CASE PRESENTATION

SLE with Depression

By-Nagaraju B

dr.bnr2011@gmail.com

Patient Name -XXXIP No -13305/13DOA - 1/12/13DOD - 3/12/13Department - MedUnit -IVAge - 31yearsSex - FemaleWeight - 56kgs, Height - 158 cms

SUBJECTIVECHIEF COMPLAINT:with c/o Sadness: 3monthsFever : 2 months Malar rash : 45 days Headache : 45 daysHISTORY OF PRESENTING ILLNESS:* Patient with sadness ,low mood , loss of interest, decreased sleep , suicidal tendency for 3 months* Patient was apparently asymptomatic 2 months back when she developed fever associated with generalized 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 rushed to KIMS hospital with fever and malar rash.

HISTORY OF PRESENTING 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 day-1 of fever, she developed macular erythema on palms, upper back 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 s/o purpuria , no oro-genital eruptions or scaly lesions on another part of the body.

PREVIOUS HISTORY: No h/o DM/HTN/TB/Asthma/Epilepsy. Mother expired 3 months

back. Feels guilt and herself responsible for the event married since 1 year

PASTMEDICATIONHISTORY/ALLERGY:

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 dyspnea No history of drug allergy No h/o similar complaints in the past.

FAMILY HISTORY:

No f/h/o DM, HTN, ASTHAMA, TB H/o Frequent quarrel with husband H/o Skipping meals H/o Crying always at home H/o Suicidal tendency (CONSUMING TABLETS) Interpersonal problems with her husband and mother-in-law

PERSONAL HISTORY: Diet-Mixed; Appetite-Decreased; Sleep-DecreasedBowel-Regular; Bladder-Normal; Habits-NoneMenstrual history-menarche at 13, cycles regular, 4/30, no dysmenorrhea, no clots. No similar complaints in the family

OBJECTIVEPHYSICAL EXAMINATION :Patient is conscious, coherent, cooperative, comfortably sitting on bed, well oriented to time, place & person. Normal hair Malar rash on face ,macular erythema on palms and back, non-discoid, non-bleachable. No oro-genital ulcers.

Eyes appear normal. O/e URT normal. No congestion or secretions noted

VITAL SIGNS:BP - 110/80mmHg PR - 80 bpmRR - 16cpm Temp- 100°F.

P[+], I[-], C[-], C[-], L[-], E[-]

SYSTEMS :P/A - soft ,no tenderness, no organomegaly, BS+ RS- NVBS+, no Adv sounds CVS - S1,S2 heard, no murmurs CNS -NormalMuskulo-skeletal system examination-no swelling or redness or tenderness over large or small joints, no limitation of movements at joints, no pain, no stiffness 

PROVISIONAL DIAGNOSIS :Depression with? Pyrexia? Connective tissue disorder ? Granulomatous disease for evaluation ? Enteric fever ? Malignancy

TEST TEST VALUE NORMAL VALUE

Hb (g/dl) 10.7% 13-18

ESR 28 0-20

Total leucocytes counts (cells/cmm)

