drug use

    FAMILY HISTORY

    No known heredofamilial diseases

    MENSTRUAL & SEXUAL HISTORY


    Menarche at 14 years old

    Regular cycle of 5 days duration

    Uses 3-4 pads/day

    Associated with dysmenorrhea

    PHYSICAL EXAMINATION
    General survey: Awake,Coherent, Afebrile , Not
    in respiratory distress
    Vital signs:

    BP- 120/80 mmHg

    RR- 20 cpm

    HR- 86 bpm

    Temp - 36.4 0 C

    O2 sat- 97%

    PHYSICAL EXAMINATION

    Skin: Warm, good turgor, (+) rashes on face and


    lower extremities
    HEENT: Anicteric sclera, pink palpebral conjunctiva,
    (-) nasal discharges, (+) dry lips, (-) LAD , (+) Oral
    ulcers

    PHYSICAL EXAMINATION

    C/L: Equal chest expansion, clear breath sounds

    CVS: Distinct heart sound, (-) murmur

    ABDOMEN: Flat, normoactive bowel sound, soft, (+)


    epigastric tenderness

    PHYSICAL EXAMINATION

    GUT: (-) Kidney punch sign


    EXTREMITY: Full range of motion , (-) edema,
    (-) cyanosis, Capillary refill time <2 sec, strong
    peripheral pulse

    NEUROLOGIC EXAMINATION

    Cranial nerves: intact

    Motor system: intact

    Motor strength: 5/5

    Cerebellum: intact

    Sensory: intact

    Meningeal signs: (-)

    SEROLOGY:
    SEROLOGY:

    REFERENCE

    DIRECT ANTIGLOBULIN TEST

    POSITIVE (+1)

    NEGATIVE

    INDIRECT ANTIGLOBULIN TEST

    NEGATIVE

    NEGATIVE

    ANTISTREPTOLYSIN O (ASO) TITER

    NEGATIVE

    COMPLIMENT (C3)

    0.10 g/L

    ( ref 0.9-1.9 g/L)

    ALBUMIN

    21.4 g/L

    39.7 49.4 g/L

    CREATININE

    0.88 mg/dL

    0.51 0.95 mg/dL

    ALT (SGPT)

    55 U/L

    < 33 U/L

    SODIUM

    140.3 mmol/L

    136 145 mmol/L

    POTASSIUM

    3.9 mmol/L

    3.5 5.1 mmol/L

    ERYTHROCYTE SEDIMENTATION RATE

    35 mm/Hr

    0 20 mm/Hr

    RETICULOCYTE COUNT

    1.5 %

    0.5 1.5 %

    AT 1:1 DILUTION OR LESS THAN 200 IU/ml

    BLOOD CHEMISTRY:

    HEMATOLOGY:

    PERIPHERAL BLOOD SMEAR

    Microcytic hypochromic anemia

    Slight anisopoikilocytosis

    Leukopenia (with relative neutrophil predominance)

    Thrombocytopenia

    CHEST X-RAY

    Mild Cardiomegaly (CTR 53%)

    Pneumonitis, Right Mid-lung Field


    Insert picture

    WHOLE ABDOMEN
    ULTRASOUND
    Normal abdominal findings

    Incidental note of minimal bilateral pleural


    effusion.

    URINE TEST
    Protein, total urine: 139.1mg/dl

    Creatinine, urine random: 47 mg/dl

    Protein Creatinine Ratio : 10.35

    ECHOCARDIOGRAPHIC
    REPORT

    Normal left ventricular dimensions with


    adequate wall motion and contractility
    Left ventricular systolic function ejection
    fraction of 74%

    ISSUES

    HISTORY OF PRESENT ILLNESS

    3 days PTA

    Is the pain severe? Is it persistent ? Are


    there(undocumented)
    other associated features like
    fever
    nausea, vomiting ?

    Intermittent

    Epigastric pain

    (+) rash on face and lower extremities

    the rash originate


    ?
    Self-medicatedWhere
    with did
    Paracetamol
    500mg
    tab
    every 4 hrs

    HISTORY OF PRESENT ILLNESS

    3 days PTA

    Intermittent fever (undocumented)

    Epigastric pain

    (+) rash on face and lower extremities


    Is there any relief
    to the patient?

    Self-medicated with Paracetamol


    500mg
    tab
    every 4 hrs

    PHYSICAL EXAMINATION
    General survey: Awake, Coherent, Afebrile , Not in respiratory
    distress
    Vital signs:

    BP- 120/80 mmHg

    HR- 86 bpm

    RR- 20 cpm

    Temp - 36.4 0 C

    O2 sat- 97%

    1. Is the patient ambulatory or


    wheelchair-borne?
    2. What is the built of the
    patient or the BMI?

    PHYSICAL EXAMINATION
    General survey: Awake, Coherent, Afebrile , Not in respiratory
    distress
    Vital signs:

    BP- 120/80 mmHg

    HR- 86 bpm

    RR- 20 cpm

    Temp - 36.4 0 C

    O2 sat- 97%

    Whats the usual range of B.P ?

