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Similar to Systemic lupus erythematosus with Vasculitis.pptx
Systemic lupus erythematosus with Vasculitis.pptx
- 1. A 32-years-old Malewith Bluish Coloration of Fingers and Toes I
- 2. Particulars of thePatient • Md. Abdul Malek • 32 years • Farmer • Monohardi, Narsingdi • 25/09/2018
- 3. Background history • SLE(2012) • Bronchial asthma (2014)
- 4. Chief Complaints 1. Painand bluish coloration of all fingers and toes for 7 days 2. Bilateral leg swelling for 15 days.
- 5. History of PresentIllness • SLE (2012) - Mucocutaneous - Musculosketetal - Systemic features - Hb- 6.4, ESR-170, WBC-10900, Plt-291000 - ANA, Anti-ds DNA (+) - Coombs test (+) - Urine: Normal
- 6. History of PresentIllness • SLE ( May, 2012) - HCQ 300 mg - Paracetamol 1500 mg daily - Prednisolone 50 mg daily - Significant improvement
- 7. History of PresentIllness • SLE (2013-2014) - Lost to follow up - Mild intermittent exacerbation - HCQ 300mg , prednisolone 5 mg daily irregularly
- 8. History of PresentIllness • SLE (2014) - Flare of symptoms - Cough, SOB, wheeze - HB-8.5, ESR 98, MCV 73, MCH 23, RDW-CV 17.2 - Lupus flare with bronchial asthma - HCQ 300 mg daily - Prednisolone 25 mg daily - Salbutamol, salmetorol/ fluticasone inhaler - Montelukast 10mg daily
- 9. History of PresentIllness • SLE(2016-2018) - Irregular follow up and treatment - Intermittent exacerbation - No major organ involvement - HCQ 300mg , prednisolone 5 mg daily irregularly
- 10. History of PresentIllness • Bluish coloration of fingers and toes for 7 days – Acute, excruciating pain – Occurs simultaneously -- Progressive , become blackish over right great toe and left 2nd toe – No discharge, ulceration – No H/O trauma, Raynaud's phenomenon
- 11. Cont.. • Bilateral legswelling for 15 days - Gradual onset - Distal part of legs and feet - Has no shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, puffy face, decreased urine output, no history of jaundice cold intolerance
- 12.
- 13. Personal History • Nonsmoker, non alcoholic • Has no history of substance abuse and intravenous drug abuse
- 14. Family History There isno such type of illness in his family and no history of premature death.
- 15. Immunization history • 2016 -Pneumococcal (polysaccharide) - Influenza -Hepatitis B
- 16. Socio-economic History • Monthlyfamily income- 25,000 taka
- 17. General Examination • Alopecia •Anemia- (+) • Pulse-80b/min, peripheral pulses normal • BP-110/80 mm(Hg) • Resp. rate-14b/min • Temp-Normal • Cyanosis- fingers and toes • Edema present • BMI -20kg/m2 • JVP-normal
- 18. MSK system • Gait-Antalgic • Arms- -Pale with distal cyanosis, -Reduced temperature -MCP squeeze test (+) • Legs- - Fingers are pale with distal cyanosis - Blackish discoloration with line of demarcation- right great toe and left 2nd toe - Reduced temperature Spine –normal
- 19. Other System Cardiovascular ,Respiratory,Abdominal and Neurological--Normal
- 20.
- 21. Investigations 18/09/18 CBC Hb WBC N L E Platelets MCV MCH MCHC RDW-CV 9.8gm/dl 10,700/cumm 67% 25% 6% 470000/cumm 73.5 fl 23.8pg 32.5gm/dl 16% ESR 101 mm in 1st hr Urine R/M/E Normal
- 22. Investigation 19/09/18 S. creatinine0.96mg/dl ALT 19U/L 23/09/18 Anti cardiolipin Ig G Negative Anti cardiolipin Ig M Negative
- 23. Investigation 24/09/18 Duplex studyof both lower limbs Normal blood flow was observed in all arteries of left/ right lower limb. Varicose veins of left /right lower limb Chronic venous insufficiency APTT 30 sec
- 24. Investigations 27/09/18 CBC Hb. WBC N L E Platelets MCV MCHC MCH RDW-CV 9.3gm/dl 12500/cumm 66% 18% 12% 380000/cumm 72.1 fl 33.3g/dl 24pg 16.4 % ESR 100 mm in 1st hr PBF Microcytic hypochromic anemia, Neutrophilic leukocytosis
- 25. Investigation 01/10/18 Bilirubin Total 0.4mg/dl Direct 0.3 mg/dl Indirect 0.1 mg/dl Reticulocyte 1.23% (˂2.5%) Iron 17 µg/dl (31-144 µg/dl ) Ferritin 544.86 ng/dl (12-300 ng/dl) TIBC 196 µg/dl (110-370 µg/dl ) TSAT 8.67 C3 o.191 g/l (0.9- 1.8 g/dl) C4 <0.0655 g/l (0.1-0.4 g/dl)
- 26. 27/09/18 FBS 3.9 mmol/l 2hrsafter 75gm glucose 6.4 mmol/l Lipid profile TC HDL LDL TG 100 mg/dl 21mg/dl 61 mg/dl 90 mg/dl HBsAg Negative Anti HBc Negative
- 27. Investigation 27/09/18 ECG Normal EchocardiographyGood LV systolic function
- 28. Investigation 29/09/18 Anti-ds-DNA CRP 110.2U/ml (< 30U/ml= negative) 152.0 mg/L ( < 6mg/L) 30/09/18 Chest X- ray P/A view Cardiomegaly (mild)
- 29.
- 30.
- 31. Nail-fold capillaroscopy • Capillarydropout (4-5/mm) • Haemorrhage (multiple) • Neovascularization • Elongated capillaries
- 32.
- 33. Hospital course • LMWheparin with Warfarin 5mg • Prednisolone 1 mg /kg • Indomethacin 150 mg /day • Calcium, vit- D • Vaccination -Pneumococcal conjugate - Influenza Ferrous sulphate, Ascorbic acid
- 34. PROVISIONAL DIAGNOSIS SLE withvasculitis DIFFERENTIAL DIAGNOSIS SLE WITH APS
- 35.
- 36. • Report pending Lupusanticoagulant D-dimer
- 37. SLE with vasculitis Pointsin favor Points against Simultaneous involvement of all four limbs Presence of cyanosis and gangrene High disease activity of SLE Normal peripheral pulses High CRP
- 38. SLE with APS Pointsin favour Points against Simultaneous involvement of all four limbs Presence of cyanosis and gangrene High CRP
- 39.