Systemic Lupus Erythematosus (SLE) BD Tmss Medical college Medicine Department presentation.

1. A CASE OF YOUNG GIRL WITH MULTIPLE
SKIN RASH
PICTURES ARE TAKEN WITH DUE RESPECT AND PERMISSION
DR.MD. ASHIF NAWAS(TMC-05)
INTERN MEDICINE
TMC&RCH

2. Particulars of the patient.
• NAME: Miss Shompa
• AGE: 21 yrs
• SEX: Female
• RELIGION: Muslim
• MARITAL STATUS: Unmarried
• OCCUPATION: Unemployed
• ADRESS: Asokhola, Hajaridighi,Bogura
• DATE OF ADMISSION:20.05.18 at 12.35pm
• DATE OF EXAMINATION:26.05.18 at 11.30 AM

3. Presenting complaints
• Skin rash for 3 years.
• Oral ulcer for 6 months.
• Fever for 7 days.

4. History of presenting illness
• According to the statement of the patient she was reasonable well 3 years back. Since then she
noticed skin rashes on the face arms and legs for the last 3 years that are aggravated on exposure to
sunlight. The patient also complains of low grade fever for last 7 days, highest recorded temperature
is 101’F. Fever is not associated with chills and rigors, subsides by taking paracetamol. There is no
history of night sweats. The patient also complaints of marked loss of weight and weakness. She
noticed progressive loss of hair and painless mouth ulcer. There is no history of bleeding, venous
thrombosis, convulsion, unconsciousness, dryness of the mouth or eyes, pain in abdomen, dysuria,
edema, Raynaud’s phenomenon, gangrene or cough. She also gave history of pain in the multiple
small and large joints in upper limbs and lower limbs. That pain persisted day and night, more marked
in the morning associated with morning stiffness and not relieved by rest but reduced with pain-
killers Her bowel and bladder habits are normal.

5. History of past illness.
• She had been suffering from pain in
multiple small joints and large joints of
both upper limbs and lower limbs. She
also suffered from typhoid fever…

6. Drug History.
• She took some medicine during treatment period after appendicitis and
typhoid fever. But there is no history of taking OCP or other drugs.

7. Family History
• There is no familial illness in her family. Her parents and sisters are
healthy

8. Menstrual History
• The patient complaints of irregular menstruation, Sometimes
associated with menorrhagia

9. General Examination
• Appearance: Ill looking an emaciated
• Alopecia is present on the scalp. Also maculopapular skin rashes are present on the dorsum of the hands and legs.
Some of these are pigmented and scaly. Oral ulcer present on inner side of lips and checks with irregular margins.
• Body Built: poor
• Decubitus: On choice
• Anaemia: Moderately anaemic
• Jaundice: Absent
• Cyanosis: Absent
• Clubbing: Absent
• Koilonychia: Absent
• Leukonychia: Absent
• Edema: Absent
• Lymph node: Not palpable
• Thyroid: Not enlarged
• Pulse: 88 beats/min
• Blood Pressure: 120/80 mmHg
• Temperature: 101’F
• respiratory rate: 20 breath/min

11. Musculoskeletal System
• Both knee and ankle joints were slightly swollen and tender but no deformity
• Wrist and metacarpo-phalangeal, interphalangeal joints of both hands are
swollen and tender.
• Gaits- Normal

12. CARDIOVASCULAR SYSTEM
• Pulse : 88 beats /min
• Blood pressure: 120/80 mmHg
• Neck vein: not engorged
• Precordium:
• Inspection-Cardiac impulse is not visible. No deformity or scar mark present.
• Palpation-Apex beat: left 5th intercostal space 7 cm from midline.
There is apical thrill,
Palpable p2 is absent
Left parasternal heave is absent
Epigastric pulsation is absent
• Auscultation:
• 1st heart sound is loud in all area
• 2nd heart sound is normal.
• Murmur: Absent

