This case discusses an 18-year-old female patient presenting with easy fatigability and other symptoms over several months. After examination and investigations, she was diagnosed with systemic lupus erythematosus affecting multiple organs including the lungs, skin, kidneys, and central nervous system. She was started on treatment including steroids, antibiotics, and other medications. The case highlights the approach to diagnosing and managing SLE, a chronic autoimmune disease with diverse clinical manifestations and organ involvement.
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. GawadNephroTube - Dr.Gawad
- English version of this lecture is available at:
https://youtu.be/zrFm0hAZk2A
- Arabic version of this lecture is available at:
https://youtu.be/M_BV8WJVbx0
- Visit our website for more lectures: www.NephroTube.com
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http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. GawadNephroTube - Dr.Gawad
- English version of this lecture is available at:
https://youtu.be/zrFm0hAZk2A
- Arabic version of this lecture is available at:
https://youtu.be/M_BV8WJVbx0
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
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Using Novel Kidney Biomarkers to Guide Drug Therapy.pdfDr.Mahmoud Abbas
Using Novel Kidney Biomarkers to Guide Drug Therapy: Presentation by Dr Sandra Gill , President SCCM at the Egyptian Critical Care Summit 2022 held at Cairo, Egypt and organized by the Egyptian College of Critical care Physicians (ECCCP)
- Recorded videos of the lecture:
English Language version of this lecture is available at: https://youtu.be/-Ynxvhbcl7U
Arabic Language version of this lecture is available at: https://youtu.be/QpK_toctVlw
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
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Using Novel Kidney Biomarkers to Guide Drug Therapy.pdfDr.Mahmoud Abbas
Using Novel Kidney Biomarkers to Guide Drug Therapy: Presentation by Dr Sandra Gill , President SCCM at the Egyptian Critical Care Summit 2022 held at Cairo, Egypt and organized by the Egyptian College of Critical care Physicians (ECCCP)
- Recorded videos of the lecture:
English Language version of this lecture is available at: https://youtu.be/-Ynxvhbcl7U
Arabic Language version of this lecture is available at: https://youtu.be/QpK_toctVlw
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
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Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxbartholomeocoombs
Clinical Scenario:
REASON FOR CONSULTATION:
Desaturation to 64% on room air 1 hours ago with associated shortness of breath.
HISTORY OF PRESENT ILLNESS:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.
REVIEW OF SYSTEMS:
Constitutional:
Negative for diaphoresis and chills.
Positive for fever and fatigue.
HEENT:
Negative for hearing loss, ear pain, nose bleeds, tinnitus.
Positive for throat pain secondary to her laryngeal cancer.
Eyes:
Negative for blurred vision, double vision, photophobia, discharge or redness.
Respiratory:
Positive for cough and shortness of breath
. Negative for hemoptysis and wheezing.
Cardiovascular:
Negative for chest pain, palpitations, orthopnea, leg swelling or PND.
Gastrointestinal:
Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.
Genitourinary:
Negative for dysuria, urgency, frequency, hematuria and flank pain.
Musculoskeletal:
Negative for myalgias, back pain and falls.
Skin:
Negative for itching and rash.
Neurological:
Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies:
Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric:
Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric.
Anti-Phospholipid Syndrome Grand Round Presentation Dhaka Medical College Hos...Mohammed Shadman Shakib
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.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)Apollo Hospitals
Severe skin adverse drug reactions can result in death. Toxic epidermal necrolysis (TEN) has the highest mortality (30–35%); Stevens-Johnson syndrome and transitional forms correspond to the same syndrome, but with less extensive skin detachment and a lower mortality (5–15%). Hypersensitivity syndrome, sometimes called Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), has a mortality rate evaluated at about 10%. It is characterised by fever, rash and internal organ involvement. Prompt diagnosis is vital, along with identification and early withdrawal of suspect medicines and avoidance of re-exposure to the responsible agent is essential. Cross-reactivity to structurally-related syndrome caused by Carbamazepine medicines is common, thus first-degree relatives may be predisposed to developing this syndrome. We report a case of DRESS secondary to use of Carbamazepine.
Rabies.pptx(Epidemiology,pathophysiology.clinical features and prevention)Melaku Yetbarek,MD
As rabies is one of public health important health issue,particularly in developing countries,this slide gives an overview of epidemiology,clinical features and prevention of rabies.
