5.
HOPC
According to my patient, he was in his usual state of health 5 years
back when he started developing wounds/ rash even after minor
scratch or itch on skin (more on lower limbs). But it was not
hindering him from routine chores and was not associated with
fever or any other complain. But 1 year ago he developed joint
pains and swellings which shifted from 1 joint to other, each joined
remained involved for 1 to 2 days and 2 to 3 joints remained
involved at a time. Large joints were involved more especially hip
and knee joints. Meanwhile his skin wounds changed into rash
involving bilateral legs below knee. Rash was pruritic in nature and
pus and blood oozed out of each lesion.
6.
HOPC
His rash and joint pains were associated with low grade fever,
undocumented weight loss and malaise, more at night time.
Patient was put on antipsychotics but it did not help. Later on
some GP prescribed him tab deltacortil 3x BD for 1 week,
then 2 x BD for next week. This treatment improved his joint
pains, he remained asymptomatic and gained weight in next 6
months but had mild joint pains occasionally associated with
taking protein rich diet. His rash started involving upper
limbs too then 5 months back he got skin biopsy which
revealed Reactive Perforating Collagenosis.
7.
HOPC
Few weeks back he again developed similar joint pains,
associated with low grade fever, worsening rash (involving
thighs & buttocks) and malaise. He took some aurvedic
treatment for 3 weeks which initially improved his condition
but when he withdrew this medicine, his condition worsened
and he started developing dry cough which gradually
worsened and he noticed hemoptysis 1 week before
presentation. Blood was dark red to brown in color, ½ table
spoon in quantity early morning and mild bleed throughout
the day. He has lost 3 kg weight in 1 month during this
episode.
8.
Past Medical Hx
He has hx of some STD leading to genital ulcers 5 months
after marriage
Past Surgical Hx
Not significant
Drug Hx
Deltacortil, aurvedic medications at different intervals
Vaccination Hx
Fully vaccinated with EPI vaccines in childhood
Received three doses of covid vaccine
9.
Family Hx
His mother has RA since young
His maternal uncles and aunts had pul TB. Last exposure was
in 2009
Personal Hx
Normal appetite
normal sleep wake cycle
Normal bowel habits
Married for 6 years and has 2 alive, healthy children
10.
No hx of blood transfusions,
No hx addictions
He has history of dust allergy(sneezing and Upper
respiratory symptoms on dust exposure)
Australian parrots as pets at home
11.
Travel Hx: Nil
Socioeconomic Hx:
He lives in a joint family with his parents, a brother & his
family. He, his brother and their father are earners, have own
home in city with basic facilities available
Systemic Inquiry:
Insignificant
12.
Clinical examination
A young male patient, average height and built sitting on
hospital bed, well oriented in time, place and person (GCS
15/15) with vitals of
BP: 120/80 mmHg, Pulse: 80 /min, SaO2: 95% on air
RR: 10 /min, Temp: afebrile,
GPE
14.
He has no joint swelling or tenderness at the moment
and has vesicular rash on lower limbs which is black in
color, painful, blood oozes out of active lesion and
healed lesions leave a black colored scar.
Skin and joints
15.
Respiratory
He has bilateral clear chest with no added sounds
Abdomen
Soft, non tender
CVS
Audible 1st and 2nd heart sound
CNS
GCS 15/15
CNS,Abdomen & CVS
26.
ATT for latent TB
Myrin p fort 4x OD
Tab Vita 6 x OD
Modified d/t raised ALT to ethambutol, amikacin and moxifloxacin
Tab Nuberol fort x SOS
Cap Risek
Tab Deltacortil
Inj Ristova/rituximab is in plan after 3 months of completion of
ATT
Management
28.
ANCA associated
vasculitis of small to medium vessels (arteries, arterioles,
capillaries)
Necrotizing granulomatous lesion of upper and lower
respiratory tract
Glomerulonephritis and
Other organ manifestations
What it is…..
29.
With an incidence of
12 cases per million per year
In 4th and 5th decades of life
Affects both genders equally
Prognosis
Generalized disease is inevitably fatal with less than 1 year
survival after diagnosis
30.
