Mrs. Vijaya, a 31-year-old housewife, presented with a 2-month history of fever, 45-day history of malar rash and headaches. Her examination found malar rash, macular erythema on palms and back, and lab tests showed positive ANA and anti-dsDNA antibodies. She met 4 of the 11 criteria for systemic lupus erythematosus (SLE). She was diagnosed with SLE and treated with methylprednisolone, azathioprine, and prednisolone, with improvement in her symptoms though she developed alopecia and GI symptoms.

1. FEVER FOR
EVALUATION
Dr N.Samatha,
(MD)INTERNAL MEDICINE

2. Chief complaints
• Mrs Vijaya, 31 yrs female, a House wife,
Presented on 12/12/2011 with C/O
Fever : 2 months
Malar rash : 45 days
Headache : 45 days

3. History of present illness
 Patient was apparently asymptomatic 2 months back
when she developed fever associated with generalised
body pains, rash on palms,back and arms, joint
pains, anorexia, sleeplessness and headache.
• Patient presented to a local hospital, treated
symptomatically, fever was relieved on medication and
was discharged.
• 10-15 days later she developed malar rash,and persistent
fever.
• Then, she presented to Esra hospital with fever and malar
rash.

4. History of present illness
• Fever was intermittent, low grade, on and off, no
chills/rigors, associated joint pains mostly involving large
joints[non migratory and non fleeting]
• From day1 of fever, she developed macular erythema on
palms, upperback and extensor aspect of arms and 10-15
days later she developed malar rash,which is slightly
raised erythematous rash on cheek and nose, precipitated
by sun exposure and non pruritic.
• No history S/O purpura, no orogenital eruptions or scaly
lesions on anyother part of the body.

5. History of present illness
• No past H/O exposure to C/O TB,mite bite,tick bite,or
exposure to rats or cats
• No history S/O malaria,chikungunya,dengue,typhoid
• No history of visual disturbances,altered sensorium & no
complaints S/O motor or sensory impairment
• No H/O cough or dyspnoea
• No history of drug allergy
• No H/O similar complaints in the past

6. Personal/family history
• Mixed diet,decreased appetite,decreased sleep
• Bowel and bladder habits regular
• Menstrual history-menarche at 13,cycles regular,4/30,no
dysmenorrhea,no clots
• No similar complaints in the family

7. General examination
• Patient is conscious, coherent, cooperative, comfortably
sitting on bed, well oriented to time, place & person
• Weight - 56kgs,BMI - 158 cms
• Pallor +,no icterus no cyanosis,no clubbing,no
lymphadenopathy,no pedal edema
• Normal hair
• Malar rash on face ,macular erythema on palms and
back,non-discoid,non blanchable
• No orogenital ulcers
• EYES appear normal O/E
• URT normal,no congestion or secretions noted

9. Physical examination
• Vitals ,BP 110/80, PR 80b/m,regular,normal
volume,character, all peripheral pulses felt.
Temp 100F , RR 16/min
• RS-BAE+,NVBS,no ADV sounds
• CVS-S1,S2 heard,no murmers
• P/A-soft ,no tenderness,no organomegaly,BS+
• CNS-NFND,Plantars-flexor
• Muskuloskeletal system examination-no swelling or
redness or tenderness over large or small joints,no
limitation of movements at joints,no pain,no stiffness

10. Provisional diagnosis
Pyrexia for evaluation
? Connective tissue disorder
? Granulomatous disease
? Enteric fever
? Malignancy

11. Investigations
CBP - HGB:10.7gm%,WBC-1,700/cu.mm, plt-
89,000,N69,M5,L10,E2
PS - Normocytic normochromic,leucopenia,lymphopenia
CUE - Pus cells-0-1,no rbc,no cystals,no casts
LFT - Sr bilirubin-1.08,SGOT-
134U/L, Sr albumin-
4.3gm/dl,ALP-WNL
RFT -NORMAL
Sr electrolytes - Sr Na-146/k-3.9/Cl-100
Chest xray - Normal
ESR -26/55mm

12. Investigations
VDRL- NR
Widal test- Negative
Dengue NS1 Ag &IgM, IgG -Negative
HBs Ag/Anti HAV/Anti HCV /Anti HEV- Negative
HIV - NR
USG ABD/Pelvis - Normal
ANA - POSITIVE(2.975)
Anti ds DNA Antibodies-positive(233IU/ml)

13. Criteria for SLE
1. MALAR RASH
2. Discoid Rash
3. PHOTOSENSITIVITY
4. Oral ulcers
5. Arthritis
6. Renal disorder
7. HEMATOLOGICAL DISORDER
8. Serositis
9. Neurological disorder
10. IMMUNOLOGICAL (Anti-Sm, and/or
anti-phospholipid, Anti dsDNA)
11. ANTINUCLEAR ANTIBODIES-ANA POSITIVE

14. Diagnosis
SYSTEMIC LUPUS ERYTHEMATOSIS

15. Management
Supportive therapy given,inj.methylprednisolone given,
At discharge, T.azathioprine,added at 2mg/kg/day, along
with oral prednisolone,40mg bid
At follow up, patient cell counts improved, rash faded
comparatively, but complained of alopecia,GI symptoms