This power point is a master piece ,dedicated to give inclusive knowledge on history, indications,types, modes,alarms and troubleshooting,Complicatons,weaning of mechanical ventilation
This power point is dedicated to deliver history of transfusion, its biology, Procedures for safe transfusion, Indications ,complications and their management.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
1. ADAMA HOSPITAL MEDICAL COLLEGE
1
GRAND ROUND
PRESENTED BY: Dr. Kebede M.(Med R2)
Dr. Melaku Y.(Med R1)
Dr. Mengistayehu T.(Intern)
MODERATOR: Dr. Shoba Ibrahim(MD internist, Assist.prof)
2. OUTLINE
2
Summary of the History, Physical Examination and Investigation.
Discussion of differential diagnosis and mgt.
Final diagnosis.
References.
6. HISTORY OF PRESENT ILLNESS
6
She is an 18 years old female patient presented with gradual onset
of the above complaint for the past two months with no aggravating
and relieving factors noticed by the pt and the family.
7. Associated to it:
7
She has dry cough of 5 months for which she visited near by hospital
one month back and was given unspecified injectable medication for
two wks, but no improvement
She has LGIF, night sweat, chest pain of three wks, dysphagia and
SOB of one wk duration
She has multiple joint pain, hand and feet swelling of 5 months
She has tinnitus, vertigo, head ache, decreased appetite of three wks
8. CONT…
8
She has also progressive type of skin lesion over the right leg
and foot which initially was fluid filled and later progressed to
pus filled for the past three months for which she visited the
near by health institution and was given un specified oral
medication ,but no improvement apart from slight improvement
from pain and decreased purulent discharge.
9. Otherwise:
9
No orthopnea, PND, palpitation
No abdominal distension, pain or bowel habit change
No yellowish discoloration of eyes or use of herbal medication
No hx of urine color change or decreased UOP
No hx of TB tx or contact with chronic cougher
No hx of ABM or LOC
10. CONT…D
10
No hx of trauma to the leg
No heat or cold intolerance or anterior neck swelling
No self or family hx of DM, HTN or cardiac illness
13. 13
H.E.E.N.T
Pale conjunctiva and non icteric sclera
LGS: No LAP
RESPIRATORY SYSTEM
Decreased air entry over the posterior lower third chest
bilaterally
Coarse crepitation over the lt lower lung field
14. 14
CARDIOVASCULAR EXAMINATION
JVP is flat
S1 and S2 well heard, no M/G
ABDOMINAL EXAMINATION
Flat and moves with respiration
- No tenderness
- No Organomegally or SFC
- Normo-active bowel sound (16/min)
15. 15
GENITOURINARY SYSTEM
No CVAT
INTUGEMENTARY AND MUSCLOSKELETAL SYSTEM
There are two well demarcated and discoid skin lesions over the medial and
dorsal aspect of the rt foot each measuring 3*4cm and 3*3 cm respectively with
hyper pigmented base and punched out center and inverted edges, no discharge.
24. In favor:
Constitutional symptoms
Anemia, increased ESR
Abnormal Urinalysis
Multiple organ involvement
Ulcer
Improvement with steroid
management
Against:
Age
No palpable purpura
No Reynaud's phenomenon
No rhinitis, sinusitis or asthma
ANA Positive
No nasal or oral involvement
5.Vasculitis
25.
26.
27.
28. Mixed connective tissue disease (MCTD) is defined as a
generalized connective tissue disorder
characterized by the presence of high titer anti-U1
ribonucleoprotein (RNP) antibodies in combination with clinical
features
commonly seen in systemic lupus erythematosus (SLE), systemic
sclerosis (SSc), and polymyositis (PM)
4.Mixed connective tissue disorders(MCTD)
29.
