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    SOUTHWESTERN UNIVERSITY 

    School of Medicine Department of Internal Medicine

    DISCUSSANTSRomero, Jiesta Anna MonicaOngayo, Stephanie Kristie

    Campugan, Harjarra KateSalazar, Bea CaressaAbraham, eonar!"himire, #eepa$

    Artiaga, %arlou

    A CAS&'R&S&%(A()O%

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    !ENERA" DATA

    • Filipino• Cebu City

    • Admitted for 2n

    at SHH

    A case of V.C.• 19 y.o

    • Female

    Single

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    CHIE# COM$"AINT

    On and off fever

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    HISTORY O# $RESENT I""NESS

    • days !"A

    – Intermittent fever (undocumented)

    – Epigastric pain

    – Rash on face and lower extremities

    – Self-medicated with Paracetamol 5mgta! ever" # hrs

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    HISTORY O# $RESENTI""NESS

    • 2 days !"A– Intermittent fever

    – Paracetamol 5mg ta! ever" # hrs wacontinued

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    HISTORY O# $RESENTI""NESS

    • Hours !"A– Sought consultation in S$$-%P&

    – '' and *+ were re,uested

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    C%CCBC RESULT REF.

    W%C &'( ) *+,-mm, 4.4-11.0

      NEU 61.1% x 103/mm3 37-80

      LYM 29.3% x 103/mm3 10-50

      MON 6.8% x 103/mm3 0-12

      EOS 2.0% x 103/mm3 0-7

      BS 0.4% x 103/mm3 0-2.5

    RBC 3.78 x 109/mm3 4.5-5.10

    H!% (', .-dl 12.3-15.3

    HCT ,+'+ / 35.9-44.6

    MC! 79 "# 80-96

    MC$C 31.1 #/& 27.5- 33.2

    R'( 13.0 % 11.6- 14.8

    $"T (0 ) *+,-mm, 150-450

    M)! 8.3 *m3 6.0-11.0

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    URINA"YSISUR+NLYS+S RESULT REFERENCE !LUE

    MACROSCO$IC E1AMINATION

      COLOR YELLO(

      TRNS)RENCY TUR%ID

      )$ 6.5

      S)EC+F+C ,R!+TY 1.015 1.003 – 1.035

    CHEMICA" $RO$ERTIES

      )ROTE+N &*m 3 NE,T+!E

      LEUOCYTES NOT 'ONE NE,T+!E

      BLOO' / $ 02 NE,T+!E

    MICROSCO$IC $RO$ERTIES

      (BC 5-8 / $)F 0-5/$)F

      RBC 25-30/ $)F 0-2/$)F

      %ACTERIA #EW

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    $AST MEDICA" HISTORY 

    $as a histor" of ronchial +sthma (...)– /o maintenance medications

    – $as no 0nown drug or food allerg"

    – /o previous surgical histor"

    –  

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    $ERSONA" 3 SOCIA"HISTORY

    /on-smo0er – /on-alcoholic !everage drin0er

    – /o histor" of illicit drug use

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    #AMI"Y HISTORY

    /o 0nown heredofamilial diseases

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    MENSTRUA" 3 SE1UA" HISTORY  

    – 1enarche at # "ears old

    – Regular c"cle of 5 da"s duration

    – ses 2-# pads*da"

    – +ssociated with d"smenorrhea

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    $HYSICA" E1AMINATION

    #eneral survey$  +wa0e3'oherent3 +fe!rile 3in respirator" distress

    Vital signs$– P- 4* mm$g RR- 4 cpm

    – $R- 6 !pm 7emp - 268# '– %4 sat- .9:

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    • S0in; +& 3 %&ulcers

    $HYSICA" E1AMINATION

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    '*>; E,ual chest expansion3 clear !reath sou• '?S; &istinct heart sound3 (-) murmur 

    • +&%1E/; @lat3 normoactive !owel sound3 epigastric tenderness

    $HYSICA" E1AMINATION

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    A7; (-) Bidne" punch sign• EC7RE1I7D; @ull range of motion 3 (-) edem(-) c"anosis3 'apillar" refill time 4 sec3 stronperipheral pulse

    $HYSICA" E1AMINATION

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    Cranial nerves; intact– ,otor system; intact

    – ,otor strengt(; 5*5

    – Cerebellum; intact

    – Sensory; intact

    – ,eningeal signs; (-)

