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Hypothyroidism in SLE

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Hypothyroidism in SLE

  1. 1. UNMASKING SLE<br />GRAND ROUNDS<br />February 20, 2006<br />PCMC Conference Room<br />Darla Kay A. de Guzman, MD<br />
  2. 2. GOOD MORNING!<br />
  3. 3. General Data:<br />M.E.C. 18 10/12 y/o Female<br />Filipino, Roman Catholic<br />Candaba, Pampanga<br />Admitted on January 6, 2006<br />
  4. 4. Chief Complaint:<br />Difficulty of breathing<br />
  5. 5. History of the Present Illness<br />5 wks PTA bipedal edema<br /> no other s/sx associated<br /> no consultation, no meds<br />4 wks PTA persistent bipedal edema<br /> consult w/ MD <br /> Imp.: Renal problem?<br /> u/a, abdominal uts: Normal<br /> Meds: Spironolactone<br />
  6. 6. History of the Present Illness<br />3 wks PTA ankle, knee pain, weakness and edema<br /> no fever, cough or colds<br /> consult same MD<br /> Chest x-ray: cardiomegaly, 2d-echo: ? results <br /> referred to PHC<br />2 wks PTA seen at PHC: cardiac problem prob sec to Hypothyroidism<br /> Advised work-up<br />
  7. 7. History of the Present Illness<br />11 days PTA fever, cough and colds, joint pain and edema<br /> Ffup at PHC: 2d-echo<br /> arterial thrombosis<br /> Meds: Aspirin<br />5 days PTA tachypnea, chest pain. Dx: ATP,Hypothyroidism<br /> Meds: Amoxicillin<br />
  8. 8. History of the Present Illness<br />3 days PTA 4 pillow orthopnea, DOB, pallor, gen. weakness<br /> consult at PCMC <br /> Labs: dec T3, T4, inc TSH<br /> Advised admx but refused<br />1 day PTA above s/sx persisted, severe respiratory distress<br /> consulted PCMC<br /> ADMITTED<br />
  9. 9. Review of Systems:<br />No headache<br />No seizure<br />No abdominal pain<br />No vomiting<br />No constipation<br />No dysuria<br />No hematuria<br />No oliguria<br />No bleeding<br />No heat/cold intolerance<br />
  10. 10. Birth and Maternal History<br />23 y/o primigravid<br />RPNCU at 3 mos AOG c/o LHC<br />No maternal illnesses<br />Delivered FT, NSD<br />At home, by midwife<br />No complications<br />
  11. 11. Immunization History<br />BCG<br />DPT x 3 doses<br />OPV x 3 doses<br />Hepa B x 1 dose<br />Measles x 1 dose<br />No boosters doses given<br />
  12. 12. Nutritional History<br />Breastfed up to 1 yrs old<br />Complementary foods at 6 mos.<br />At present: picky eater<br />
  13. 13. Developmental History<br />1 mo:regards<br />4 mos: head control<br />8 mos: sits w/o support<br />9 mos: cruises, utters ‘mama’<br />1 y/o: walks w/ support<br />2 ½ y/o: runs fast<br />-At present, has reached first year high school w/ average grades.<br />
  14. 14. Past Medical History<br />7 y/o: Dx w/ Hypothyroidism<br />Maintained w/ L-Thyroxine<br />Poor compliance, no follow-ups<br />Admitted at 14 y/o: DHF 2 <br />Discharged after 5 days<br />No previous accidents, surgeries<br />No allergies to food or drugs<br />
  15. 15. Family History<br />43<br />42<br />15<br />A maternal uncle was diagnosed of goiter and presently on medication. No family history for diabetes, CVD, hypertension and tuberculosis.<br />
