An interesting case of fever

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In the Name of God, Most Gracious, Most Merciful

An interesting case of fever: 

- Dr. Mohammed Sadiq Azam PG M-I, Prof. Md.Siraj’s Unit Department of Internal Medicine Deccan College of Medical Sciences @ PEH An interesting case of fever

History – chief complaints: 

History – chief complaints Mrs. A, 32/F, presented on 14/08/2006 with c/o: FEVER – 15 days Oral Ulcers – 15 days Loose stools – 15 days Generalized body pains – 15 days Generalised weakness – 15 days Generalised swelling – 15 days

History of presenting illness: 

History of presenting illness Asymptomatic 1 month back, when she developed fever with chills and rigors with generalized body pains involving all joints. Got admitted at a private nursing home on 4/8/2006 and has been treated for typhoid fever for one week with Inj. Cefotaxime 1g iv BD. No relief in symptoms even with therapy, hence got discharged and went home. One week later she developed swelling all over the body with oral ulcers and persistent low grade temperature with random spikes. At this point, she sought admission at OHRC.

PAST HISTORY: 

PAST HISTORY Fever – SINCE 6 MONTHS!!!!! – on/off, low grade, intermittent type, associated with joint pains (non migratory, not flitting/fleeting, relieved by analgesics), no chills/rigors/no other localizing features. No past H/O exposure to an adult case of TB, no past H/o of typhoid, malaria, dengue, chickungunya , exanthematous fevers in past/childhood, no rheumatic history. No h/o rash anywhere on face or body, no high risk behaviour .

Personal / FAMILY history: 

Personal / FAMILY history Mixed diet, sleep decreased, appetite normal. Bladder and bowel movts – normal. Recently married (<1yr), no issues yet. Menstrual history: Menarche: 14 yrs , reg cycles, 5/28, regular, normal flow, no pain, no clots. Teacher by occupation at a private school. Illness has affected her school performance (increased sick absenteeism) ALLERGIC to Penicillin. Family History: No similar complaints in family.

On examination:: 

On examination: Moderately built lady, sitting on the bed, is conscious, cooperative, coherent, oriented to time, place and person. Dyspnoeic , Tachypnoeic , Anaemic ++, BPPE ++, Facial puffiness +, Abdomen distended, no generalised LA, I -, Cy -, Cl -. Oral ulcers +, buccal mucosa 2 ulcers on each side, approx 1x2cm size, floor granular, egde sloping, no slough, sub mandibular tender LA + VITALS: BP-100/70mmHg, PR-95bpm, reg , normal vol & character, Temp: 100 F, JVP: raised (8mm) CVS: S1, S2 +, no murmurs/added sounds RS: BAE+, NVBS, B/L basal creps + occasionally P/A: Abd distended, FF + (SD+, FT -), no palpable organomegaly . CNS: NFND, PERRLA+, B/L plantars flexor.

PROVISIONAL DIAGNOSIS: 

PROVISIONAL DIAGNOSIS Pyrexia for evaluation: ? Koch’s ? Autoimmune disease ? Blood dyscrasia

INVESTIGATIONS:: 

INVESTIGATIONS: CBP: Hb : 8.5g% , TC- 2,300 cells/cu.mm, DC – N79, L16, M3, E2, Platelet count- 1.09 lakh. Reticulocyte count: 2.5%, ESR- 35/40mm LFT – ALP, AST/ALT – Normal RFT – Normal (42/0.9) S.Albumin – 5g%  3.4g% (over 15 days) P/S: Pancytopaenia , BM aspiration: Hypocellular marrow, no abnormal/ immature cells in either. CxR PA: WNL, Mantoux : Negative S.Electrolytes : Na: 110, K: 3.9, Cl : 90, Urine Na:79 meq /l (20-80)

INVESTIGATIONS:: 

INVESTIGATIONS: CUE: Alb +  3 + (over 15 days) RBCs: NIL  5-6 (over 15 days) Pus cells 3-4  plenty (over 15 days) 24h urine protein: 1200mg/24 hrs Urine C/S : Sterile Blood for CRP: Positive Blood for RA Factor: Negative S.Uric acid: 4.5

INVESTIGATIONS:: 

INVESTIGATIONS: USG abdomen: Moderate ascites +, no organomegaly , no lymphadenopathy. Apparent mild thickening of rectal walls, bilateral mild pleural effusion. PT: 13sec(T) 12sec(C) Ascitic fluid analysis: GM Stain: No organisms seen, AFB: Negative Protein: 1.7 mg/dl, Alb : 0.21mg/dl, Glucose: 91mg/dl ADA: 02 U/L Ascitic fluid cytology: only 2 cells – lymphocytes. HbsAg : Negative, HIV: Non Reactive

Going back… Provisional diagnosis: 

Going back… Provisional diagnosis Pyrexia for evaluation: ? Koch’s ? Autoimmune disease ? Blood dyscrasia

CRITERIA FOR SLE:: 

CRITERIA FOR SLE: Malar Rash Discoid Rash Photosensitivity Oral Ulcers Arthritis Serositis (Effusions/Ascites) Renal disorder (Proteinuria >0.5g/d or >/= 3+ or cellular casts) Neurologic disorder (Seizures, Psychosis with no other cause) Haematologic disorder ( Haemolytic anaemia or leucopaenia (<4000/ uL ) or lymphopaenia or thrombocytopaenia (<100000/ uL ) in the absence of offending drugs) Immunologic disorder (Anti dsDNA , anti- Sm , and/or anti-phospholipid Ab Antinuclear antibodies (ANA) positive

INVESTIGATIONS:: 

INVESTIGATIONS: ANA: POSITIVE Anti dsDNA : POSITIVE

final diagnosis: 

final diagnosis Autoimmune disorder: Systemic Lupus Erythmatosus

Treatment:: 

Treatment: Started on Steroids, Prednisolone 0.6mg/kg/day Supportive therapy

FOLLOW UP:: 

FOLLOW UP: Patient developed GTCS involving Right UL/LL 3 days after initiating therapy. CT Brain (Plain): Focal hypodensity in Rt. High parietal lobe posteriorly (?infarct). Suggested review with contrast after 1 week Review scan: Hypodensities in bilateral parieto -occipital regions s/o infarct. Wedge shaped hypodense areas of alterations valus (16-24 Hz) noted in posterior parietal regions bilaterally. s/o Infarct, ? White matter oedema .

FOLLOW UP:: 

FOLLOW UP: MRI Brain with MR Venogram : Bilateral cortical and subcortical T2 hyperintensity in parieto -occipital and frontal lodes which may represent ADEM.

FOLLOW UP:: 

FOLLOW UP: Continued steroids Added LMWX, Sodium Valproate 300mg BD with Folic acid 1g OD Supportive therapy. Patient is on regular follow up. Conceived 6 months later, had a FTND, baby healthy, resumed job, has a healthy good QOL now.

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