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M4 CLINICAL CLUB THE PHANTOM MENACE ? Chair:- Prof. Dr. C Jayakumar Presented by:- Dr Shybin Usman
28

The phantom menace

Jun 23, 2015

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Shybin Usman

A challenging case that needs modification of treatment according to evolution of the problem
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Page 1: The phantom menace

M4 CLINICAL CLUB

THE PHANTOM MENACE ?

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

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OUTSET

Maya 31 years old Housewife 2 Children

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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

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EVIDENCE

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

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VERDICT

Systemic Lupus Erythematosus

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CONCLUSION

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

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SEQUEL

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

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CHEST X-RAY

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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

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CT REPORT

Consolidation with air bronchogram in the apicoposterior segment of left upperlobe

Minimal right pleural effusion with basal atelectasis

Moderate pericardial effusion

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DILEMMA

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

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Suspicion shifted to the next accused:-

Lupus Pneumonitis

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

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

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SLE and the Pulmonary SystemAn overview

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Pleural Disease

Common Pleurisy in 33% Pleural thickening Effusions :-

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

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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)

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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

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Contd.

Lupus Pneumonitis Acute Infection

CRP ↑ ↑↑

CO Transfer ↑/↓ N

BAL Haemosiderin laden macrophages

Infective Organism

Definitive investigation :- Open-lung biopsy

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Contd..

Rx :- High dose Steroids / Immunosuppressants

Mortality ≈ 50%

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Miscellaneous

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

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THANK YOU