  16. 16. Psycho-Social History<br />Lives w/ her family in the province.<br />Closest to her maternal grandparents<br />Stopped schooling after 1st year high school due to financial problems<br />Enjoys watching TV and going out w/ cousins. She has no crushes or suitors at present.<br />Never tried smoking, drinking liquor or using prohibited drugs<br />No suicidal ideations, but is sad for her health condition<br />
  17. 17. Physical Examination<br />Gen. Survey: awake, pale, in respiratory distress<br />Vital Signs: CR: 150/min RR: 50/min T: 38’c BP: 100/60 Wt: 53 kg (p50) <br /> Ht: 148 cm (p50), BMI: 24.1<br />No active dermatoses, diaphoretic<br />Anicteric sclerae, pale palpebral conjunctiva, (+) alar flaring, (+) mucoid nasal discharge, no tonsilopharyngeal wall congestion, (+) CLAD, (+) neck vein engorgement<br />Equal chest expansion, (+) SC and IC retractions, (+) decreased breath sounds left lung field, (+) rales bilateral lung fields, tactile/vocal fremiti dullness<br />
  18. 18. Physical Examination<br />Adynamic precordium, tachycardic, (+) muffled, distant heart sounds, no murmurs.<br />Globular abdomen, NABS, (+) fluid wave, soft, (+) hepatomegaly, no masses palpated<br />Tanner SMR stage 5<br />(+) grade 3 bipedal edema, no cyanosis, no clubbing, full and equal pulses, CRT: 2-3 secs.<br />
  19. 19. Neurologic Examination:<br />Cerebral: awake, conscious, oriented to 3 spheres<br />Cranial nerves:<br /> I: intact<br /> II: 2-3 mm pupils, ERTL, no papiledema or hemorrhages<br /> III, IV, VI: intact EOM’s<br /> V: brisk corneals<br /> VII: no facial asymmetry<br /> VIII: intact gross hearing<br /> IX, X: good gag<br /> XI: good shoulder shrug<br /> XII: midline tongue<br />
  20. 20. Neurologic Examination<br />Motor: good muscle bulk and tone, 5/5 both upper extremities, 4/5 both lower extremities.<br />Sensory: intact<br />Reflex: +2 all extremities<br />No Babinski, no clonus<br />Supple neck<br />Cerebellar: no nystagmus, good finger-to-nose test<br />
  21. 21. Admitting Impression<br />Congestive Heart Failure, Cardiac Tamponade probably secondary to Hypothyroidism<br />Late Adolescent w/ Psychosocial Issues<br />No Wasting, No Stunting<br />
  22. 22. Course in the Ward<br />
  23. 23. S>DOB, easy fatigability, cough, colds, joint pain.<br />First Hospital Day<br />O>CBC- n/n anemia, WBC, plt ct, toxic gran<br /> > CXR: cardiomegaly, pulmonary congestion<br /> >12 L EKG: sinus tachycardia<br /> > 2d-echo: severe pericardial effusion, RA, RV MPA collapse<br />O>awake<br /> >febrile, tachycardic, tachypneic<br /> > pale, neck vein engorgement<br /> > SC and IC retractions > muffled, distant heart sounds<br /> > globular abdomen, hepatomegaly<br /> > grade 3 bipedal edema<br />
  24. 24. A>CHF, Cardiac Tamponade prob sec to Hypothyroidism<br />First Hospital Day<br />> Referred to RICU, Cardio<br /><ul><li>Cefuroxime (50)
  25. 25. Dopamine (5)
  26. 26. L-Thyroxine
  27. 27. “E” Pericardiostomy: 438 cc pericardial fluid</li></ul>P>O2 support<br /> > venoclysis<br /> > NPO<br /> >PRBC transfusion<br />
  28. 28. 2nd Hospital Day<br />S>(+) episodes of DOB<br /> (+)weakness<br /> (+) cough<br /> (+) joint pain<br />2nd Hospital Day<br />A> CHF w/ Cardiac Tamponade prob sec to Hypothyroidism s/p Pericardiostomy tube Insertion<br /> Bacterial Pericarditis<br />O> awake, tachypneic, tachycardic, febrile, adequate U/O, normotensive<br /><ul><li>2d-echo: decrease in pericardial effusion, pleural effusion
