The phantom menace

M4 CLINICAL CLUB

THE PHANTOM MENACE ?

Chair:- Prof. Dr. C JayakumarPresented by:- Dr Shybin Usman

OUTSET

Maya 31 years old Housewife 2 Children

Referred from local hospital c/o fever of 1 month duration Treatment till then unsuccessful Common infective causes ruled out Next line of workup started

EVIDENCE

Pt had :- Arthritis Oral ulcers Serositis (pleural and pericardial effusions) Anaemia + High LDH + DCT positivity Anti ds-DNA positivity

VERDICT

Systemic Lupus Erythematosus

CONCLUSION

Started on steroids Pt afebrile by end of 1st week General condition improved

SEQUEL

New c/o cough and recurrence of fever Pt in 2nd week as IP Lt sided chest pain Scanty expectoration

CHEST X-RAY

SOLDIERING ON

Pt on steroids New onset cough and pleuritic pain New patches on chest X-Ray First suspect:-

INFECTIVE AETIOLOGY Added antibiotics CT chest taken

CT REPORT

Consolidation with air bronchogram in the apicoposterior segment of left upperlobe

Minimal right pleural effusion with basal atelectasis

Moderate pericardial effusion

DILEMMA

After 2 weeks of antibiotic therapy Bouts of fever persisting Cough persisting Chest pain has become right sided Repeat chest X-Ray

Suspicion shifted to the next accused:-

Lupus Pneumonitis

Steroid dose hiked Fever disappears Cough subsides Chest pain subsides Chest X-Ray repeated after 1 week

Pt discharged Repeat chest X-Ray @ 2 weeks follow-up

SLE and the Pulmonary SystemAn overview

Pleural Disease

Common Pleurisy in 33% Pleural thickening Effusions :-

Small, bilateral Exudate ANA, anti ds-DNA & LE cells in fluid

Diaphragmatic dysfunction (AKA Shrinking Lung)

Dyspnoea with lung volume loss CXR –

Small clear lung fields Bilateral high diaphragm

Theories – Diaphragmatic dysfunction Multiple small infarcts (due to vasculitis)

Acute Lupus Pneumonitis +/-Pulmonary Haemorrhage

Dramatic and severe complication 10% patients SLE flare associated Fever, dyspnoea, hypoxemia Haemoptysis rare Tachypnea, crackles (fine/coarse) CXR – Diffuse infiltrates (mimic ARDS) Diffuse alveolar inflammation, vasculitis

and haemorrhage

Contd.

Lupus Pneumonitis Acute Infection

CRP ↑ ↑↑

CO Transfer ↑/↓ N

BAL Haemosiderin laden macrophages

Infective Organism

Definitive investigation :- Open-lung biopsy

Contd..

Rx :- High dose Steroids / Immunosuppressants

Mortality ≈ 50%

Miscellaneous

Atelectasis (rarely clinically significant) Bronchiolitis obliterans Interstitial fibrosis (rare) Restrictive PFT Thromboembolism

THANK YOU