A 31 YESR OLD WITH HIGH GRADE FEVER WITH ORAL ULCERS AND JOINT PAINS

 MEDICINE CASE DISCUSSION 

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January 12,2022

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SHIVANI THOTA,134

31 year old female, who studied till degree and is a housewife by occupation came with chief complaints of: 

• B/L knee pains since 2 weeks
• Fever on and off since 2 weeks
• Oral ulcers since 6 months 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 years ago (March,2020) and then she developed pain in her right shoulder (she could not raise her hand above her shoulders) which was dull aching type and continuous, for which she went to an Orthopaedic and was given medication. The pain kept alternating between right and left shoulder and sometimes both simultaneously. She experienced tightness of shoulder joints on waking up and needs someone to pull her up from the bed. Her pain was relieved on medication but it kept recurring for 6 months. 

•  After 1 month of developing shoulder pain,her proximal interphalangeal joints were swollen, which was associated with decreased function as she was not able to write properly, open bottle cap etc.
• She also developed B/L knee pains and generalized weakness.
• Then she developed fever, oral ulcers ( was not able to eat food) , redness of eyes and diminished vision, facial puffiness and went to a private hospital. 
• She also developed hair loss 2 years ago, which was gradually progressive.
• On routine investigations, they found that she was losing a lot of proteins ( nephrotic range proteinuria) in her urine, and increased protein creatinine ratio of 4.99, due to which and her diminishing vision they decided to a kidney biopsy.
• Renal biopsy was done on 5/08/2022
•  Biposy showed focal mild increased endocapillary cellularity pointing towards FOCAL GLOMERULONEPHRITIS, after which the diagnosis of SLE was made as she also showed positive ANA profile as follows:
• Anti -RNP/ Sm and Anti- Sm, Anti-Jo 1, Anti - ds DNA, nucleosomes and RIBOSOMAL P- PROTEIN

She was put on Tab. OMNOCORTIL 50 mg for 3 days and steroid injections and was tapered over 6 months to 2.5mg.

After 6 months, steroids were stopped and was started on

•  Tab. MFM for 4 months (2 tab at 8 AM and 1 tab at 8 PM), which she used and stopped after one month after tapering. She was also advised to perform exercises.
• IN FEBRUARY 2021, She was started on FOLITRAX after which she noticed increase in number of oral ulcers , so she went to a private hospital 15 days later, and was started again started on OMNOCORTIL 5mg
• She later developed blurring of vision more in day light, for which she was diagnosed with cataract in her left eye.

Past history:

Patient is a known case of HYPOTHYROIDISM since and is on Thyronorm 50mcg .

Not a known case of DM, HTN, EPILEPSY, TB, BRONCHIAL ASTHMA

PERSONAL HISTORY:

DIET- mixed

Appetite: Normal

Bowel and bladder movements are normal

Sleep: Adequate

No known addictions and allergies.

Menstrual History:

She bleeds for 3 days in a 30 day cycle 

She uses 3 pads per day.

Recently, she complains of spotting 5 days before her first day of menses ( oligomenorrhea)

Marital history:

In 2014 Dec, when she was 24 years she was a married. 

Antenatal history:

P3 L2 A1

In 2015, her first pregnancy reached full term and NVD was done. 

She developed high grade fever in her 6th month, and was diagnosed with malaria.

She developed severe back and loin pain in her 8th month, and USG was done which showed swollen kidneys for which she was prescribed antibiotics and sent home.

In 2018, her second pregnancy, she suffered an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication. 

In 2019, her third pregnancy, reached full term and NVD was done. 

Family History:

Insignificant

Surgical history: 

Cataract surgery of left eye in February 12, 2022. 

Treatment history: 

Patient is currently on:

1. Tab. MMF 500mg PO BD (8AM & 8 PM)
2. Tab. FOLITRAX 10mg weekly once 
3. Tab. LIVOGEN PO BD 
4. TAB. HCQ 200mg OD
5. Tab. SHELCAL PO OD
6. Tab. THYRONORM 50mcg

GENERAL EXAMINATION: 

Prior Consent was taken from patient and her mother in a written form.

Patient was examined in well lit room

Patient is conscious, coherent and cooperative. 

No signs of pallor, icterus, kolionychia, cyanosis, lymphadenopathy, edema

Vitals :

Temp: 99°F

BP: 100/50

PR: 101 bpm

RR: 21 cpm

SYSTEMIC EXAMINATION:

CVS: S1 S2 present 

No murmurs or thrills heard 

RS: BAE present, NVBS heard 

CNS: INTACT

GCS- E4V5M6

P/A: soft, non tender 

CLINICAL IMAGES:
Rash on her forehead 

INVESTIGATIONS

Hemogram: 

Hb: 9.3

TLC: 3500

N/L/E/M: 78/15/2/5

Plt: 2.3

CUE: 

Albumin: trace 

Sugars: nil

Pus cells: 2-3 

Epithelial cells: 2-3 

APTT: 32s

PT: 16s

INR: 1.11

Temperature charting: 

DIAGNOSIS: 

SYSTEMIC LUPUS ERYTHMATOSUS - CLASS III LUPE NEPHRITIS

WITH HYPOTHYROIDISM 

WITH BILATERAL RETINAL VASCULITIS 

TREATMENT: 

1. IVF NS RL @ 75ml/hr
2. Inj. NEOMOL 1 gm IV SOS
3. Tab. DOLO 650mg PO/QID
4. MUCOPAIN GEL for L/A over ulcers.
5. Tab. MMF 500mg PO BD (8AM & 8 PM)
6. Tab. FOLITRAX 10mg weekly once 
7. Tab. LIVOGEN PO BD 
8. TAB. HCQ 200mg OD
9. Tab. SHELCAL PO OD
10. Tab. THYRONORM 50mcg