  29. 29. Pericardial fluid analysis: 65% PMNs, (+) g+ cocci, LDH , (-) AFB
  30. 30. ABGs- normal
  31. 31. Blood c/s- no growth
  32. 32. Pericardial fluid drained: 410cc</li></ul>P> Referred to PIDS<br /> > Oxacillin started<br /> > Dopamine<br /> > L-thyroxine<br />
  33. 33. S> (+) afebrile seizure<br /> (-) DOB<br /> (+) fair intake<br />3rd-4th Hospital Day<br />A> Pleural Effusion sec to Myxedematous Pericardial Effusion sec to Hypothyroidism r/o Parapneumonic Effusion s/p pericardiostomy<br />Seizure secondary to Electrolyte Imbalance<br />O> (+) fever<br /> > (+) rales, RLF<br /> > distinct heart sounds<br /> > Normal neuro exam’n<br /> > urine KOH- negative<br /> > U/A: pyuria<br /> > S. elec: K, Ca<br />P>Feeding resumed<br /> > Kalium Durule<br /> > Ca gluconate<br /> > Antibiotics<br /> > Referred to Pulmo<br /> > UTZ guided Thoracentesis<br />
  34. 34. S> recurrence of afebrile seizure, same character<br /> > joint pains<br /> > fair intake<br />5th-6th Hospital Day<br />A> Pleural Effusion sec to Myxedematous Pericardial Effusion sec to Hypothyroidism r/o Parapneumonic Effusion s/p Pericardiostomy<br /> Seizure sec to Electrolyte Imbalance<br />O> awake, (+) fever<br /> > tachypnea<br /> > tachycardia<br /> > (+) rales BLF<br /><ul><li>Normal Neuro exam’n
  35. 35. S. electrolytes: Ca
  36. 36. CBC- normal
  37. 37. Chest UTS- no fluid R hemithorax, minimal fluid L</li></ul>P> Midazolam IV<br /> > Calcium gluconate<br /> > Oxacillin<br /> > L-Thyroxine<br /> > Amikacin<br /> > Thoracentesis- deferred<br />
  38. 38. S> no seizure recurrence<br /> > no DOB<br /> > fair intake<br /> > joint pain<br />8th Hospital Day<br />A> Pleural Effusion 2 to Myxedematous Pericardial Effusion sec to Hypothyroidism r/o Parapneumonic Effusion<br /> Seizure sec to Electrolyte Imbalance, resolved<br /> t/c SLE<br />S > low to mod grade fever<br /> > tachypneic, tachycardic<br />> painless, oral mucosal lesions<br /> > CXR: haziness R, consolidation vs pleural thickening<br />P> Trans out to 121<br /><ul><li>Antibiotics continued</li></li></ul><li>S> no seizure recurrence<br /> > no DOB<br /> > cough<br /> > poor intake<br />10th-11th Hospital Day<br />A> Myxedematous Pericardial Effusion s/p Pericardiostomy w/ Pleural Effusion prob sec to Hypothyroidism Sepsis Unspecified<br />O> moderate to high grade fever<br /> > tachypneic, tachycardic<br /> > (+) rales BLF, distinct heart sounds<br /> > chest uts: bilat. Pleural fibroses, min pleural & pericardial effusion L. <br />P> Oxacillin continued<br /> > Cefotaxime started<br /> > Amikacin shifted to Gentamicin<br />
  39. 39. S> no seizure<br /> > no DOB<br /> > poor intake<br />12th-15th Hospital Day<br />A> SLE<br /> Hypothyroidism<br /> Nosocomial sepsis<br />O>mod-high grade fever<br /> > tachycardic, tachypneic, normotensive<br /> > oliguria, hepatomegaly<br /> > 2d-echo: pericardial effusion<br /> > ESR: 120 mm/hr<br /> > s. Albumin: decreased<br /> > s. Creatinine: normal<br />P> Increased fluid intake encouraged<br /> > for ANA, anti-DS DNA<br />
