1. This case discusses a 45-year-old female patient presenting with progressive breathlessness, swelling of the lower limbs, and hard nodules on the palms and soles.
2. Differential diagnoses considered include mixed connective tissue disease, lupus, scleroderma, and rheumatoid arthritis.
3. Investigations revealed a strongly positive ANA, elevated markers of inflammation, interstitial lung disease, pulmonary hypertension, and features consistent with calcinosis cutis.
4. The final diagnosis was mixed connective tissue disease with interstitial lung disease, pulmonary hypertension, and calcinosis cutis. Management involves immunosuppressants like corticosteroids and
Weekly Case Presentation. Department of Medicine. EMCH.
Case: Tuberculous Pleural Effusion.
Our case this week (Nov. 5th, 2017) was 19 year old male presenting with fever, weight loss and cough for a prolonged duration. By means of proper history taking, physical evaluation and clinical investigation we have tried to adequately manage the case and it was presented before an audience comprising of clinical students to professors at our institute.
P.S. This presentation was made by interns of the institute. Hope any mistakes or faults will be met with constructive criticism as we look forward to improving ourselves.
Thank you.
Rheumatic fever- a multifactorial disease that follows GAS pharyngitis in a susceptible individual who lives under deprived social conditions, characterized by acute inflammation of the heart, joints, skin, subcutaneous tissue & CNS, that gives rise to typical clinical feature including Arthritis, Carditis, Chorea, Subcutaneous nodules & Erythema marginatum.
Latent period of 2-3 weeks following GAS pharangitis.
Destructive effects on heart valves leads to RHD with serious hemodynamic disturbances causing HF, stroke & infective endocarditis.
Weekly Case Presentation. Department of Medicine. EMCH.
Case: Tuberculous Pleural Effusion.
Our case this week (Nov. 5th, 2017) was 19 year old male presenting with fever, weight loss and cough for a prolonged duration. By means of proper history taking, physical evaluation and clinical investigation we have tried to adequately manage the case and it was presented before an audience comprising of clinical students to professors at our institute.
P.S. This presentation was made by interns of the institute. Hope any mistakes or faults will be met with constructive criticism as we look forward to improving ourselves.
Thank you.
Rheumatic fever- a multifactorial disease that follows GAS pharyngitis in a susceptible individual who lives under deprived social conditions, characterized by acute inflammation of the heart, joints, skin, subcutaneous tissue & CNS, that gives rise to typical clinical feature including Arthritis, Carditis, Chorea, Subcutaneous nodules & Erythema marginatum.
Latent period of 2-3 weeks following GAS pharangitis.
Destructive effects on heart valves leads to RHD with serious hemodynamic disturbances causing HF, stroke & infective endocarditis.
Case Report : Integrating Review Inflammation and Commorbid diseasesSoroy Lardo
Diabetes is associated with atherosclerosis and COPD contributed to the chronic inflammation within the systemic vascular. Management of CVI with diabetes and COPD requires multi-disciplinary approach
A case presentation and discussion of TB Meningitis presented in a Tertiary Care Hospital ER. Includes presenting complaints, work-up, diagnosis and relevant case discussion.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
2. Case History
45 year female, R/o Nana peth, Pune
Came with
c/o Progressive breathlessness since last 6 months
c/o Swelling over both lower limbs since 1 month
Breathlessness gradually increased from NYHA GRADE I to
GRADE IV. It was more on recumbent position.
H/o orthopnea +
H/o joint pains on and off in past,
H/o myalgia and body ache.
3. No h/o chest pain, palpitations
cough with expectoration
fever, rash or oral ulceration
decreased urine output.
swelling of joints or joint stiffness.
• Past history:
No h/o Tuberculosis, DM, HTN, COPD in past.
No history s/o rheumatic fever in childhood.
4. • Family history:
No h/o similar illness in family, no h/o Koch's contact.
• Personal history:
No any addictions, Sleep-disturbed
• Menstrual history:
H/o menopause at the age of 40 yrs.
No postmenopausal bleeding.
5. • GENERAL EXAMINATION:
Afebrile
P- 96/min irregular, all peripheral pulses well felt
No radiofemoral delay.
BP- 130/80mm Hg
Pallor +
Pedal edema + pitting type
No icterus/clubbing /cyanosis/lymphadenopathy.
JVP- Raised.
Raised hard nontender nodules with ulceration discharging
whitish granular discharge from it present over palms ,
soles and digits.
6. • SYSTEMIC EXAMINATION
• CVS:
Inspection: Precordium normal.
Apical impulse seen Lt 5th ICS In Ant. axillary line.
Palpation: Apex beat felt in Lt 5th ICS in Ant. axillary line.
Left parasternal heave+
Asculatation: S1 audible, P2 loud
PSM + in TA.
ESM+ in PA
7. • RS: B/I crepts + in IMA, IAA, ISA
B/l scattered inspiratory ronchi heard all over chest.
• P/A: Soft ,nontender.
Liver 2 cm palpable, nonpulsatile, No splenomegaly.
• CNS: No signifiacant abnormality.
