A case of 20 year female presenting with fever, respiratory distress and joint pain.This case was presented in grand round session of Department of Medicine , Dhaka Medical College Hospital on 6th July, 2019.

1. A-20-year-old female
presenting with fever,
respiratory distress & skin
rash
Dr.Md Shadman Shakib
Intern Doctor
Dhaka Medical College Hospital.

2. Salient Features
Mrs.Shanta, 20-year-old-woman, hailing from Jurain, Dhaka was seen
by the medicine admission unit on 9th June,2019 at this hospital for
respiratory distress , fever & rash involving both lower limbs, trunk &
upper limbs.

3. On the day of admission, she presented with respiratory distress (MRC
grade 3) for last 5 days associated with occasional dry cough but not
associated with orthopnea or PND or any history of SOB since childhood.
She also complains high grade intermittent fever, the highest recorded
temperature was 103 degree F that was not associated with any chills &
rigors, but relieved with paracetamol.She also noticed pinkish to violet

4. coloured skin rash that is occasionally itchy, painless & gradually both
lower limbs,trunk & upper limbs for last 4 days
On query, she gives a history of non specific joint pain involving small
joints of hands & also knee joint 3 days back that was associated with
swelling of the entire hand, spontaneously resolved on the day before
admission.She also gave a history of 1 bag whole blood transfusion at a
local clinic on that

5. day.No reaction occured.She denied any history of abdominal
pain,jaundice,cough with productive sputum,previous history of low
grade fever associated with night sweat & evening rise of temperature
,chest pain, hemoptysis , history of leg swelling or swelling of
abdomen,bloody urine or stool, nasal crusting, epistaxis, weight gain,
cold intolerance, constipation, hisory of pregnancy or spontaneous

6. abortion/loss of pregnancy, convulsion, gum bleeding, oral ulcer, alopecia,
photosensitivity, menorrhagia or passage of any blood clots during
menstruation, per vaginal discharge or burning micturition or lower
abdominal pain, significant weight loss, bone painExtramarital affair, h/o
travelling to Malaria or Kala Azar endemic zone, previous history of
asthma or similar type of illness in childhood, h/o vaccination with

7. tetanus toxoid.Drug history was negative for taking any anti-
arrhythmic,anti-hypertensive, anticonvulsant or biologic drugs or
consumption of INH, minocycline & pyrazinamide .
1 weeks before this evaluation, the patient was seen in the OPD of a
private hospital.She was diagnosed with left sided pleural effusion & was
prescribed Cefuroxime-Clauvulonic acid & paracetamol along with advise
for hospitalisation, however she denied to be admitted there.

8. Menstrual history
Period 5-7 d, Cycle 21-28 Flow -average
Contraceptive history
Did not adopt any contraceptive method so far.

9. Patients family history was not noteworthy of asthma/ TB or any
rheumatological condition or any history of pregnancy loss in mother or
siblings.She is married for 6 months & her electrician husband works in
Oman.She lives in her in laws house situated in old town of Dhaka.

10. Past history
10 weeks before this presentation, when she noticed fever , respiratory
distress associated with dry cough & sore throat for 3 days, patient was
evaluated in the OPD of another tertiary care hospital.The patient was
empirically treated as a case of Para-pneumonic effusion.Initially she was
prescribed azithromycin, pantoprazole, paracetamol for 7 days, later
Azithromycin was substituted with combination of co amoxiclav &

11. clarithromycin & patient was Improved.
8 weeks before this evaluation,during follow-up at that that hospital, her
condition was slowly improving, however, she was again prescribed co
amoxiclav & clarithromycin for 14 days in addition to salbutamol &
fluticasone inhaler, montelukast & rabeprazole.She took them accordingly
& she describes her condition was stable & she was symptom free after
taking them.

12. Physical Examination
General Examination
Ill looking, anxious
Body Built- Average
Co-operative, Decubitus on choice
Pulse -90/min, regular rhythm
BP - 104/72 mm Hg
Respiratory Rate 25 /min
Temperature-101^F

13. Anemia- Mild
Jaundice/Cyanosis/ clubbing/koilonychia/leukonychia/flapping
tremor/edema/dehydration -Absent
Lymph Node- not palpable
Thyroid gland- normal
JVP-Not raised

14. Skin survey revealed pinkish to violet coloured painless macular skin rash
in both lower limbs, more in legs, along with eccymoses in both the
popliteal fossae.There were some non palpable purpuric spots present
in the abdomen & upper limbs.

17. • Repiratory System
Trachea- deviated to right
Chest movement asymmetrical
Reduced chest expansion in left mid zone & lower zone( <1.5 cm ),apex
beat in left 6th ICS medial to the MCV line, normal in character
Vocal fremitus reduced in left mid to lower zone (4th ICS downwards) but
normal in the rest of the lung fields.

18. Percussion note was stony dull & breath sound absent in the
aforementioned area of the lung, along with reduced vocal resonance.
Rest of the lung field was normal.There was no added sound.
Except some reddish to purplish non palpable purpura in the abdomen,
abdominal exam did not yield any positive sign i.e. any palpable organ or
any abdominal/ pelvic mass or ascitis & there was no scare mark.

19. Cardiovascular exam revealed no sign of pericardial
effusion/pericarditis/vulvular heart disease/HF.All the peripheral pulses
were palpable with normal character, there was no audible bruit.
Examination of the Musculoskeletal system was not remarkable for any
sign suggestive of tender/swollen joint.