  40. 40. S> DOB<br /> > poor intake<br /> > weak<br />17th-19th Hospital Day<br />O> CXR: cardiomegaly, pulm congestion, bilat pleural effusion<br /> > Abd’l uts: hepatomegaly w/ parenchymal changes<br /> > U/A: pyuria, (+) FGC<br /> > sputum AFB: (-)<br /> > Urine C/S: (-) <br /> > ABGs- normal<br />O> high grade fever<br /> > oliguric, normotensive<br /> > tachypneic, tachycardic<br /> > dry lips, and skin<br /> > jaundice, icteric<br /> sclerae, petechial rash<br /> > (+) rales BLF<br /> > s. electrolytes: Na, K<br /> > CBC: n/n anemia<br /> >Reticulocyte ct: <br /> > RBS, AST, ALT: <br />
  41. 41. 17th-19th Hospital Day<br />A> SLE w/ Pericardial Effusion<br /> Hypothyroidism<br /> Pre-Renal failure Sec to Dehydration Sec to Poor Intake <br /> Nosocomial Sepsis <br />P>Co-managed w/ Nephro<br /> > Fluid Resuscitation<br /> > PRBC transfusion<br /> > Ceftazidime started<br /> > Gentamicin cont.<br />
  42. 42. S> (+) DOB<br /> (+) irritable<br /> (+) weakness<br />20th Hospital Day<br />A> CHF, Pericardial Effusion sec to SLE<br /> Nosocomial Sepsis<br />O> high grade fever<br /> > tachypneic, tachycardic<br /> > adequate U/O<br /> > (+) distant heart sounds<br /> > hepatomegaly<br /> > Chest uts: min pleural effusion<br />> T4: normal<br /> > CBC: leukopenia<br /> > ANA: +4<br /> > Anti-DS DNA : (+)<br />P> “E” pericardiocentesis<br /> > Dopamine, Dobutamine<br /> > Fluids at 75% BSA<br /> > Antibiotics continued<br />
  43. 43. S> (+) DOB<br /> (+) weakness<br /> (+) poor intake<br />21st-23rd Hospital Day<br />O> SLE w/ Pericardial Effusion<br /> Hypothyroidism<br /> Nosocomial Sepsis<br />O> mod grade fever<br /> > tachypneic, tachycardic<br /> > jaundice, petechial rash<br /> > rales BLF, distant heart sounds<br /> > hepatomegaly<br />P> Methylprednisolone pulse therapy, x 3 doses<br />
  44. 44. S> no DOB<br /> > improved appetite<br /> > better well-being<br />25th Hospital Day<br />A> SLE<br /> Hypothyroidism<br /> Nosocomial sepsis<br />O> afebrile<br /> > stable vital signs<br /> > jaundice resolved<br /> > fine rales BLF<br /> > distinct heart sounds<br />> Serum bilirubin, CBC: normal<br />P> seen by ophthalmology svc<br /> >CBC<br /> > s. bilirubin<br /> > 2D-echo, CXR<br />
  45. 45. Final Diagnosis<br />Systemic Lupus Erythematosus With Serositis (Pericardial Effusion, Severe, s/p Pericardiocentesis, Pericardiostomy, Pleural Effusion, Bilateral) <br />Congestive Heart Failure, Resolved<br />Hypothyroidism<br />Nosocomial Sepsis, resolved<br />Late Adolescent w/ Psychosocial Issues<br />No Wasting, No Stunting<br />
  46. 46. 18 y/o F<br />-bilateral edema<br /> -edema<br /> - joint pain<br /> - weakness<br /> - cardiomegaly<br /> - fever -edema<br /> - cough/colds – joint pain<br />5 wks PTA<br />3-4 wks PTA<br />11 days PTA<br />
  47. 47. 18 y/o, F<br />- above s/sx<br /> - chest pain<br /> - tachypnea<br /> - orthopnea<br /> -pallor<br /> - weakness<br /> -respiratory distress<br />5 days PTA<br />3 days PTA<br />Day of Admission<br />
  48. 48. Past Medical History<br />Dx w/ Hypothyroidism at 7y/o<br />Poor medical compliance<br />No follow-ups<br />
  49. 49. Pertinent PE Findings<br />Pale, RD<br />Alar flaring, neck vein engorgement<br />SC, IC retractions, rales BLF, decreased BS left<br />Tachycardic, muffled and distant heart sounds<br />Globular abdomen, (+) fluid wave, hepatomegaly<br />Grade 3 bipedal edema<br />
  50. 50. Difficulty of Breathing<br />Unlikely Causes<br />CNS<br />Trauma/Injury<br />Most Likely Causes<br />Respiratory<br />Cardiovascular<br />Metabolic<br />
  51. 51.