30. In favor:
All non specific constitutional symptoms
Bilateral joint pain
Dysphagia
Heartburn
ANA –Positive
Increased LDH
Remission after steroid
Against:
No proximal muscle weakness
No Reynaud's phenomenon
No localized muscle pain
Markedly increased ESR
Age
Renal and lung involvement
4.Mixed connective disorders
31. Describes those patients having overlapping features of SLE and
Rheumatoid arthritis
In these cases sever joint deformities, nodules and erosions may
occur
3.Rhupus
32. In favor:
Joint swelling
Constitutional symptoms
Duration of symptoms(>6
weeks
Increased ESR
ANA-Positive
Failed antibiotic treatment
Improvement with steroid
Against:
No morning stiffness
Large joint involvement
Decreased platelets
3.Rhupus
33. In favor:
TB symptom Complex
Epidemiology
Lung, Pleura and skin
Increased ESR
Marked Improvement after anti-
TB treatment
Against:
No TB contact history
Sputum gene X-pert-negative
Chest x-ray finding
Pleural fluid analysis
Relapsing and remitting course
Kidney involvement
2.Disseminated Tuberculosis( Lung, Pleura,Skin)
34. In favor:
Fulfills diagnostic
criteria(EULAR 2019)
Marked Improvement after
treatment for SLE
Against:
Pleural fluid analysis
Skin lesions are not on photo-
Sensitive areas
1.Systemic Lupus Erythematosus
35.
36.
37.
38. CASE SUMMARY
This is an 18-yr old F patient admitted to MW 3 weeks back
complaining of worsening of cough of 3 months and SOB of 2
months.
She also has multiple joint pain, swelling of hands and feet,and
fatigue of 5 months.
In addition,she has night sweating, pleuritic chest pain, skin
color change with ulceration and LGIF.
After admission,she also abnormal behaviour,lack of
sleep,headache and tingling sensation.
Her past medical history was Rx with antibiotics twice with no
improvement.
39. Her lab Ixs from CBC:wbc-3700,L-6%;hgb-6.6;plt-
916000;ESR-100;
Cr-3.99;Urea-154;AST-84,ALT-48;
U/A-albumin +4;RBC +3;
CXR-symmetric mid lung bilateral opacity ;
ANA +ve;Hbsag and HCV ab –ve;PIHCT –ve;
Abd,U/S-normal.
Pleural fluid analysis-gluc-46,alb-1.5g/dl,RBC-1500,WBC-
7500:N-77%;sputum gene xpert –ve;
40. Final Dx
Life-threatening SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
(hematologic,renal,cns,pulmonary,skin)+?Diss.
TB(lung,pleura,skin)+NCPE 2ry to AKI 2ry to
Lupus Nephritis+?CAP+Mod. Anemia 2ry ACD
+Ecthyma
43. Introduction
SLE is a chronic inflammatory multisystem disease of
unknown cause.
Ninety percent of patients are women of child-bearing years;
people of all genders, ages, and ethnic groups are
susceptible.
Sixty-five percent of patients with SLE have disease onset
between the ages of 16 and 55
44. Etiology and pathogenesis
Interactions between susceptibility genes and
environmental factors result in abnormal immune
responses:
lowered activation thresholds and abnormal activation
pathways in adaptive immunity cells
ineffective regulatory CD4+ and CD8+ T cells and
reduced clearance of immune complexes and of
apoptotic cells
45.
46. Clinical Manifestations
SLE is a multisystem disease with diverse organ involvement
and multiple different manifestations within an organ system.
The system most commonly involved is the musculoskeletal
system, with 95% of patients having involvement, usually as
arthralgias or myalgias.
Arthritis is also common and is one of the diagnostic criteria for
SLE.
53. The goals of therapy for SLE are :
to ensure long-term survival,
achieve the lowest possible disease activity,
prevent organ damage,
minimize drug toxicity,
improve quality of life, and
educate patients about their role in disease management
55. PHARMACOLOGIC:
Renal disease
Treatment of LN includes an initial induction phase, followed
by a more prolonged maintenance phase.
MMF and CYC are the IS agents of choice for induction
treatment;
MMF or AZA may be used as maintenance therapy
56. Induction
0.5 –1g of methylprednisolone IV daily for 3d then prednisone 0.5–
1mg/kg/d for 4–6wks thereafter, doses are tapered or
Prednisone 0.5–1mg/kg/day PO 4–6wks then taper
+
Cyclophosphamide 3 g every 2 wks over 3mo or
Mycophenolate mofetil 3 g/d for 6 months or
Azathioprine (Less effective) 2 mg/kg body weight/day
58. Haematological disease
GC in combination with IS agent (AZA, MMF or cyclosporine)
Initial therapy with pulses of intravenous MP (1–3 days) is
encouraged.
In patients with no response to GC or relapses, RTX should
be considered, considering also its efficacy in ITP
59. Thrombopoietin agonists or splenectomy should be reserved
as last options.
