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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