Unknown etiology but possibly triggered by
Environmental exposures including
RTIs
living in northern latitudes
farming
allergies
exposure to solvents or silica
Host factors including
Genetic factors (α-1 antitrypsin, CTLA4, PTPN22*620W,
DPB1*0401, Fcϒ receptor IIIb on neutrophils and
macrophages)
Cellular immune responses
Etiology
31.
Develops over 4-12 months
Upper respiratory tract symptoms (90% pts)
Nasal congestion, crusting, ulceration, bleeding and
perforation of nasal septum may lead to ‘saddle nose
deformity’
sinusitis
otitis media
mastoiditis
Inflammation of gums
Stridor due to subglottic stenosis
Features
32.
Lower respiratory tract symptoms (40-80%)
cough
dyspnea
hemoptysis
Migratory oligoarthritis (predilection for large joints)
Ocular disease
unilateral proptosis (orbital pseudotumor)
Red eye (scleritis, episcleritis, ant uveitis, peripheral
ulcerative keratitis)
Features
33.
Skin disorder
Purpura
other lesions
Dysesthesia
Renal involvement (3/4th of cases)
subclinical until advanced disease
will develop in majority of untreated patients
Fever, weight loss and malaise
Newly acquired HTN (rarely)
Venous thrombotic events
Features
34.
CBC
Anemia
Mild leukocytosis
ESR, CRP
ANA (0-15%)
RF (50%)
ANCA (93-96%)
PR3-ANCA/c-ANCA(>90% specificity, >95% sensitivity)
MPO-ANCA(10-25% pts)
Urine RE
Proteinurea
red cells/red cell casts
Diagnosis
36.
Biopsy/Histopath
Lung biopsy
Vasculitis, granulomatous inflammation/granulomas,
geographic necrosis, acute and chronic inflammation
Nasal biopsy
Chronic inflammation
Kidney biopsy
Pauci-immune glomerulonephritis
segmental necrotizing glomerulonephritis with multiple
crescents(characteristic but not diagnostic
37.
Early treatment is crucial
in preventing end-organ complications
and preserving life
Remission Induction
Depends on severity of disease
Mild(no significant kidney dysfunction/immediately life threatening
disease)
Severe(life or organ threatening disease/RPGN/pul hemorrhage)
Remission Maintenance
Management
38.
Severe disease
Corticosteroids plus Rituximab
375mg/m2 IV once a week for 4 weeks of Rituximab with 1mg/kg
PO prednisolone daily
Coricosteroids plus Cyclophosphamide
Remission induced in > 90% pts
Prednisolone (1mg/kg/day P/O) plus cyclophosphamide
(2mg/kg/day P/O dose adjustment required for >70y/o and with
kidney disease).
Intermittent high dose IV cyclophosphamide is associated with
higher relapse risk compared to daily oral
To avoid toxicity give cyclophosphamide for 3-6 months
Remission Induction
39.
Non severe disease
Methotrexate plus glucocorticoids
Remission Induction
40.
Azathioprine 2mg/kg/day P/O
Methotrexate 20-25mg/wk P/O or IM
Rituximab (500mg IV repeated in 14 days then 6monthly)
Mycophenolate mofetil
Rituximab is better in remission maintenance and overall
survival than other drugs
One trial showed that relapse after 28months was 5% with
rituximab and 29% with azathioprine
Remission Maintenance
41.
Relapse with severe disease manifestation
o Who are not receiving Rituximab for maintenance give
Rituximab
o Who receive rituximab switch to cyclophosphamide rather
than giving additional dose
Relapse management
42.
Switch to other therapy rather than combining both
Add IVIG to current therapy
Refractory disease
CTLA4 is involved in T cell activation
PTPN22 is with T cell activation
DPB1 is with chronic beryllium disease
Immunoflourescence assays for ANCA should be confirmed by enzyme immunoassays
Full range of pathologic changes usually evident only on lung biopsy specimen
Both rituximab and cyclophosphamide increase opportunistic infections including progressive multifocal leukoencephalopathy
Give prophylaxis for PCP with single strength trimethoprim sulphamethoxazole daily