    NEURO"O!IC E1AMINATION

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    SER%>%AD; RE@ERE/'E

    &IRE'7 +/7IA>%>I/ 7ES7 P%SI7I?E (F) /EA+7I?E

    I/&IRE'7 +/7IA>%>I/ 7ES7 /EA+7I?E /EA+7I?E

    A-"S"/0!"OS- O (+S%) 7I7ER /EA+7I?E +7 ; &I>7I%/ %R >ESS 7$+/ 4 I*ml

    CO,!,0-" %C' 8 g*> ( ref 8.-8. g*

    3OO4 CH0,S"/$

     +>1I/ 48# g*> 2.89 G #.8# g*>

    'RE+7I/I/E 8 mg*d> 85 G 8.5 mg

     +>7 (SAP7) 55 *> 22 *>

    S%&I1 #82 mmol*> 26 G #5 mm

    P%7+SSI1 28. mmol*> 285 G 58 mmo

    H0,A"OO#$

    ERD7$R%'D7E SE&I1E/7+7I%/ R+7E 25 mm*$r G 4 mm*$r  

    RE7I'>%'D7E '%/7 85 : 85 G 85 :

    SEROLOGY:

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    $ERI$HERA" %"OOD SMEAR

    ,icrocytic (ypoc(romic anemia• Slight anisopoi0iloc"tosis

    • eu5openia (with relative neutrophil predom

    • "(rombocytopenia

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    CHEST 14RAY 

    • 1ild 'ardiomegal" ('7R 52:)• Pneumonitis3 Right 1id-lung @ield

    + ":*

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    WHO"E A%DOMENU"TRASOUND

    • /ormal a!dominal findings

    • Incidental note of minimal bilateral pleeffusion.

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    URINE TEST

    Protein3 total urine; 2.8mg*dl• 'reatinine3 urine random; #9 mg*dl

    • Protein 'reatinine Ratio ; 825

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    ECHOCARDIO!RA$HICRE$ORT

    /ormal left ventricular dimensions withade,uate wall motion and contractilit"

    • >eft ventricular s"stolic function e=ection

    fraction of 9#:

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    I U

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    HISTORY O# $RESENT I""NESS

    • days !"A

    – Intermittent fever (undocumented)– Epigastric pain

    – (F) rash on face and lower extremities

    – Self-medicated with Paracetamol 5mgever" # hrs

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    HISTORY O# $RESENT I""NESS

    • days !"A

    – Intermittent fever (undocumented)– Epigastric pain

    – (F) rash on face and lower extremities

    – Self-medicated with Paracetamol 5mgever" # hrs

    Is there an" relief to the

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    $HYSICA" E1AMINATION

    Aeneral surve"; +wa0e3 'oherent3 +fe!rile 3 /ot in respira

    distress

    ?ital signs;

    – P- 4* mm$g

    – $R- 6 !pm

    – RR- 4 cpm

    – 7emp - 268# '

    – %4 sat- .9:

    8 Is the patient am

    wheelchair-!orneH

    48

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    $HYSICA" E1AMINATION

    Aeneral surve"; +wa0e3 'oherent3 +fe!rile 3 /ot in respira

    distress

    ?ital signs;

    – P- 4* mm$g

    – $R- 6 !pm

    – RR- 4 cpm

    – 7emp - 268# '

    – %4 sat- .9:

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    • C/L E;*& :

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    SA"IENT #EATURES

    • . "8o single3 female

    • $istor" of 2 da"s fever 

    • Epigastric pain J tenderness

    • %ral ulcers

    • Rash on face and lower extremities• 1inimal !ilateral pleural effusion

    8

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    SA"IENT #EATURES

     +nemia3 throm!oc"topenia and leucopenia• Proteinuria and hematuria

    • Positive &irect 'oom!s test

     >ow serum complement

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    DI##ERENTIA" DIA!NOSIS

    Salient feat8re7

    4rug6induced

    upus

    Systemic upus0ryt(ematosus

    !arvo 319

     Virus infection

    4en

    Fe

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    DEN!UE IN#ECTION

    • !resents )it( febrile illness

    • 3ody muscle and 7oint pain

    • 3ody malaise 8 fatigue

    • Autoimmune features li5e %&' 4irect Coombs

    • Hematological disorders %t(rombocytopenia+leucopenia' in endemic area

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    DEN!UE IN#ECTION

    RU"E IN

    • >ives in endemic area• Presents as fe!rile illness of 2-5 da"s• (F) Rashes3 epigastric pain• (F) Pleural effusion• (F) 7hrom!oc"topenia* leucopenia• (F) >ow complement level• (F) ?aria!le autoimmune features

