This document presents a case study of a 36-year-old female patient diagnosed with pemphigus vulgaris, an autoimmune blistering disease of the skin and mucous membranes. The patient presented with fluid-filled lesions over her trunk and extremities that ruptured and formed erosions. A biopsy, Tzank smear, and immunofluorescence testing confirmed the diagnosis of pemphigus vulgaris. She was treated with corticosteroids, immunosuppressants, antibiotics, and supportive care. Her hospital course was monitored for treatment responses and adverse drug reactions.

1. PEMPHIGUS VULGARIS
A CASE PRESENTATION BY,
ZAHED ULLA KHAN,
Pharm.D Intern,
H.S.K College of Pharmacy
SNMC & H.S.K Hospital and research centre,
Bagalkote.

2. AUTOIMMUNE
VESCICULOBULLOUS
DERMATOLOGICAL MANIFESTATION AFFECTIING EPIDERMIS
CHARECTERIZED BY ACANTHOLYSIS
INTRODUCTION

3. AUTOIMMUNE
ACCOUNTS FOR 70% OF PEMPHIGUS SPECTRUM
DUE TO IGG ANTIBODIES
ALL GENDERS EQUALLY AFFECTED
MEAN AGE IS 30-45 Years
RARELY SEEN IN CHILDERN
RARELY DRUG INDUCED (MAY BE DUE TO PENICILLIN, ACE INHIBITORS)
JEWS, INDIANS,MEDITERANIAN POPULATION
INCIDENCE RATE: 0.5-3.3/Yr, PER 100,000 POPULATION (1)
AETIOLOGY AND EPIDEMIOLOGY

4. GENETIC PREDISPOSITION
HERPES INFECTION
UNDERLAYING AUTO IMMUNE DISORDER
DRUG SENSITIVITY (RARE)
RADIATION
RISK FACTORS

5. PATHOPHYSIOLOGY
RUPTURE OF JUNCTIONS
RELEASE OF CELLULAR FLUID
FORMATION OF BULLA
RUPTURE LEADING TO EROSION
SEPSIS

6. CUTANEOUS EXAMINATION ( NIKOLOSKY’S AND INDIRECT NIKOLOSKY’S)
BIOPSY TZANK SMEAR IMMUNOFLUROSCENCE
DIAGNOSIS

7. Demiographic Data
Name: Mrs. RSG Age: 36
Sex :F
Dept. SKIN Unit : A
DOA: 6/01/2022 DOD: 27/01/2022
CASE PRESENTATION:

8. C/O FLUID FILLED LESION SINCE 1 YEAR, INSOIDIOUS AND PROGRESSIVE
REASON FOR ADMISSION

9. NOT K/C/O HTn, DM, TB, EPILEPSY
PAST MEDICAL HISTORY

10. THE PATIENT WAS APPARENTLY ALRIGHT ONE YEAR AGO, THEN DEVELOPED FLUID FILLED LESION OVER TRUNK,AND
ON UPPER EXTRMITIES WHICH WERE SPREADING
THE BULLAE LATER RUPTURED TO FORM EROSIONS ASSOCIATED WITH A FEW CRUSTED LESIONS OVER BODY
EROSION + OVER MOUTH AND PALATE
NO Hx OF IBR, DRUG INTAKE, PHOTOSENSITIVITY, JOINT PAIN, WEIGHTLOSS, RASH.
HISTORY OF PRESENT ILLNESS

11. NAD
SOCIO FAMILIAL HISTORY

12. Moderately built and nourished
Conscious and oriented
PICCLE : -ve
B.P – 120/80 mmhg
P.R - 80 bpm
GENERAL PHYSICAL EXAMINATION

13. CVS :
RS:
NAD
CNS :
P/A:
SYSTEMIC EXAMINATION

14. MULTIPLE EROSIONS +OVER TRUNK, EXTREMITIES, BACK, FACE, AND A FEW LESIONS WERE WITH THICK
CRUST.
MULTIPLE EROSION + ORAL MUCOSA
NAIL, HAIR, GENITAL MUCOSA : NORMAL.
CUTANEOUS EXAMINATION

15. CBC
RBS, LFT
RFT
Sr.ELECTROLYTES
ECG
HIV
INVESTIGATIONS

16. OBSERVATIONS
INVESTIGATION OBSERVED VALUE NORMAL VALUE
Hb (g/dl) 12.8 12.0-16.0
WBC (CELLS/Ul) 11,800 4500-10500
Polymorphs% 80% 40-70
Basophiles% 00 0-1
Eosinophiles% 02 0-5
Lymphocytes% 15 20-40
Monocytes% 00 0-7
RBC (mill/uL) 3.97 4,2-5.4
PLT (Cells/Cumm) 2,37,000 1,50,000-4,50,000

17. IVESTIGATION OBSERVED VALUE NORMAL RANGE
Sr. Urea 19.0 mg/dl 15-30 mg/dl
Sr. creteatinine 0.6 mg/dl 0.6-1.2 mg/dl
ALT 10.0 U/L 6-38 U/L
AST 24.0 U/L 6-40 U/L
ALP 35-140 U/L 323.0 U/L
TOTAL BILIRUBIN O.6 mg/dl 0.2-1.o mg/dl
Direct
Indirect
0.2
0.4
1- 0.4 mg%
1 – 0.6 mg%
RBS 180.0 60-140 mg/dl

