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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