  52. 52. Pericardial disease<br />Pericarditis<br />Pericardial Effusion<br />Cardiac Tamponade<br />
  53. 53. Cardiac<br /> Tamponade<br />CARDIAC<br />ARF/ RHD<br />METABOLIC<br />HYPOTHYROIDISM<br />RENAL<br />UREMIA<br />INFECTIOUS<br />TB, VIRAL<br />PULMO<br />PNEUMONIA<br />CONNECTIVE TISSUE DSES<br /> JRA SLE<br />
  54. 54. Differential Diagnoses<br />Rheumatic Fever <br />Viral Pericarditis<br />Tuberculosis<br />Pneumonia<br />Hypothyroidism<br />SLE<br />
  55. 55. Differential Diagnoses<br />Acute Rheumatic Fever<br /><ul><li>age group
  56. 56. arthritis
  57. 57. carditis
  58. 58. fever</li></li></ul><li>Differential Diagnoses<br />Viral Pericarditis<br /><ul><li>Most common cause
  59. 59. Fever
  60. 60. Chest pain</li></ul>- Rarely progresses to cardiac tamponade<br />
  61. 61. Differential Diagnoses<br />Tuberculosis<br /><ul><li>in developing countries
  62. 62. fever
  63. 63. chest pain</li></ul>- no exposure<br />
  64. 64. Differential Diagnoses<br />Pneumonia<br /><ul><li>URTI
  65. 65. fever
  66. 66. chest pain</li></li></ul><li>Differential Diagnoses<br />Hypothyroidism<br /><ul><li>(+) history</li></ul>- rarely cardiac tamponade<br />
  67. 67. Differential Diagnoses<br />SLE/ JRA<br /><ul><li>age group
  68. 68. joint pain
  69. 69. fever
  70. 70. Pericarditis effusion</li></li></ul><li>Course in the Ward<br />
  71. 71. Day of Admx-Days 1-2<br />- pale<br /><ul><li>fever
  72. 72. generalized weakness
  73. 73. joint pain
  74. 74. respiratory distress
  75. 75. tachypneic, tachycardic
  76. 76. N/N anemia
  77. 77. cardiomegaly, pulm congestion
  78. 78. pericardial effusion, severe</li></li></ul><li>Days 3-8:<br /><ul><li>painless, oral lesions
  79. 79. fever
  80. 80. afebrile seizure
  81. 81. Pericardial fluid analysis</li></ul>- (-) AFB<br /><ul><li>Pleural effusion</li></li></ul><li>Days 12-15<br />- petechial rashes<br /><ul><li>hepatomegaly
  82. 82. oliguria
  83. 83. Pericardial effusion
  84. 84. Sputum AFB (-)</li></li></ul><li>Day 17-20<br /><ul><li>jaundice, icteric sclerae
  85. 85. hepatomegaly
  86. 86. shortness of breath
  87. 87. cardiomegaly, pulm congestion, bilat pleural effusion
  88. 88. N/N anemia
  89. 89. Inc. LFTs
  90. 90. T4- normal
  91. 91. ANA: +4
  92. 92. Anti- DS DNA: +</li></li></ul><li>Day 21-23<br /><ul><li>decreasing jaundice
  93. 93. Lysis of fever
  94. 94. Improvement of appetite and well-being
  95. 95. Methylprednisolone 3 doses given</li></ul>IMPROVEMENT<br />
  96. 96. :non-constitutional<br /> signs and symptoms<br />
  97. 97. <ul><li>Painless oral ulcers
  98. 98. rashes
  99. 99. Arthritis
  100. 100. Serositis
  101. 101. GIT involvement</li></ul>:non-constitutional<br /> signs and symptoms<br />
  102. 102. <ul><li>Painless oral ulcers
  103. 103. rashes
  104. 104. Arthritis
  105. 105. Serositis
  106. 106. GIT involvement</li></ul>:non-constitutional<br /> signs and symptoms<br />Laboratory parameters<br />
  107. 107. <ul><li>Painless oral ulcers
  108. 108. rashes
  109. 109. Arthritis
  110. 110. Serositis
  111. 111. GIT involvement</li></ul>:non-constitutional<br /> signs and symptoms<br />Laboratory parameters<br />SYSTEMIC LUPUS ERYTHEMATOSUS<br />
  112. 112. The 1982 Revised Criteria for Classification of Systemic Lupus Erythematosus<br />Malar rash<br />Discoid rash<br />Photosensitivity<br />Oral ulcers<br />Arthritis<br />Serositis<br />Renal disorder<br />Neurologic disorder<br />Hematologic disorder<br />Immunologic disorder<br />Antinuclear antibody<br />
  113. 113. Systemic Lupus Erythematosus<br />
  114. 114. FREQUENCIES & CLIN FEATURES OF SLE AT DIAGNOSIS & AT ANY TIME AMONG CHILDREN AND ADOLESCENTS<br />
  115. 115. FREQUENCIES & CLIN FEATURES OF SLE AT DIAGNOSIS & AT ANY TIME AMONG CHILDREN AND ADOLESCENTS<br />
  116. 116. PCMC<br /><ul><li>39 cases, 1998-2004
  117. 117. Ages: 10-19 y/o
  118. 118. M:F, 1:6.8
  119. 119. 51%- SLE w/ Nephritis
  120. 120. 2%- SLE w/ CNS inv.
