Welcome to Clinical Meeting

Presented by DR. Dhiraj Chandra Biswas DR. Amlendra K. Yadav Resident (phase-A)

Particulars of the Patient

Name : NUPUR Age : 10 years Sex : Female Address :

Noaokhali Reg. no. : 550/02 Date of Admission :18/06/2014 Date of examination :18/06/2014 Informant : Mother

Chief Complaints

Fever for 4 months. Pain over multiple Joints for same duration. Rash all over body for same duration.

History of Present illness

According to the statement of informant mother, her child was reasonably well 4 months back, then she developed fever which was high grade, intermittent in nature, highest recorded temperature was 1030F, not associated with chills and rigors but subsided after taking antipyretics.

Contd……………

She also developed pain over multiple joints which first appeared both knee joint followed by both ankle, both wrist, elbow and small joints of hand and feet. Pain was non-migratory in nature, associated with morning stiffness lasting for 10- 20 minutes.

Contd……………

She also developed rash all over the body for last 4 months which appeared first over cheeks, nasal bridge but spared the nasolabial fold, then on both upper and lower extremities, chest and abdomen which were non pruritic in nature. On query, mother gave h/o of red color urine and painless oral ulceration.

Contd…………… She had no history of joint swelling,

photosensitivity, hair loss, respiratory distress, abdominal discomfort, headache or convulsion.

For these above mentioned complain she was treated in Dhaka sishu hospital with NSAIDs, antibiotics, hydroxychloroquine and 2 unit blood transfusion 2 months back but condition did not improved.

Contd……………

As the condition of child did not improve she was referred to BSMMU for further evaluation and management .

Birth History Antenatal History: Mother was on regular Ante natal

check up.

Natal history: Delivered at term at home by NVD.

Postnatal History: Uneventful. Cried immediately after birth.

Immunization History Immunized as per EPI schedule.

Milestones of Development Age appropriate.

Feeding History On normal family diet .

Family History She is the 4th issue of her parents.

other family members are healthy .

Socio-Economical History

Belongs to low socio-economical background, father is a farmer, stay in kacha house and drinks tub-well water.

Physical ExaminationGeneral Appearance : Ill-looking. Pallor : Moderately pale Edema Jaundice Cyanosis Clubbing Absent Koilonychias Dehydration

Neck vein : Not engorged

Lymph Node :- Not enlarged

Skin survey : – BCG scar mark present. Erythematous rash present over cheeks and nasal bridge sparing nasolabial fold and some blackish rash on both upper and lower extremities, chest and abdomen which are non palpable and does not blanch on pressure.

Signs of meningeal irritation : – Absent.

Bony tenderness : – Absent

Bed side urine for albumin : Nil

Vital Signs Temperature – 101o F

H.R – 110 beats /min

B.P – 120/90 mmHg (lies above 95th centile)

R.R – 28 breaths /min

ANTHROPOMETRY:

Weight - 22 kg ( 3rd to 5th centile)

Height - 126cm ( 3rd to 5th centile)

Systemic Examination

Locomotor system Look: No swelling , no deformity or muscle

wasting, position of the limb normal.

Feel: Tenderness present (grade 2/4) over B/L knee joint ,ankle joint , elbow joint and meta-tarsophalengeal joint.

Move: Movement of all joint are restricted.

Other Systemic examination reveals normal

Gastrointestinal System

Oral cavity :– Multiple oral ulceration present. Abdomen :- Soft , not distended , non-tender,

umbilicus centrally placed & inverted,

Liver and spleen not palpable.

Shifting dullness absent.

Bowel sound present.