18. ECG: SINUS TACHYCARDIA
HIV : NEGETIVE

19. BRAND NAME GENERIC NAME DOSE &
ROUTE
FREQUENCY DAY
1
2 3 4 5 6
Inj.dexona Dexamethasone 2cc iv 1-0-1 y y y ______ stop ______
inj.Augmentin Amoxicillin+ Clavunalic
acid
625 mg 1-0-1 y y y y y STOP
Inj.NS withMVI Multi vitamin 1ampule in
100ml ns
0-1-0 y y y y y y
Propygenta cream Clobetasol 0.5%
Salycylic acid0.3%
Q.S
topical
0-0-1 Y Y Y Y STOP
Kenocort cream Triamcinolone Q.S Mucosal 1-1-1 y y y y y y
Tab. Phosmid Cyclophopsphamide 50 mg
P/O
1-0-0 y y y y
Gentian violet solution Gentian violet Q.S 1-0-1 Y Y y y
Inj.Avil Pheniramine maleate 1cc IV 0-0-1Y Y Y Y
Inj. Dexona Dexamethasone 2cc-0-1cc
iv
1-0-1 y y STOP
Inj.Actrapid H.Insulin Acc.S.C S/C As Needed y y SKIP
Inj.Zulig Tigecycline 50mg iv 1-0-1 y
Inj.Dexona Dexamethasone 2cc Iv 1-0-0 y
TREATMENT CHART

20. PEMPHIGUS VULGARIS
FINAL DIAGNOSIS

21. The patient was followed up till discharge and her stay was comfortable.
Soon after starting Dexamehasone, The parient developed Hyperglycemia which was treated by Insulin according to
Sliding scale, She also experienced Aloepecia which was due to Cyclophosphamide,
The patient was counselled to have plenty of water post ingestion of Cyclophosphamide to reduce the severity.
Follow up

22. CARE PLAN

23. SUBJECTIVE EVIDENCE
FLUID FILLED LESION OVER TRUNK,AND ON UPPER EXTRMITIES WHICH WERE
SPREADING
THE BULLAE LATER RUPTURED TO FORM EROSIONS
ASSOCIATED WITH A FEW CRUSTED LESIONS OVER BODY
EROSION + OVER MOUTH AND PALATE

24. RBS- 180 Mg/dl
W.B.C -11,800
Sr.Na+ - 128.0
Multiple bulla + all over body
Immuno fluroscence : +ve for Pemphigus vulgaris
OBJECTIVE EVIDENCE

25. Based on Subjective and objective evidence, the patient is diagnosed to be having
“PEMPHIGUS VULGARIS”
ASSESSMENT

26. GOALS:
1) Relieve burning sensation
2) Prevent further bulla formation
3) Provide symptomatic relief
4) Monitor for any adverse events
5) Avoid further sepsis
CARE PLAN

27. RBS
NIKOLSKYS SIGN
NEW BULLA
ELECTROLYTES
DIFFRENTIALS
Monitoring Parameters

28. TWO ADVERSE DRUG REACTIONS WERE FOUND
1) DEXAMETHASONE INDUCED HYPERGYCEMIA
MANAGED BY DOSE ADJUSTMENT AND INSULIN THERAPY
PHARMACIST INTERVENTION

29. 2) CYCLOPHOSPHAMIDE INDUCED ALOPECIA
DAY 1 DAY 2 DAY 3

30. NO DRUG-DRUG INTERACTIONS FOUND
NO MAJOR INTERVENTIONS NEEDED
PHARMACOECONOMIC MANAGEMENT OF TIGICYCLINE DONE.

31. ABOUT DRUGS
CYCLOPHOSPHAMIDE INDUCED ALOPECIA IS REVERSIBLE,
USE GLOVES WHILE APLLYING GENTIAN VIOLET
KENOCORT ISNT HARMFUL EVEN IF SWALLOWED
IN CASE OF ANY ADVERSE EVENT, NOTIFY THE NURSR/ PYSICIAN/PHARMACIST IMMIDIATELY
ABOUT DISEASE:
PV IS AN AUTOIMMUNE DISORDER WHICH ARISES DUE TO INTERNAL LACK OF IMMUNO IDENDTIFICATION.
IT IS NOT ANY KIND OF PUNISHMENT FOR DEEDS
THE DISEASE IS MANAGABLE WITH MAXIMUM RESTORATION OF ACTIVITY
UNFORTUNATELY THERE IS NO PERMANENT CURE>
PATIENT COUNSELING

32. MINIMIZE SUN EXPOSURE/ USE SUNSCREEN IF NECESSARY
AVOID GARLIC, LEEKS AND OTHER IMMUNO STIMULANTS
TAKE PLENATY OF WATER WHILE USING CYCLOPHOPHAMIDE
USE SOFT CLOTHING
PLANTAIN LEAVES CAN BE USED INDTEAD OF BEDCOVERS
LOOK FOR BED SORES
MILD EXERCISE IS DESIRABLE
LIFE STYLE MODIFICATIONS

33. ANY QUESTIONS???

34. THANK YOU!!!