  121. 121. 0- SLE w/ Serositis</li></li></ul><li>Arthritis<br />Persistent knee and ankle pain<br />Non-erosive, non-deforming<br />2 or more peripheral joints<br />Tenderness, swelling, effusion<br />Anti-inflammatory meds.<br />
  122. 122. Mucocutaneous Involvement<br />Beseler, Silvermann<br />Pediatr Clin N Am<br />52 (2005) 443-467<br />
  123. 123. Mucocutaneous Involvement<br />Petechial rash, ecchymoses<br />not as frequent <br />r/o other lesions of platelet count abnormalities<br />aggravated by sun exposure<br />‘..definite photosensitivity occurs in 16% of children…’<br /> Downing, Mesina<br /> N Engl J Med<br /> 1992; 227:408-409<br />
  124. 124. Mucocutaneous Involvement<br />‘rashes occur frequently in children w/ SLE but only 30-50% ever manifest the typical butterfly rash.’<br />Glidden, Mantzouranis, Borel<br /> Clin Immunol Immunopathol<br /> 1983; 29;196-210<br />
  125. 125. Hematologic Involvement<br />Pallor; normocytic/ normochromic anemia<br />‘ …the most common hematologic manifestation of SLE in children and adolescents is anemia…’<br />Wallace, Hahn2002<br />
  126. 126. Hematologic Involvement<br />Anemia, thrombocytopenia, leukopenia: 50-75%<br />normocytic normochromic anemia <br /> microcytic hypochromic<br />Coagulation abnormalities<br />Menorrhagia<br />
  127. 127. Cardiac Involvement<br />Pericardial effusion cardiac tamponade<br />‘… Cardiac manifestations rarely are prominent in children and adolescents w/ SLE, but occasionally they are catastrophic…’<br />Auito, Stanbouly, Boxer<br /> Clin Pediatr 1993;32:566567<br />
  128. 128. Cardiac Involvement<br />Common Cardiac Pathology<br /> - Pericarditis<br /> - Myocarditis<br /> - Mild Valvular Involvement<br />‘…The most common form of cardiac involvement is pericarditis w/ pericardial effusion…’<br />Chan, Li, Tam<br /> Scand J Rheumatol 2003;32:306-308<br />
  129. 129. Cardiac Involvement<br /><ul><li>Many children w/ SLE are anemic and develop few murmurs. Libman-sacks endocarditis may occur in childhood however, and this predisposes to bacterial endocarditis..</li></ul>Wallace, Hahn 2002<br />
  130. 130. Pulmonary Involvement<br />Pleural effusion, bilateral<br />‘… Pleurisy and pleural effusion are the most common pulmonary manifestations…’<br />Delgado, Mulleson, Pine<br /> Semin Arthr Rheum<br /> 1990; 29: 225-293<br />
  131. 131. Pulmonary Involvement<br />Other Pulmonary complications:<br /> - pneumothorax<br /> - pneumonia<br /> - chronic restrictive lung dse.<br /> - pulmonary HPN<br /> - acute pulmonary hemorrhage<br />Most fatal complication in children and adolescents: pneumonia<br />
  132. 132. Pulmonary Involvement<br />‘…Pneumonia was the cause of death for 9 of 26 children w/ SLE coming to autopsy…pulmonary hemorrhage contributed to death of 5 others…’<br />Nadora, Landing<br /> Pediatr Pathol 1987: 7;118<br />
  133. 133. GIT Manifestations<br />Jaundice, hepatomegaly, abnormal LFT’s<br />Other s/sx:<br /> - abdominal pain, anorexia, weight loss<br />Often resolve w/ corticosteroid therapy<br />