13. GASTROINTESTINAL SYSTEM
• Lips teeth ,tongue are pale. But oral ulcer was present on inner side of lips and check some are coated
with irregular margin.
• Abdomen:
• Inspection: No abnormality detected.
• Palpation: No organomegaly
Kidneys are not ballotable
Fluid thrill: Absent
There is no tenderness over the renal angle
• Percussion: Shifting dullness absent
• Auscultation: No renal bruit
• Other system reveals no abnormality……

14. SALIENT FEATURE
• Miss Sompa, 21 yrs old young girl, hailing from Asokhola, Hajradighi Bogura presented with skin rashes
on the face, arms(palm), legs(sole) for the last 3 years that are aggravated on exposure to sunlight. The patient
also complains of low grade continued fever for the last 7 days, highest recorded temperature is 101’F. Fever is
not associated with chills and rigors, subsides by taking paracetamol. There is no history of night sweats. The
patient also complains of marked weight loss and weakness. She noticed progressive loss of scalp hair and
painless mouth ulcer. There is no history of taking OCP or other drug, bleeding history, venous thrombosis,
convulsion, unconsciousness , dryness of the mouth or eyes, pain abdomen, dysuria, edema, Raynaud’s
phenomenon, gangrene or cough. Her bowel and bladder habits are normal. She also added about continuous
irregular menstruation, sometimes associated with menorrhagia. She was once suffered from appendicitis and
took some drugs to relief from the symptoms but could not mention the name. She also suffered from typhoid
fever. There is no positive family history of such kind of illness. She was treated with some NSAIDs or multiple
drugs by local physicians. Now she came RCH for better treatment.. On general examination she was ill looking
moderately anaemic, Nasolabial folds are raised and fixed also had some maculopapular rash on external ear
palm of the hand and sole of the foot those are scaly and pigmented. On systemic examinations her wrist,
metacarpo- phalengial and knee joints are slightly tender and swollen but gaits normal. Her bowel and bladder
habits were normal.

15. DIFFERENCIAL DIAGNOSIS
• Rheumatoid Arthritis
• Mixed connective tissue disease.

16. HAEMATOLOGICAL
REPORT
1. Haemoglobin-9.4g/dl
2. ESR-95mm/1st hr
3. Red blood cells-3.24×10^12/L
4. Neutrophils-80%
5. HCT(PCV)-26.001/l

17. URINE EXAMINATION
Protein(Albumin) : ++(present)
Pus Cells: 5-7/HPF

18. ULTRASONOGRAM OF
WHOLE ABDOMEN
Mild Ascites
Bilateral Plural effusion.

19. BIOCHEMICAL ANALYSIS
C-reactive protein(CRP)-8.00mg/l

20. IMMUNOLOGICAL REPORT
Anti-ds DNA->240 IU/mL
Anti- nuclear Ab(ANA)-
12(Positive)

21. OTHER INVESTIGATION FOR EVALUATION
• Complements- C3 ,C4 .
• Immunoglobulin-High titer of IgM and IgG.
• Serum anti- phospholipid antibody.
• VDRL- false positive.
• Platelet count-Low
• Prothrombin time-prolonged
• Activated thromboplastin time(APTT)-prolonged
• 24 Hours Urinary Protein, Serum Urea, Serum Creatinine, Creatinine Clearance
• Skin biopsy-Immunofluorescence test shows deposition of immune complex at dermo-epidermal
junction(Lupus Band)
• CNS involvement-EEG,CT,MRI.

22. CONFIRM DIAGNOSIS
• Systemic lupus erythematosus

23. SLEDAI-2000

24. TREATMENT PLAN
• Bed Rest
• Diet –Normal
• TAB. RECONIL (200mg) (Hydrochloroquine sulphate)
• 1/2+0+ ½
• Tab. IMUREN (50mg)
• 1+0+1
• Tab. METHIPRED (16mg)
• 1+0+0 (After meal)
• Tab. MASTEL (10mg)
• 0+0+1 (Before meal
• Tab. ECOSPRIN (75mg)
• 0+1+0 (half an hour before meal)
• Tab. MOTIGUT (10mg)
• 1+1+1 (After meal)
• Tab. RANITID (150mg)
• 1+0+1 ( half an hour after meal)

25. THANK YOU ALL FOR PATIENCE
HEARING
ENDS …………..