Autoimmune leucopaenia is common in SLE but rarely needs
treatment
60. In refractory or relapsing disease, RTX may be considered.
CNIs may be considered as second-line agents for induction
or maintenance therapy mainly in membranous LN,
podocytopathy, or in proliferative disease with refractory
nephrotic syndrome
61. Neuropsychiatric disease (NPSLE
Treatment of NPSLE depends on whether the underlying
pathophysiological mechanism is inflammatory or
embolic/thrombotic/ischaemic
GC and/or IS agents should be considered in the former, while
anticoagulant/antithrombotic treatment is favoured when aPL
antibodies are present
62. Skin:
Protection from ultraviolet exposure with broad-spectrum sunscreens and
smoking cessation
topical agents (GC and/or CNIs) and antimalarials, with or without
systemic GC
MTX can be added.
Others retinoids, dapsone and MMF or EC-mycophenolic acid
63. Lung
mild, may respond to treatment with nonsteroidal anti-
inflammatory drugs (NSAIDs);
when more severe, patients require a brief course of
glucocorticoid therapy.
Life-threatening pulmonary manifestations probably require
early aggressive immunosuppressive therapy as well as
supportive care.
64. Infections
Risk of infection in SLE is associated with both disease-related
and treatment-related factors
Protection against infections should be proactive, focusing
both on primary prevention, as well as timely recognition and
treatment.
Vaccination is preferable during stable disease
65. Abstract
infection one of the leading causes of morbidity and mortality
The reasons for the high incidence of infection are immunosuppressive
therapy and immune disturbances of lupus itself.
Bacterial infections are most frequent, followed by viral and fungal infections
Vaccination is the most important tool in the prevention of infections.
Prophylaxis of tuberculosis and pneumocystosis are also recommended to
prevent those deadly infections.
66. TB and SLE:(From Journal of Clinical and Diagnostic Research)
SLE and TB are intricately related with an increase in the risk of TB in SLE.
There were case series of five female patients of SLE with TB who presented
between January 2015 and December 2015 in a tertiary care teaching
hospital in North Eastern India.
All the patients were young to middle aged females having SLE with or
without lupus nephritis who were on immunosuppressive therapy with
corticosteroids, mycophenolate mofetil or cyclophosphamide.
67. Two of the cases had sputum positive pulmonary tuberculosis
while rest had Extra-Pulmonary TB (EPTB).
The response to anti-tubercular therapy led to clinical
improvement in all the cases except one who had an adverse
outcome.
The series further substantiates the increased risk of TB in
SLE thus, prompting further research towards better
management of these two disease entities in conjunction.
68. SLE are prone to develop intercurrent infections because of:
(i) compliment deficiency;
(ii) mannose binding lectin (MBL) deficiency;
(iii) chronic inflammation and tissue damage; and
(iv) use of immunosuppressive therapy
69. TB is a common infection in SLE patients and the prevalence
of TB in patients with SLE ranges from 5% - 11.6% in studies
reported from India.
The incidence of TB in SLE patients is considered to be 15-
fold higher;
extra-pulmonary involvement and disseminated TB are more
common
70. differentiating disease flare from active TB disease in patients with
SLE based remains a challenge.
Evidence is available suggesting that monoclonal antibodies raised
against TB can cross react with DNA,
features of autoimmunity are evident in mycobacterium induced
arthritis in experimental models,and
detection of antibodies in patients with TB similar to that found in
SLE
71. In a study from Taiwan among 2721 patients with SLE
antecedent TB was present in 44 (1.8%) of patients;
TB patients were found to have an odds ratio of 2.09 for
subsequent development of SLE after controlling for other
potential risk factors.
Some even advocated isoniazid prophylaxis in patients with
SLE receiving long term corticosteroid treatment.
72. Follow up
At least quarterly visits recommended
CBC,sCr,U/A
Complement levels and anti-dsDNA as adjuncts to detect lupus
flares
Opportunistic infection detection
Contraception and Family planning
74. TAKEHOME MESSAGE
TB and SLE share several similar clinical manifestations
So, differentiating disease flare from active TB disease in
patients with SLE based on clinical manifestations alone
remains a challenge.
high index of suspicion and focussed evaluation in the
diagnosis of intercurrent infections, particularly, TB in patients
with SLE is crucial.
75. REFERENCES
HARRISON 20th Edition
EULAR 2019 Management of SLE
ACR and EULAR 2019 Classification criteria
UPTODATE 2018
Journals