  134. 134. Infections in SLE<br />Patient developed nosocomial sepsis due to her immunocompromosed state<br />Major cause of mortality and morbidity<br />Plat et al: 55 separate infections in 70 patients, over 9 years.<br /> >Results from:<br /> 1. combined effects of SLE<br /> 2. drugs used to mediate it <br />
  135. 135. Infections in SLE<br />‘…The frequency of infection increases w/ increasing steroid dosage…’<br />Guizler, Deamond, Kaplan<br /> Arthr Rheum 1978; 21:37-44<br />Careful use and reduced dosage of corticosteroids decreases frequency of infections<br />
  136. 136. Laboratory Evaluation<br />ANA<br />Anti- DS DNA<br />Anti- Smith Ab<br />Autoantibodies <br />Hypergammaglobulinemia<br />
  137. 137. Endocrine Involvement<br />Thyroid<br />Hypothyroidism>Hyperthyroidism<br />‘…Up to 35% of SLE patients have anti-thyroid antibodies, w/ 10-15% of patients developing overt hypothyroidism…’<br />Eberhard, Laxer, Eddy<br /> J Pediatr 1991;119:277-9<br />
  138. 138. Treatment<br />Depends on target organs and disease severity<br />Pericardiostomy tube insertion, antibiotic coverage, immunosuppresive therapy<br />
  139. 139. IMMUNOSUPPRESSIVE TREATMENT OF CHILDHOOD SLE<br />
  140. 140. Cornerstone of Treatment of Children w/ Rheumatic Disease<br />Accurate diagnosis and education of family<br />Medications<br />Physical medicine and rehabilitation<br />Physical and psychosocial growth and development<br />Coordination of care<br />
  141. 141. Chronic Disease in Adolescents: Issues Involved<br />1.Compromised mental health may make management of the physical illness more difficult. <br /> - increased risk for psychiatric disorders and social adjustment problems.<br /> - non-compliance w/ medical treatment.<br />2. Risk taking in the areas of sexuality and substance use is an important contributor to morbidity.<br /> - management of high-risk pregnancies, w/c demands a high degree of compliance and medical regimentation.<br />3. Functional impairments increase the risk of academic and adjustment problems. <br />
  142. 142. Chronic Disease in Adolescents:Trends in Management<br /><ul><li>Needs a biopsychosocial, multidisciplinary approach
  143. 143. Improved nutritional management</li></ul> better growth and development<br /> normative social behavior , including risk-taking behaviors<br /><ul><li>Assistance in becoming functioning adults: employment, sexuality and marriage
  144. 144. Programs to help them transition from pediatric into adult-oriented health care.</li></li></ul><li>Incidence of Adverse Outcomes in 72 Children w/ SLE<br />OUTCOME<br /> renal failure<br /> severe CNS dse.<br /> stroke<br /> chronic thrombocytopenia<br /> chronic active dse<br /> death<br />INCIDENCE (%)<br /> 15<br /> 11 <br /> 1<br /> 7<br /> 56<br /> 18<br />
  145. 145. Predictors of Poor Prognosis in SLE<br />Persistent anemia: Hb <10g for 6 mos.<br />Persistent hypertension: diastolic BP>90mmHg for >6 mos.<br />Persistent hematuria: >20 rbc/HPF for > 6 mos.<br />Pulmonary hypertension<br />Recurrent emergency admissions.<br />
  146. 146. CONCLUSION<br />
  147. 147. Thank you!<br />

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