    PHYSICAL EXAMINATION

    C/L: Equal chest expansion, clear breath


    sounds
    CVS: Distinct heart sound, (-) murmur

    Is It direct and rebound


    ABDOMEN: Flat, normoactive
    tenderness ? bowel sound,

    soft, (+) epigastric tenderness

    SALIENT FEATURES

    19 y.o single, female

    History of 3 days fever

    Epigastric pain & tenderness

    Oral ulcers

    Rash on face and lower extremities

    Minimal bilateral pleural effusion


    .

    SALIENT FEATURES

    Anemia, thrombocytopenia and leucopenia

    Proteinuria and hematuria

    Positive Direct Coombs test

    Low serum complement

    DIFFERENTIAL DIAGNOSIS
    Salient features

    Systemic Lupus
    Erythematosus

    Drug-induced
    Lupus

    Parvo B19
    Virus infection

    Dengue
    Fever

    DENGUE INFECTION

    Presents with febrile illness

    Body muscle and joint pain

    Body malaise & fatigue

    Autoimmune features like (+) Direct Coombs test

    Hematological disorders (thrombocytopenia,


    leucopenia) in endemic area

    DENGUE INFECTION
    RULE IN

    Lives in endemic area


    Presents as febrile illness of 3-5 days
    (+) Rashes, epigastric pain
    (+) Pleural effusion
    (+) Thrombocytopenia/ leucopenia
    (+) Low complement level
    (+) Variable autoimmune features

    RULE OUT

    Common in 7-15 year old children


    (-) muscle & joint pain
    Oral ulcers are rare
    Autoimmune features in dengue are
    not well recognized
    Proteinuria is not explained

    Salient features

    Systemic
    lupus
    erythematous

    Drug induced
    lupus

    Parvo B19
    virus infection

    Dengue
    infection

    PARVO B19 VIRUS INFECTION

    Parvovirus is a small, single-stranded DNA virus.


    Infects children more commonly then adults via
    respiratory droplets and cause flu like symptoms
    Clinical manifestations in adults include fever,
    rash, arthropathy & hemolytic or aplastic anemia.
    Diagnosis is clinical & may be confirmed by B19specific antibody testing and viral DNA testing.

    PARVO B19 VIRUS INFECTION


    RULE IN

    RULE OUT

    Epigastric pain occurs less


    Most common feature in adults is
    arthopathy (-)
    Rashes on extremity are not common
    (-) Travel history
    Retic count of 1.5 % makes aplastic
    anemia unlikely .

    Common in childhood and teenagers


    (+) fever , facial rashes, oral ulcers
    (+) Abdominal pain
    Proteinuria 20 to glomerulonephritis
    Anemia, leukopenia & thrombocytopenia

    Usually has Positive Direct coombs test


    and low complement level

    Salient features

    Systemic
    lupus
    erythematous

    Drug induced
    lupus

    Parvo B19
    virus infection

    Dengue
    infection

    DRUG INDUCED LUPUS

    Agents causing lupus like syndrome are procainamide,


    hydralazine, isoniazid, OCP, propylthiouracil
    Antihistone antibodies (+) are frequent for drug induced
    lupus
    Resolves within days to months after withdrawal of the
    culprit agents

    DRUG INDUCED LUPUS


    RULE IN

    (+) facial rashes, oral ulcers


    Autoimmune features like DAT &
    cytopenia
    (+) epigastric pain
    (+) proteinuria
    (+) microscopic hematuria to
    nephrotic syndrome

    RULE OUT

    Equally common in males


    and females

    No agents triggering lupus are taken


    by patient

    Salient features

    Systemic
    lupus
    erythematous

    Drug induced
    lupus

    Parvo B19
    virus infection

    Dengue
    infection

    SYSTEMIC LUPUS ERYTHEMATOUS (SLE)

    Protean autoimmune disease most common in women


    of child bearing age
    Has non specific organ involvement, but more
    commonly affects joints, kidney, skin & CNS.
    Drug induced lupus Should be excluded before
    diagnosis of SLE
    Diagnosis is made using clinical criteria.

    SLE Criteria

    Any combination of four


    or more criteria, with at
    least one in the clinical
    and one in the
    immunologic category,
    well documented at any
    time during an
    individuals history,
    makes it likely that the
    patient has SLE.

    Systemic Lupus International


    Collaborating Clinic Criteria for
    Classification of SLE

    Salient features

    Systemic
    lupus
    erythematous

    RULED IN

    Drug induced
    lupus

    Parvo B19
    virus infection

    Dengue
    infection

    Most Likely Diagnosis

    SYSTEMIC LUPUS ERYTHEMATOUS


    (SLE) in FLARE

    Clinical
    Features
    of SLE

    Fig. Clinical features of SLE

    Pathogenesis of SLE

    ROLE OF AUTOANTIBODY IN
    SLE

    LUPUS NEPHRITIS

    Nephritis is the most serious manifestation of SLE


    Nephritis and infection are the leading causes of
    mortality in the first decade of disease
    Renal biopsy is recommended with evidence of
    nephritis.

    CLASSIFICATION OF LUPUS NEPHRITIS


    (International Society of Nephrology and Renal
    Pathology Society)

    FINAL DIAGNOSIS

    SLE IN FLARE
    (Lupus nephritis class IV)

    Good Morning !

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