    RU"E OUT

    • 'ommon in 9-5 "ear • (-) muscle J =oint pain• %ral ulcers are rare• +utoimmune features

    not well recogniKed• Proteinuria is not expla

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    Salient feat8re7

    4rug inducedlupus

    Systemiclupus

    eryt(ematous !arvo 319virus infection

    4in

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    $ARVO %*( VIRUS IN#ECTION

    • Parvovirus is a small3 single-stranded &/+ v

    • Infects children more commonl" then adults respirator" droplets and cause flu li0e s"mpt

    • 'linical manifestations in adults include feverash3 arthropath" J hemol"tic or aplastic ane

    • &iagnosis is clinical J ma" !e confirmed !"specific anti!od" testing and viral &/+ testin

    $ARVO %*( VIRUS IN#ECTION

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    $ARVO %*( VIRUS IN#ECTION

    RU"E IN

    • 'ommon in childhood and teenagers• (F) fever 3 facial rashes3 oral ulcers• (F) +!dominal pain• Proteinuria 4 to glomerulonephritis• +nemia3 leu0openia J throm!oc"topenia

    • suall" has Positive &irect coom!s test

    and low complement level

    RU"E OUT

    • Epigastric pain occurs le• 1ost common feature in

    arthopath" (-)• Rashes on extremit" are• (-) 7ravel histor"• Retic count of 85 : ma

    anemia unli0el" 8

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    Salient feat8re7

    4rug inducedlupus

    Systemiclupus

    eryt(ematous !arvo 319virus infection

    4in

    DRU! INDUCED "U$US

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    DRU! INDUCED "U$US

    • +gents causing lupus li0e s"ndrome are proc

    h"dralaKine3 isoniaKid3 %'P3 prop"lthiouracil• +ntihistone anti!odies (F) are fre,uent for drlupus

    • Resolves within da"s to months after withdraculprit agents

    DRU! INDUCED "U$US

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    DRU! INDUCED "U$US

    RU"E IN

    • (F) facial rashes3 oral ulcers•  +utoimmune features li0e &+7 J

    c"topenia• (F) epigastric pain•

     (F) proteinuria•  (F) microscopic hematuria to

    nephrotic s"ndrome

    RU"E OUT

    • E,uall" common in male

    and females

    • /o agents triggering lup

    !" patient

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    Salient feat8re7

    4rug inducedlupus

    Systemiclupus

    eryt(ematous !arvo 319virus infection

    4in

    SYSTEMIC "U$US ERYTHEMATOUS

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    SYSTEMIC "U$US ERYTHEMATOUS

    • !rotean autoimmune disease most common in

    of c(ild bearing age• Has non specific organ involvement+ but more

    commonly affects 7oints+ 5idney+ s5in 8 C-S.

    • 4rug induced lupus S(ould be e*cluded before

    diagnosis of S0• 4iagnosis is made using clinical criteria.

    S"E C it i

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    S"E Criteria

    • :=m= =A fo8r 

    = m= :> @< & =

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    Salient feat8re7

    4rug inducedlupus

    Systemiclupus

    eryt(ematous !arvo 319virus infection

    4in

    /:04 -

    Mo7t "i

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    Mo7t "i

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    Clinical#eat8re7of S"E

    #i.' Clinical feat8re7 of S"

    $atho.ene7i7 of S"E

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    $atho.ene7i7 of S"E

    RO"E O# AUTOANTI%ODY IN

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    RO"E O# AUTOANTI%ODY INS"E

    "U$US NE$HRITIS

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    "U$US NE$HRITIS

    • /ephritis is the most serious manifestation o

    • /ephritis and infection are the leading causemortalit" in the first decade of disease

    • /enal biopsy is recommended with eviden

    nephritis8

    C"ASSI#ICATION O# "U$US NE$HRITIS5International Societ9 of Nephrolo.9 and Renal

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     5International Societ9 of Nephrolo.9 and Renal$atholo.9 Societ96

    #INA" DIA!NOSIS

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    #INA" DIA!NOSIS

    S"E IN #"ARE5"8p87 nephriti7 cla77 IV6

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    ! d M i