20. Nervous system examination revealed no cognitive impairment,HPF was
normal.Cranial nerves in conjunction with motor system & sensory system
were intact.Fundoscopy revealed no sign of retinal haemorrhage.There
was no cerebellar sign.

21. Problem List
History
Recurrent respiratory distress
Fever
Rash involving both lower limbs & trunk
Physical Examination
Anemia
Non palpable purpura & echymosis
Left sided massive pleural effusion

22. Provisional Diagnosis

23. SLE

24. Points in favour
Fever
Recurrent pleural effusion
Anemia
History of polyrthritis

25. D/D
• Anti-Phospholipid Syndrome
• Dengue Fever
• Systemic Vasculitis
• Atypical Pneumonia

26. Investigations
Blood Picture
Date 24.03.19 03.06.19 10.06.19 11.06.19 17.06.19
Hb% 9.8 8.8 11.1 9.3 8.4
RBC (/cmm) 4,78,000 4,54,000 5,09,000 4,24,000 3,75,000
WBC (/cmm) 17,500
(Neutrophil-80%
Lymphocyte-
10%)
9000
(Neutrophil-63%
Lymphocyte-
29%)
9,000
(Neutrophil-65%
Lymphocyte-
30%)
10,230
(Neutrophil-83%
Lymphocyte -
11.9%)
7,870
Neutrophil-
68.6%
Lymphocyte -
20.5%)
Platelet (/cmm) 3,50,000 3,30,000 4,45,000 3,16,000 3,23,000
Hct % 32.2 30 34 29.3 28.2
ESR (mm/hr) 41 74 60 112 -

27. PBF (11.06.19)
● Anisopoikilocytosis with Microcytic hypochromic anemia
● WBCs are mature , No blast cell
● Platelets are normal in distribution
Sputum for AFB & Gene Xpert (-)ve (27.03.19) (ICDDR,B)
Dengue NS1 (-)ve (03.06.19)

28. Chest X-ray PA view
Date 24.03.19 28.03.19 15.04.19 03.06.19 10.06.19
Impression Right sided
pleural effusion
No fibrosis or
patchy opacity
Right sided
pleural effusion
No fibrosis or
patchy opacity
Right sided
pleural effusion
(improved)
No fibrosis or
patchy opacity
Left sided
massive
pleural effusion
No fibrosis or
patchy opacity
Left sided
pleural effusion
-improved
No fibrosis or
patchy opacity

29. Urine R/M/E (10.06.19)
Protein
Glucose
RBC cast.
WBC cast.
RBC (Isomorphic ) Nil
Dysmorphic RBC
Hyalin cast
Pus cell 8-10/HPF

30. UPCR- 0.35 (13.06.19)
Thyroid profile (10.06.19)
TSH -2.10 pg/mL
FT3 -1.68 ng/dL
FT4 -1.80 uIU/L

31. Pleural fluid
Drainage note - With all aseptic precautions, about 1L of straw coloured pleural
fluid was drained.Appearance was clear, neither turbid nor hemorrhagic.
Study report (10.06.19)
Microscopic examination
WBC 390/cmm (90% lymphocyte, 5% plasma cells , 5% lymphocyte)
RBC 310/cmm

32. Bacteriological examination
Gm stain - no organism detected
Zn Stain -AFB not found
Biochemistry
Glucose 9.0 g/dL (markedly reduced)
Protein 5.0 g/dL (mildly elevated)
Pleural fluid ADA -38 U/L

33. USG (13.06.19)
Normal size of liver or spleen
No abdomino-pelvic lymphadenopathy
No ascitis / pericardial effusion
Moderate effusion in left pleural cavity having multiple septations

34. PT - 13.3 sec (control 12.0 sec) (16.06.19)
INR -1.11 (16.06.19)
APTT -29.0 sec (control 28.0 sec) (16.06.19)
HBsAg
Anti HCV. Negative (10.06.19)
HIV screening

35. Antibody Titre Ref. Value Inference
ANA (ELISA) 5.5 U/mL <10 U/mL Negative
c-ANCA (ELISA) 3.10 U/mL <6.00 U/mL Negative
p-ANCA (ELISA) 2.88 U/mL <6.00 U/mL Negative
Anti-ds-DNA
(ELISA)
10.2 U/mL <30.0 U/mL Negative

36. Antibody Titre Reference
range
Inference
aPL Ig-M
(ELISA)
22.5 <10 U/mL POSITIVE
aPL Ig-G
(ELISA)
5.23 <10 U/mL Negative
aCL Ig-M
(ELISA)
22.0 <10 U/mL POSITIVE
aCL Ig-G
(ELISA)
4.82 <10 U/mL Negative

37. Skin biopsy was planned but was not possible according to the opinion of
Department of Dermatology, DMCH.

38. Final Diagnosis
SLE

39. Follow Up- After 1 month
Further plan
-Repeat ANA , aCL Ig-M & Ig-G, aPL Ig-M & Ig-G after 3 month
-Biopsy from affected skin lesion, if recurrence

40. -Fundoscopic examination in each follow up.
-VDRL test
-Echocardiogram
-CTPA
-Duplex study of lower limbs
-ENA Profile

41. Inputs &
Discussion