RESPIRATORY SYSTEM Inspection

• Shape of the chest : normal• R/R : 28 breaths/min• Visible vein & Pulsation : absent

Palpation• Trachea : centrally placed• Apex beat : left 5th ICS, medial to midclavicular line

Percussion note Resonant all over the lung fields

Auscultation Breath sound : Vesicular Added sound : Absent Vocal resonance : Normal & symmetrical

CARDIOVASCULAR SYSTEM

Inspection:• No visible pulsation

Palpation:• Thrill : Absent • P2 : Not palpable• Apex beat : left 5th ICS medial to midclavicular line• Lt. parasternal heave : Absent

Auscultation:• 1st & 2nd heart sounds audible in all 4 areas Murmur : Absent

Genito urinary system

Kidney – Both kidney not ballot able

renal angle – non-tender

Bladder – Not palpable

Salient Features

Nupur , 10yrs old female child 4th issue of non-consanguineous parent got admitted with a complaints of high grade intermittent fever and pain over multiple joints with Haematuria and oral ulceration for last 4 months . She also developed non-pruritic rash over face, trunk and extremities.

Salient Features contd………..

For that she had treated with NSAIDs , antibiotics, hydroxychloroquine and 2 unit blood transfusion but condition did not improved. She had no history of joint swelling, photosensitivity, hair loss, respiratory distress, abdominal discomfort, headache or convulsion

Salient Features contd………..

O/G/E- Patient was ill llooking, febrile, moderately pale, multiple painless ulceration present .

Skin survey : Erythematous rash present over cheeks and nasal bridge sparing nasolabial fold and some blackish rash on both upper and lower extremities, chest and abdomen which are non palpable and does not blanch on pressure.

Salient Features contd………..

Bed side urine for albumin= nil. Vitals: temperature 101o F, She is hypertensive. Systemic examination: Locomotors system

examination reveals arthalgia present. Other systemic examination- normal.

Provisional Diagnosis

???

Provisional Diagnosis

Systemic Lupus Erythematous (SLE)

Differential diagnosis

Systemic onset JIA

Point in favor Point against

SLE

• Female child• Fever • Arthralgia • Typical rash• Oral Ulcer• Hematuria• Hypertension

SOJIA

• Age less than 16 years • Intermittent fever • Arthralgia

No characteristics rash

INVESTIGATION

CBC Test Date 19/06/2014

Hb% 6.8 g/dl

ESR 10 mm in 1st hour

Total count of WBC 4500 cumm

Neutrophil 70%

Lymphocyte 27%

Platelet count 3,50,000 cumm

CRP < 6 mg/dl

Blood Group AB Positive

CBC

Test Date 19/06/2014

ANA Positive

Anti-ds-DNA 154.5 U/ml ( positive )

Coomb’s Test Positive

C3 level 0.093 g/l ( decreased )

C4 level 0.317 g/l ( decreased )

SGPT 24 U/L

S. Creatinine 0.6 mg/dl

Chest X-ray Normal Findings

On 21/06/2014

MT 02 mm

Blood culture No growth of bacteria

Urine R/M/E Pus cell – (6-7)/hpf RBC - (10-15)/hpf

Urine Culture No bacterial growth

UTP 0.94 gm/day

UTV 1200 ml/day

HBsAG Negative

PT 12.6 sec

APTT 41.6 sec

Final diagnosis

SLE with Lupus Nephritis

Management

Counseling: About the nature and future of the disease Renal Biopsy Diet

Drug therapy: IVF – 10% dextrose IV antibiotics ( Inj. Ceftriaxone ) Tab. Hydroxychloroquine Tab. Naproxen Tab. Ranitidine Tab. Paracetamol Tab. Calcium with Vitamin D Tab. Folic acid Tab. Captopril

Follow up

F/U On25.6.2014

Subjective Objective Assessment Plan

Fever still persistOral mucosal ulcer present

Ill- looking, mildly pale, FebrileRR – 24/minHR – 96/minBP – 90/60mmhgBSUA - Nil

Not improving Continue antibiotics & plan to start inj. Methylprednisolone and Inj. Amikacin

Subjective Objective Assessment Plan

No new complain(Fever subsided)

Well, allert , afebrile Vitals within normal limit BSUA – nil

Improving Started oral prednisolone and cyclophosphamide

F/U On 29.6.2014

Thank You..