1. The Case.
A patient presents with a h/o JOINT PAINS,
TIREDNESS, ORAL ULCERS, and a RASH
on the hands and the front of her chest. Her
husband, who accompanied her to the
consultation states now that he has noticed
her face to be brighter and redder than usual.

2. How to approach this case?
- Vandana V.

3. Presenting Symptoms
A female patient presenting with symptoms of:
- Joint Pains
- Tiredness
- Oral Ulcers
- Rash – hands, front of chest, face
*unknown duration
*unknown examination and laboratory findings

4. Assessment of Symptoms
• JOINT PAINS :
-Acute or Chronic?
-Number of joints involved? Symmetry?
Acute(less than 8weeks) Chronic(more than 8weeks)
Single joint: Bacterial (Septic
arthritis), Trauma, Crystal (Gout)
Multiple joints:
-Asymmetrical: Rheumatic fever,
Reactive arthritis
-Symmetrical: Hepatitis B, Serum
sickness
Single joint: Trauma, Ankylosing
spondylitis, TB, OA, Rheumatoid
arthritis, Psoriasis
Multiple joints:
-Asymmetrical: Psoriatic
arthritis
-Symmetrical:Rheumatoid

5. * What we do not know whether is associated
Fever?-Viral etiology, Rheumatoid arthritis
• Tiredness: Anemia, systemic diseases like
Hypothyroidism, Diabetes mellitus, etc.
Haemogram, peripheral smear, blood
investigations needed for evaluation.
• Oral ulcers: SLE, Behcet’s, Infections(Herpes,
Aphthous ulcers), Stress and anxiety
• Rash:-on hands and chest: Dermatitis, Herpes
- on face: “Malar rash”-suggestive of SLE

6. Differential Diagnosis
In a young woman of reproductive age group,
• Joint pain with tiredness: - Chronic fatigue
syndrome, SLE, Rheumatoid arthritis,
Fibromyalgia
• Joint pain with tiredness with oral ulcers: - SLE,
Behcet’s
• Joint pain with tiredness, oral ulcers and malar
rash: - SLE

7. - Rheumatoid arthritis: fever, muscle aches, joint pain
and stiffness, weakness, fatigue, anemia, hand and
feet deformities. Anti-CCP antibodies. X-ray:
juxtaarticular osteopenia, soft tissue swelling,
symmetric joint space loss, and subchondral
erosions; including joint subluxation and collapse in
advanced RA.
- Behcet’s disease: recurrent genital ulcers, oral
ulcers, eye lesions, skin lesions- Pathergy test +ve.

8. • American College of Rheumatology’s
“Eleven Criteria of Lupus”:
1. Malar rash
2. Discoid rash
3. Oral ulcers
4. Arthritis
5. Serositis: pericarditis, pleuritis, peritonitis
6. Photosensitivity
7. Blood: Hemolysis, low total WBC count, low
platelet count

9. 8. Renal: proteinuria, cellular casts
9. Antinuclear antibodies
10. Immunological: Anti-ds-DNA, Anti-Smith,
Anti-cardiolipin antibodies
11. Neurological: seizures, psychosis

10. • 3 out of the 11 criteria for diagnosis of SLE are
fulfilled in this case:
• Further clinical examination and investigations
are required to confirm the diagnosis:
- Complete blood counts, Haemogram, Peripheral smear
- Urinalysis
- Immunology
- Radioimaging: chest X-ray; USG abdomen and pelvis
- Renal biopsy
- Malar rash
- Oral ulcers
- Arthritis

11. Thank You.