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Learning from Mistakes - Lesson from the Masters Case Study IRACON 25 th Nov,2016 Dr.Sukumar Mukherjee MD FRCP(London) FRCP ( Edin) FSMF FICP Ex-Prof and HOD of Medical College Kolkata
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LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Feb 07, 2017

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Page 1: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Learning from Mistakes - Lesson from the Masters

Case Study

IRACON 25th Nov,2016

Dr.Sukumar MukherjeeMD FRCP(London) FRCP ( Edin) FSMF FICP

Ex-Prof and HOD of Medical College Kolkata

Page 2: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Disclosures

None

Page 3: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

References • Kasper D , Hauser S , Jameson J C : Harrisons’ Principles of

Internal Medicine 19th Edition Vol 2 P 1716-1719

• Mc Graith E , Barber C : CMAJ , Nov 2010 , Bilateral Plural Effusion

• Hochberg MC , Silman A , Smolen J et al : Rheumatology Fourth ed.2008 , P 1287-88 , P 1535-36

• D Sen, David Isenberg ,ANCA in SLE, Lupus 2003 , Vol 12 ;651

• New Diagnostic and Classification criteria of ANCA associated Vasculitis (DCVAS) , ACR Annual Meeting , Washington 2016

• Randa YE , Arrayhani M et al , C-ANCA in SLE : An overlapping Syndrome ? , African JMCR , Vol 2 , P -022-023 , Feb 2014

Page 4: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Mistakes are the STEPPING STONES to Learning

“All men make mistakes but only wise men learn from their mistakes”

Sir Winston Churchill

Page 5: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Despite Significant Progress In Rheumatology

ImmunologyMolecular & Cellular BiologyNewer Diagnostic & assessment toolsTissue characterizationNewer Biologics

However, confusion , consensus or discordance in decision making – still a

ground reality !

Page 6: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Theme

Changing Goal Post in Clinical Decision

Page 7: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Case Vignette – Phase 1 • RS 72 F; Chronology of events:

• 2009 : Late onset chronic bronchial asthma on intermittent steroid inhalation . Non Diabetic , Normotensive & euthyroid.

• 2012 : Bilateral TKR . • April 2015 : Worsening dry cough with SOBE . No

fever , haemoptysis or wt loss • May-June 2015 : bilateral pleural effusion diagnosed .

Screened for heart failure ,chronic hepatic, renal ,thyroid and malignant disease. Pleural fluid – straw coloured lymphocytic exudate , normal sugar raised protein(3 grms/dL) LDH ( 704 ) ADA 36 . Negative microbiology and malignant cells . Hb 11.5 , ESR 70 , CRP 9.2 , TB Gold negative , TST 10 mm , ANF 1/80 Positive , other autoantibodies negative

Page 8: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Case Contd…• July -August 2015 : Emperical standard ATD

started along with steroids on and from 13th Aug and continued till 6th Feb 2016

• Oct 2015 : Pt responded well and steroid withdrwan

• Nov 2015 : Recurrence of bilateral pleural effusion more on right. No fever no wt loss ,

• Dec 2015 : retapped pleural effusion and found to have Lymphocytic exudate with elevated protein and LDH .Pleural fluid for ANF and Gene Xpert were not available . ATD continued & steroid restarted.

• Jan 2016 : Diagnosis recurrent bilateral pleural effusion – unresolved

Page 9: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Imaging chest : Pleural EffusionMar-April 2015

Page 10: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Case Contd... Phase 2• Jan2016 : Recurrence of cough

with SOBE , mild dysphonia , no fever , myalgia , arthralga , synovitis , uveitis , skin rash . oral ulcers Marginal wt loss .

• Chest xray shows pleural effusion again .

Page 11: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Chest Xray in Jan 2016

Page 12: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Bilateral Pleural Effusion Jan 2016

Page 13: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

CT Scan Chest Jan 2016

Page 14: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

AutoantibodiesJan 2016

Autoantibodies Results ANF (Hep 2) 1/640 CentromereDS-DNA (Crinthdia) 1/10 +veC3 143.9C4 52Anti CCPAb -veRheumatoid Factor -veAnti U1RNP -veAnti Sclero 70 -veAntinucleosome -veAnti SM -veAnti RO -ve

Page 15: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Case Contd…• Comorbidities : Osteoporosis (Tscore : -2.8) , LAHB , Low Vit D .

