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
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