? SYSTEMIC LUPUS ERYTHEMATOSIS/MIXED CONNECTIVE TISSUE DISORDER WITH ?VASCULITIS WITH ACUTE INFARCT IN PONS WITH STEROID INDUCED NEPHROPATHY WITH SERONEGATIVE ARTHRITIS WITH ANEMIA(NORMOCYTIC NORMOCHROMIC) WITH HYPOTHYROIDISM

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25YR OLD FEMALE WITH C/O FEVER SINCE 15 DAYS

GENERALIZED WEAKNESS SINCE 1 WEEK

HEADACHE , BODY PAINS SINCE 1 WEEK

SHORTNESS OF BREADTH SINCE 3 DAYS

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN SHE DEVELOPED FEVER SINCE 15 DAYS HIGH GRADE,ASS WITH CHILLS AND RIGORS RELIVED ON TAKING MEDICATION, GENERALIZED WEAKNESS SINCE 1 WEEK , HEADACHE B/L FRONTAL REGION AND BODY PAIN SINCE 1 WEEK. SOB SINCE 3 DAYS MORE DURING EPISODES OF FEVER

NO ORTHOPNEA NO PND

PAST HISTORY:

K/C/O HYPOTHYROIDISM ON TAB LEVO THYROXINE 25MCG

H/O 3 ABORTIONS, 2 IN 1ST TRIMESTER AND 1 IN 2ND TRIMESTER

MARRIED AT THE AGE OF 20 YRS 

1ST PREGNANCY :

AFTER 3 MONTHS 

COMPLETE ABORTION AT 1 MONTH(4WEEKS)

2ND PREGNANCY :

AFTER 3 MONTHS

COMPLETE ABORTION AT 2MONTHS

3 RD PREGNANCY :

AFTER 1 YEAR

WENT FOR FOLLOW UP SCAN AND NO FETAL HEART RATE AT 5 MONTHS OF GESTATION 

MEDICAL ABORTION FAILED 

WENT FOR SURGICAL ABORTION

H/O MULTIPLE JOINT PAINS INVOLVING SHOULDER, NECK AND LOWER BACK SINCE 3YEARS

USED CORTICOSTEROIDS INTERMITTENLY FOR 3 YEARS AND PATIENT DEVELOPED FACIAL PUFFINESS 2 WEEKS BACK 

NOW COMPLAINING OF NECK PAIN AND LOW BACKACHE , NO INVOLVMENT OF WRIST JOINT , MCP JOINTS , DIP , PIP JOINTS

GENERAL EXAMINTION:

PT IS CCC

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHADENPATHY

BP 120/80

PR 76 BPM

RR 17 CPM

SPO2 98 @ RA

 GRBS 121 MG/DL

SYSTEMIC EXAMINATION:

CVS S1 S2 +

RA BAE+

GIT NT SOFT

CNS :

                 RT          LT

TONE UL     N            N

         LL     N            N

POWER

         UL     4/5        4/5

         LL     4/5         4/5

REFLEXES

         B      ++        ++

         T       ++        ++

         S      ++         ++

         K      ++         ++

         A       ++         ++

  PLANTAR  FLEXION   FLEXION

SENSORY EXAMINATION:

1. SPINOTHALAMIC

                                 RT             LT

  CRUDE TOUCH         N               N

  PAIN                       N                N

  TEMPERATURE         N               N

2.POSTERIOR COLUMN

                               RT             LT

  FINE TOUCH            N              N

  VIBRATION              N              N

  POSITION SENSE    COULD NOT FOLLOW / OBEY

                                COMMANDS DUE TO CONFUSION

  ROMBERGS SIGN    ABSENT     ABSENT

3.CORTICAL                                 RT   LT

  TWO POINT DISCRIMINATION     N     N

  TACTILE LOCALIZATION             N     N

  GRAPHAESTHESIA                     N     N

   STEROGNOSIS                         N     N

CEREBELLAR SIGNS

TITUBATION - PRESENT INITIALLY NOW NOT PROMINENT

NO ATAXIA

NO NYSTAGMUS

NO DYSARTHRIA

NO HYPOTONIA

REBOUND PHENOMENON ABSENT

INTENTION TREMOR ABSENT

PENDULAR KNEE JERK ABSENT

TANDEM WALKING - COULDNOT FOLLOW COMMANDS DUE TO PAIN

CO ORDINATION:

                                                    RT             LT

1. UPPER LIMB 

    FINGER NOSE TEST                   N                N

    FINGER FINGER NOSE TEST      N                N

   DYSDIADOKINESIA                   N               ABSENT

2. LOWER LIMB               

   KNEE TO HEEL TEST  - COULD NOT PERFORM DUE TO PAIN / FATIQUE

Course in the hospital -
Patient presented to us with the above mentioned complaints, thorough clinical and metabolic evaluation was done. With history of fever since 15days and Investigations revealed raised Total leucocyte counts
after sending blood and urine cultures, IV antibiotics were started.
At the time of admission creatinine and urea levels were raised ?Acute kidney injury
Patient gave a history of facial puffiness since 10days and history of Joint pains and generalised body pains since 3 years for which she was treated with steroids intermittently in these 3 years by Local RMP and NSAIDs abuse present.
We treated her for Steroid Induced Cushing syndrome and steroids were tapered gradually during the course in the hospital.
With the history of Multiple joint pains, Elevated ESR and CRP and Rheumatoid factor negative report, patient was clinically diagnosed with Seronegative arthropathy and Hydroxychloroquine was started.
Patient being a young female with h/o recurrent abortions (3times), Systemic Lupus erythematosus was suspected and ANA profile was done, which relieved

ANA Blot test reported Positive as antibodies detected against following antigens from ANA Blot profile : -SS-A/Ro60 antigen with an index 7.36 and Interpretation (+++)
-SS-B/La antigen with an index 5.92 and Interpretation (+++)
-SS-A/Ro52 antigen with an index 3.47 and Interpretation (++)
-U1-snRNP antigen with an index 1.95 and Interpretation (+)

Orthopedic opinion was taken for neck pain and the advised no active intervention for their side.
patient is having neck pain with stiffness since 3days with B/L eye abduction restriction , Neurologist opinion was taken as was suspected to have Raised intracranial tension
? CNS infection ?Aseptic Meningitis ?Benign intracranial hypertension and MRI brain was advised.
Fundoscopy was done, showed no raise in intracranial pressure
MRI Brain showed acute infarct in left paramedian pons. Old infarct in B/L striatocapsular regions.
Touted clinically to be ?SLE vasculitis
Patient is being discharged in hemodynamically stable condition and is advised to follow up in our general OPD after taking Rheumatologist opinion

INVESTIGATION:

Name  Value  Range	Name  Value  Range
COMPLETE URINE EXAMINATION (CUE)   15-12-2023 08:53:PM   COLOUR Pale yellow    APPEARANCE Clear    REACTION Acidic    SP.GRAVITY 1.010    ALBUMIN +    SUGAR Nil    BILE SALTS Nil    BILE PIGMENTS Nil    PUS CELLS 2-4    EPITHELIAL CELLS 2-3    RED BLOOD CELLS Nil    CRYSTALS Nil    CASTS Nil    AMORPHOUS DEPOSITS Absent    OTHERS Nil	LIVER FUNCTION TEST (LFT)   15-12-2023 08:53:PM   Total Bilurubin 0.63 mg/dl 1-0 mg/dl  Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 19 IU/L 31-0 IU/L  SGPT(ALT) 29 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 203 IU/L 98-42 IU/L  TOTAL PROTEINS 6.8 gm/dl 8.3-6.4 gm/dl  ALBUMIN 2.4 gm/dl 5.2-3.5 gm/dl  A/G RATIO 0.57
PHOSPHOROUS   15-12-2023 08:53:PM 5.9 mg/dl 4.5-2.5 mg/dl	SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   15-12-2023 08:53:PM   SODIUM 141 mEq/L 145-136 mEq/L  POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L  CHLORIDE 99 mEq/L 98-107 mEq/L  CALCIUM IONIZED 1.10 mmol/L mmol/L
SERUM CREATININE   15-12-2023 08:53:PM 1.6 mg/dl 1.1-0.6 mg/dl	BLOOD UREA   15-12-2023 08:53:PM 88 mg/dl 42-12 mg/dl
HBsAg-RAPID   15-12-2023 09:00:PM Negative	Anti HCV Antibodies - RAPID   15-12-2023 09:00:PM Non Reactive
WIDAL TEST   15-12-2023 09:00:PM   S.typhi "O" Antibodies No Agglutination seen    S.typhi "H" Antibodies No Agglutination seen    S.PARATYPHI "AH" ANTIBODY No Agglutination seen    S.PARATYPHI "BH" ANTIBODY No Agglutination seen	T3, T4, TSH   16-12-2023 05:30:AM   T3 1.61 ng/ml 1.87-0.87 ng/ml  T4 19.19 micro g/dl 12.23-6.32 micro g/dl  TSH 3.44 micro Iu/ml 5.36-0.34 micro Iu/ml
BLOOD UREA   17-12-2023 12:00:AM 88 mg/dl 42-12 mg/dl	SERUM CREATININE   17-12-2023 12:00:AM 1.5 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   17-12-2023 12:00:AM   SODIUM 135 mEq/L 145-136 mEq/L  POTASSIUM 4.4 mEq/L 5.1-3.5 mEq/L  CHLORIDE 99 mEq/L 98-107 mEq/L  CALCIUM IONIZED 1.01 mmol/L mmol/L	BLOOD UREA   18-12-2023 06:40:AM 92 mg/dl 42-12 mg/dl
SERUM CREATININE   18-12-2023 06:40:AM 0.8 mg/dl 1.1-0.6 mg/dl	SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   18-12-2023 06:40:AM   SODIUM 139 mEq/L 145-136 mEq/L  POTASSIUM 3.9 mEq/L 5.1-3.5 mEq/L  CHLORIDE 99 mEq/L 98-107 mEq/L  CALCIUM IONIZED 1.22 mmol/L mmol/L
BLOOD UREA   18-12-2023 09:49:PM 70 mg/dl 42-12 mg/dl	SERUM CREATININE   18-12-2023 09:49:PM 1.3 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   18-12-2023 09:49:PM   SODIUM 139 mEq/L 145-136 mEq/L  POTASSIUM 4.1 mEq/L 5.1-3.5 mEq/L  CHLORIDE 102 mEq/L 98-107 mEq/L  CALCIUM IONIZED 1.04 mmol/L mmol/L	LIVER FUNCTION TEST (LFT)   18-12-2023 09:49:PM   Total Bilurubin 0.86 mg/dl 1-0 mg/dl  Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 30 IU/L 31-0 IU/L  SGPT(ALT) 36 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 205 IU/L 98-42 IU/L  TOTAL PROTEINS 6.7 gm/dl 8.3-6.4 gm/dl  ALBUMIN 3.5 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.09
RFT   22-12-2023 05:10:AM   UREA 49 mg/dl 42-12 mg/dl  CREATININE 1.3 mg/dl 1.1-0.6 mg/dl  URIC ACID 4.9 mg/dl 6-2.6 mg/dl  CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dl  SODIUM 138 mEq/L 145-136 mEq/L  POTASSIUM 4.7 mEq/L 5.1-3.5 mEq/L  CHLORIDE 101 mEq/L 98-107 mEq/L	LIVER FUNCTION TEST (LFT)   22-12-2023 05:10:AM   Total Bilurubin 0.77 mg/dl 1-0 mg/dl  Direct Bilurubin 0.16 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 26 IU/L 31-0 IU/L  SGPT(ALT) 25 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 193 IU/L 98-42 IU/L  TOTAL PROTEINS 7.0 gm/dl 8.3-6.4 gm/dl  ALBUMIN 3.6 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.08

DIAGNOSIS:

? SYSTEMIC LUPUS ERYTHEMATOSIS/MIXED CONNECTIVE TISSUE DISORDER WITH ?VASCULITIS WITH ACUTE INFARCT IN PONS WITH STEROID INDUCED NEPHROPATHY WITH SERONEGATIVE ARTHRITIS WITH ANEMIA(NORMOCYTIC NORMOCHROMIC) WITH HYPOTHYROIDISM

TREATMENT:

INJ PIPTAZ 2.25 GM IV /TID

INJ MONOCEF 2 GM IV /BD

INJ TRAMADOL 1 AMP IN 100 ML NS/SOS

INJ NEOMOL 1 GM IV/SOS

TAB PAN 40 MG PO/OD

TAB ZOFER 4MG PO/SOS

TAB HCQ 200 MG PO/OD

TAB NAPROXEN 250MG PO/BD

TAB DOLO 650 MG PO/SOS

ADVICE AT DISCHARGE:

TAB PREDNISOLONE  5MG  PO/OD  ALTERNATE DAYS

TAB HCQ 200MG PO/OD

TAB ULTRACET 1/2 TAB PO/QID X 2 DAYS

TAB NAPROXEN 250MG PO/BD X 5 DAYS

TAB DOLO 650MG PO/SOS