25. Final diagnosis….
Case of Mixed connective tissue disease with
ILD with severe Pulmonary hypertension
with Corpulmonale with Calcinosis cutis
26. DISCUSSION…. MCTD..
• Overlap syndrome consisting of SLE, systemic
sclerosis, RA, and polymyositis
• These overlap features seldom occur concurrently
• “The crux of the MCTD diagnosis is the presence of
high titers of antibodies to U1-RNP”
• The first clue to diagnosing MCTD is usually a positive
ANA with a high titer speckled pattern.
• Four different diagnostic criteria have been proposed
–
–
–
–
Sharp
Kasukawa
Alarcon-Segovia
Kahn
27. Diagnosis….Sharp’s criterias
Major Criterias
Minor Criterias
Myositis
Pulmonary Involvement
Reynaud's phenomenon
or esophageal dysmotility
Swollen hands or
sclerodactyly
High anti-U1-RNP with
negative anti-Sm
Definite – 4 major (including serology)
Probable – 3 major or 2 major (1st 3
listed) and 2 minor; and serology
Alopecia
Leucopenia
Anemia
Thrombocytopenia
Pleuritis
Pericarditis
Arthritis
Trigeminal Neuralgia
Malar Rash
29. Pulmonary Manifestations….
• Pleural Effusions
The most discriminatory
• Pulmonary Hypertension
lung function test is DLCO.
• Pleuritic Pain
• Interstitial Lung Disease (30-
50%)
High-resolution CT is
the most sensitive test to
determine the presence
of ILD in MCTD.
• Thromboembolic Disease
The major cause of
• Obstructive Disease
death in MCTD is
• Pulmonary Vasculitis
Pulmonary Hypertension
30. Pericardial Disease….
Pericardial Involvement
Scleroderma 59%
SLE
44%
RA
24%
MCTD
30%
ECG : abnormal in
20 % of cases .
RVH, Intraventricular
conduction defects.
MCTD
At autopsy – 56% had pericardial disease
Asymptomatic pericardial effusion – 24-38%
31. Renal involvement….
• 25% of cases
• Glomerulonephritis, nephrotic syndrome, scleroderma renal
crisis, amyloidosis and renal infarcts
• High titer of anti-U1RNP are relatively protective against the
development diffuse proliferative GN.
• When pt do develop renal change,they usually develop
membranous GN
32. Other systems…
GASTROINTESTINAL
Occurring in 60-80
% of patient
Gastroesophageal
reflux, dyspepsia,
dysphagia.
Autoimmune
hepatitis
JOINTS
Arthritis
(Polyarticular)
Juxtraarticular
osteopenia,erosive
arthritis, digital tuft
resorption
HAEMATOLOGY
Anemia of chronic disease,
Thrombocytopenia,
autoimmune hemolytic anemia.
RF: Positive in 50% of patients.
CNS
Trigeminal
neuropathy(MC),
Headache
Angiographic study
reported a high
prevalence of
medium-size vessel
occlusion.
33. Laboratory Findings….
High titre, speckled ANA pattern
Leucopenia, anemia, thrombocytopenia
Elevated ESR
High titre U1 RNP antibody.
Complement levels usually normal or high
Rheumatoid Factor positive in 70% of patients
Negative findings include anti-dsDNA and anti-Sm antibodies
(if positive, it may represents exclusion criteria for MCTD)
35. Management ….
Immunosuppressants
Corticosteroids and cytotoxic agents, most often
cyclophosphamide, are the most frequently used.
Recommendation for management are based on
conventional treatment for SLE, PM,DM,RA and Scl
Drug therapy:CCBs
Prostaglandins
Editor's Notes
Extensive soft tissue calcification involving thumb b/l index n little finger region, destruction and necroosteolysis seen in left distal phalanx. Flexion deformity seen in rt proximal and distal interphalyngeal joint. Imp. Findings are consistent with connective tissue disorder/ calcinosis cutis
Multiple descrete tender hard white coloured nodules present over bilateral fingers ,great toe,
Emphysematous changes in the form of pathy areas of air trapping with few areas of centriacinar emphysema in bilateral lung fields, subtle fibrotic changes in rt middle lobe, pulmonary hypertension with cardiomegaly
Areas of fibrosis
Section studied shows tissue lined by hyperkeratotic and hyperplastic stratified squamous epithelium and subepithelium shows areas of dystrophic calcificationIMP: Calcinosis cutis
Emphysematous changes in the form of pathy areas of air trapping with few areas of centriacinar emphysema in bilateral lung fields, subtle fibrotic changes in rt middle lobe, pulmonary hypertension with cardiomegaly
Emphysematous changes in the form of pathy areas of air trapping with few areas of centriacinar emphysema in bilateral lung fields, subtle fibrotic changes in rt middle lobe, pulmonary hypertension with cardiomegaly
Emphysematous changes in the form of pathy areas of air trapping with few areas of centriacinar emphysema in bilateral lung fields, subtle fibrotic changes in rt middle lobe, pulmonary hypertension with cardiomegaly