• A presumptive diagnosis of SLE with recurrent pleural effusion was made and Omnacotril 30 mg/d with HCQ 400 mg /d was initiated

• She remained well

• Feb 2016 : admitted in Mumbai Hosp with aggravation of cough , SOBE without fever , reaspiration of pleural fluid was done and the nature of fluid was suggestive of lymphocytic exudate . No CVD , CLD or renal ds were found . Discharged on Omnacortil , HCQ and Antibiotics

• April 2016 : Nonbloody thick nasal discharge , CXR showed Encysted pleral effusion and left pleural thickening , treated with antibiotics and anti allergics

Page 16: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

• Still not quite right about the diagnosis ?

However SLE may be a possibility (SLICC Criteria)

Page 17: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee
Page 18: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Case Contd…Phase 3• June-July 2016 : recurrence of

cough ,SOBE and thick nasal discharge

• Now she has been found to have hearing loss with left sided conductive deafness

• Xray PNS – Bilateral pan sinusitis

• CT Scan PNS – bilateral maxillary and sphenoidal sinusitis , bilateral nasal spur

Page 19: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Paranasal Sinusitis

June-July 2016

Pleural effusionJune – July 2016

Page 20: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

CT ScanJune-July 2016

Page 21: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Test ResultHb 10.2WBC 8200/cummESR 80mmCRP 2.54Platelet 2.3AN7(Hep2) 1/640Centromere +veDS-DNA (Crithidia) -veC-ANCA (PR3)IgG >100 An/mlP-ANCA (MPO)IgG -ve (4.2An/ml)Urine Normal

Page 22: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

• Again utter confusion or consensus about the diagnosis ?

• Pt declined to go for pleural biopsy or sinus endoscopic tissue biopsy

Page 23: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Revised classification of GPA based on scoring ACR Annual Meeting , November 2016

Clinical

Laboratory

Nasal Discharge -3 Abnormal CXR -2

Nasal polyp -4 CANCA-5

Cartilage Involvement -2 PANCA – 1

Hearing loss-1 Biopsy - 3

Red eyes -1 Eosinophil 1X10⁹ - 3

Summation score more than 5 strongly suggestive of GPA

DCVAS

Page 24: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

CXR Oct 2016

Page 25: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

• Limited expressions of GPA occur , especially disease confined to the upper or lower respiratory tract , or the eye . These pts may have no identifiable evidence of systemic vasculitis , but when they exhibit clinical and pathologic changes identical to those seen in GPA respiratory tract involvement , and especially if they are ANCA positive , they should be included in the GPA category

- CHCC 2012

Page 26: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

• Randa YE , Arrayhani M et al , C-ANCA in Systemic Lupus Erythematosus : An overlapping Syndrome ? , African JMCR , Vol 2 , P -022-023 , Feb 2014

Page 27: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Summary Points • Elderly lady with symptomatic recurrent pleural effusion with

exclusion of infection , CVD , CLD , CKD and malignancy

• Increased inflammatory markers .Treated initially with standard ATD

• Persistent and high titre positive ANF with variable DS-DNA

• New Development of nasal discharge and left conductive deafness

• Recurrent pleural effusion with out lung nodules or cavitation on imaging

• Presence of significantly positive C- ANCA and negative P ANCA

• Normal urinary findings

Page 28: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

• So the diagnosis ? ANCA associated with limited non

renal GPA Or

SLE and GPA overlap syndrome ?with

comorbidities

Page 29: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Acknowledgement

• My Patients (RS)• Dr Somnath Bhar ,MRCP• Ms Pampita Chakraborty , PhD

Fellow • Mr Amarnath Mukherjee

Page 30: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee
Page 31: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Questions for Vote • Pleural fluid sugar is higher than 60ml/dL in the

following conditions except A.Active Rheumatoid Arthritis B.Systemic Lupus ErythematosusC.Parapneumonic effusion

Page 32: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Which type of ANCA is commonly associated with SLE and Vasculopathy ?

A. C-ANCA (PR3)B. Atypical ANCAC. P-ANCA(MPO)

Page 33: LEARNING FROM MISTAKES – LESSONS FROM THE MASTERS CASE BASED DISCUSSION - Dr Sukumar Mukherjee

Which drug is inappropriate in the treatment of index patient

A. MycophenolateB. MethotrexateC. CorticosteroidsD. Cyclophosphamide