1,700/cu.mm 4000-11000

N (%) 69% 40-75

L (%) 10% 20-45

E (%) 10% 1-6

M (%) 5% 2-10

B (%) 6% 0-1

Platelets (cells/cmm) 89,000 1.5-4.0 lakh/cmm

Bl. U (mg/dl) 17mg/dl 12-40mg/dl

Sr. Cr (mg/dl) 0.8mg/dl 0.2-1.4mg/dl

Urine Routine Sugar: Nil Albumin: +

Urine Microscopy Pc: 0-1 Ep: 1-2 cells

LABORATORY INVESTIGATIONS

TEST TEST VALUE NORMAL VALUE

LFT

TB 1.08mg/dl 0.4-1.2 mg/dl

DB 0.2mg/dl Up to 0.4 mg/dl

AST/SGOT 14.5iu/L 8-40 iu/L

ALT/SGPT 16.8iu/L 8-40 iu/L

ALP 91iu/L Up to 120iu/L

Total protein 6.6-8.3 gm/dl

Albumin 4.3g/dl 3.5-5 .5 gm/dl

Globulin 2.4g/dl 2.3-3.5 gm/dl

Urine RoutineUrine Microscopy

Sugar: Nil Albumin: +

Pc: 0-1 Ep: 1-2 cells

TEST TEST VALUE NORMAL VALUE

Ser. Cl- 100 Up to 103 mEq/L

Ser. Na+ 145 136-145mmol/L

Ser. K+ 3.3 3.5-5.1 mmol/L

PS - Normocytic normochromic, leucopenia, lymphopenia

VDRL Non-reactive

Widal Negative

HBsAg/HAV/HCV/HEV/HIV Negative

Dengue card& serology Negative

ANA - POSITIVE (2.975)

Anti ds DNA Antibodies- Positive (233 iu/ml)

CXR/USG-Abd&Pelvis NAD

ASSESMENT

Based on the subjective & objective evidence the patient was diagnosed to have SYSTEMIC LUPUS ERYTHEMATOSIS with DEPRESSION

GOALS OF TREATMENT

To prevent recurrence (depression) Eliminate depression with complete remission of

symptoms Treatment include management of acute and chronic Goals are preventing progressive loss of organ

function, minimizing disease disabilities, preventing complication from therapy.

BRAND NAME GENEROIC NAME DOSE FREQUENCY

DATE DATE END

Inj. Solumedrol Methyl Prednisolone 1g iv 0-1-0 1/12 3/12

Inj Lorzep Lorazepam 2mg iv sos 1/12 3/12

MEDICINE ON DISCHARGE

Tab. Wysolone Prednisolone 40mg 1-0-1 4/12 15/12

Tab. Azoran Azathioprine 50mg 1-0-1 4/12 15/12

Tab. Clozep Clonazepam 0.5mg 0-0-1 4/12 15/12

MEDICINE ON REVIEW DT: 16/12/13

Tab. Azoran Azathioprine 50mg 1-0-1 16/12 30/12

Tab. Wysolone Prednisolone 40mg 1-0-1 16/12 30/12

Tab. Pantodac Pantoprazole 40mg 1-0-1 16/12 30/12

Tab Nexito Escitalopram 10mg 1-0-1 16/12 30/12

MEDICATION CHART

PROGRESS NOTE:From Day-1 to 3:Patient was feeling better from Day-3.Patient was discharged and advised to take Azathioprine 5omg, Clonazepam 0.5mg and Prednisolone 40mg for 2 weeks.

At Review on 16/12/13:Patient cell count improved, rash faded comparatively, but complained alopecia, GI symptoms. Patient was to take Prednisolone 40mg bd, Azathioprine50mg bd, Pantoprazole 40mg bd and Escitalopram 10mg bd.

Suggestion to Physician-SLE

• No drug interaction is found.• Methyl Prednisolone would have been given 1g i.v for

every 3 days instead of consecutively for 3 days.• Iron supplements might have been added in the

prescription, since patient is anemic.• Antipyretic/Analgesics would have been advised for

symptomatic relief for patient’s feel better.• At least on review, MVI&MM might have been advised, as

Patient was c/o alopecia.DEPRESSION• No suggestion is required to be given in this regard.

PLAN

Advice to patient-SLE• Adhere to medication.• Maintain hygiene.• Regular follow-up. • Drink plenty of water.• Consume fresh fruits and vegetables.• Avoid exposure to sunlight or artificial UV light.• Seek medical attention immediately, if exacerbations occurs.• Take more protein containing foods like beans, nuts, peas. • Co-operate with the Physician till remission of treatment/ Diagnosis and

treatment.• Take orange juice and iron rich foods like chicken, meat, egg and green leafy

vegetables like spinach and beetroot.

DEPRESSION• Family has been advised to arrange Counseling, Couple-focused therapy,

Family therapy, Hypnotherapy, Music therapy, Behavioral activation and interpersonal therapy is recommended as a treatment option for patients with depression

THANK YOU…