case presentation of SLE with Nephritis

1. Welcome
to
Clinical Meeting
Presented by
DR. Dhiraj Chandra Biswas
DR. Amlendra K. Yadav
Resident (phase-A)

2. 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

3. Chief Complaints
 Fever for 4 months.
 Pain over multiple Joints for same duration.
 Rash all over body for same duration.

4. 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.

5. 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.

6. 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.

7. 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.

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

9. 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.

10. Milestones of Development
Age appropriate.
Feeding History
On normal family diet .

11. 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.

12. Physical Examination
General
Appearance : Ill-looking.
 Pallor : Moderately pale
 Edema
 Jaundice
 Cyanosis
 Clubbing Absent
 Koilonychias
 Dehydration
 Neck vein : Not engorged

13.  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

14. 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)

15. Systemic Examination

16. 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.

17. 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.

18. 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

19. 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

20. Genito urinary system
 Kidney – Both kidney not ballot able
renal angle – non-tender
Bladder – Not palpable

21. 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.

22. 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

23. 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.

24. 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.

25. Provisional Diagnosis
???

26. Provisional Diagnosis
Systemic Lupus Erythematous (SLE)
Differential diagnosis
Systemic onset JIA

27. 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

28. INVESTIGATION

29. CBC
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

30. 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

31. 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

32. Final diagnosis
SLE with Lupus Nephritis

33. Management

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

35. 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

36. Follow up

37. F/U On25.6.2014
Subjective Objective Assessment Plan
Fever still
persist
Oral mucosal
ulcer present
Ill- looking, mildly pale,
Febrile
RR – 24/min
HR – 96/min
BP – 90/60mmhg
BSUA - Nil
Not improving Continue antibiotics
& plan to start inj.
Methylprednisolone
and Inj. Amikacin

38. 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

39. Thank
You..