Case discussion of a 30 year old Female with Dermatomyositis And Pulmonary Nocardiosis

Case discussion of a 30 y/o Female with Dermatomyositis With Pulmonary Nocardiosis

- Tuesday, March 29, 2022

• This is online E log book to discuss our patient’s de-identified health data shared after taking his/her guardian’s signed informed consent.
•  Here we discuss our individual patient's problems through a series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective, current, best evidence based inputs. 
• This e-log book also reflects my patient centered online learning portfolio and your valuable inputs in the comment box  is welcome

A case of 30  y/o Female with Cough and Dyspnea

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

ACKNOLEDGEMENTS:

• https://rhea9895.blogspot.com/2022/01/29-years-old-female-with-co-joint-pains.html

• https://nikitha0510.blogspot.com/2022/03/dermatomyositis.html

I am extremely grateful to Dr. Simran Ma'am (Intern), Dr. Nikitha Ma'am (Intern) and Dr. Saicharan Kulkarni sir (PG) for guiding me through the case and helping me build this blog.

March 15,2022

30 years old female homemaker by occupation came to the General Medicine OPD with the 

CHIEF COMPLAINTS:

• B/L joint pains  associated with edema over legs from knee to ankle joint including dorsum of foot since 4 days
• C/O dyspnea in rest since 4 days
• C/O cough since 4 days
• High grade fever since 1 day

HISTORY OF PRESENTING ILLNESS:

• Patient was apparently asymptomatic 12  months ago. 
• Then she developed symmetrical bilateral joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors and relieved on medication i.e. Tab. HYDROXYCHLOROQUINE 200 mg 
• Associated with morning stiffness.
• Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black. 
• C/O Alopecia since 12 months. It was gradually progressive leading to severe hair loss over the past 12 months. Associated with thinning of hair.
• C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands since 12 months
• C/O generalized pain.
• C/O Difficulty in walking.
• C/O distal muscle weakness manifested in the form of difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt, 
• C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.
• C/O vaginal discharge since 10 months. It was initially curdy white which later changed to watery discharge. Associated with itching. 
• C/O weight loss of 4 kg over the last 10 months.
• C/O oral ulcers and genital ulcers since 10 months.
• C/O Dyspnea on exertion (NYHA- 3), gradually progressive since 6 months.
• She visited many local RMPs, received pain killers  as there is no improvement, she visited a health center 2 months back. 
• Presence of facial hair since 1 month

• C/O Dyspnea on rest (NYHA- 4), gradually progressive since 4 days

• h/o cough since 4 days associated with sputum.
• -h/o fever since 4 days
• C/o throat pain since 4 days

Past History:

• Not a K/O/C of DM, HTN, BA, epilepsy, Asthma, CVA, CAD.
•  Had similar complaints in the past 2 months.

Menstrual History

•  AOM- 11 years
•  3/25-28, regular , no pains, no clots.

Marital History

• ML- 14 years, NCM
•  Primary infertility (Nulligravida) 
• Has recently adopted a girl from her sister-in-law. 

Family History

• No similar complaints in the family 

Personal History

• Diet- Mixed
• Appetite- Decreased
• Sleep- Inadequate since 12 months. Wakes at 2 AM-3AM because of pain in legs.
• Bowel and bladder habits- Irregular
• C/O loose stools for 4 days followed by constipation for 3 days since 8 months.
• No addictions
• No known drug allergies 

DAILY ROUTINE OF THE PATIENT :

The patient lives in a family of 3 ..(of late the family has expanded) which constitutes her husband ,her mother in law and herself . They follow Islam.

A usual day in her life :

4.40 am : wakes up and bathes

5.00 am : Prayer 

 5.15 am : She doesn't sleep but lies on her bed and rests for another one or two hours .

7.30 am : washes dishes from the last day, washes clothes, makes the morning tea for herself and her family members

9.00am : gets food ready for her husband who goes out for work after breakfast 

9.30 am : Serves breakfast for her mother in law and herself

Rests for a while

11.00 am : Prepares for the day's cooking

Rests for a while

12.00 noon : cooks for the day

1.00 pm : Serves lunch for her husband who comes back during afternoon 

2.00 pm : Serves lunch for her mother in law and herself

3.00 pm : Rests 

4.00 pm : Prayer

5.00 pm : Makes tea for everyone in the house 

In the evening mostly all of them sit down and watch television 

7.00 pm : Preparations for dinner.

8.30 pm : Serves dinner for the family and then for herself

10.00 pm : Sleeps

Following are the clinical images when she visited health center 2 months back:

She was diagnosed with dermatomyositis with vaginal candidiasis 

Treatment given 2 months back:

1. Tab.wysolone 50mg po/od
2. Syp.mucaine 10ml/po/tid
3. Tab.ultracet 1/2 po/QIT
4. Candid cream for L/A is advised

Patient was referred to other health center for muscle biopsy.

Patient went to health center, her ANTI NUCLEAR ANTIBODY IMMUNOFLUOTESCENCE showed homogeneous pattern. Intensity 4+ associated antigens involved-ds DNA, histones.

HRCT WAS DONE ON 21/1/22

IMPRESSION: Few patchy areas of ground glass opacities in peri bronchovascular distribution-s/o pneumonitis .Corads-4

She didn't undergo muscle biopsy as the doctors there advised it is not necessary 

THEY PRESCRIBED:

1. TAB.CALTEN
2. TAB.AUGMENTIN
3. TAB.NAPROXEN SODIUM
4. TAB.FOLVITE
5. CANDID CREAM
6. TAB.WYSOLONE
7. TAB.ESOMEPRAZOLE
8. TAB.SODIUM ALENDRONATE WEEKLY ONCE.

General physical examination

• The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished. 
• Pallor- present
• No icterus, cyanosis, clubbing, lymphadenopathy.
• Pedal Edema- present 

O/E:

Patient images after treatment of 2 months:

DEVELOPED FACIAL HAIR GROWTH  POSSIBLY DUE TO TREATMENT WITH WYSOLONE (CORTICOSTEROID)

 

WHITE PATCH OVER TONGUE AND TONSILS

Vitals

• Temperature- Afebrile
• BP- 150/100 mm Hg
• PR- 114bpm
• RR- 30cpm
• SpO2- 93% @ RA

FEVER CHARTS:

INFERENCE: MULTIPLE FEVER SPIKES SEEN

SYSTEMIC EXAMINATION

Respiratory system examination

A. Inspection 

• Symmetrical chest
• Decreased air entry on right side
• V shaped line seen below the neck 
• No dilated veins or scars visible

B. Palpation 

• No lymph nodes palpable 
• Tactile vocal fremitus increased In lower part of right lung 
• Trachea centrally positioned 
• Apex beat felt at the 5th intercostal space along the mid-clavicular line

C. Percussion 

• Impaired note over right infrascapular region, all other regions are resonant

D. Auscultation 

• Normal vesicular breath sounds heard 
• Decreased air entry in right infrascapular ,right mammary and inframammary areas

OTHER SYSTEMS

• CVS- S1, S2 sounds heard. No murmurs
• CNS- Sensory and motor systems intact. Normal muscle power, tone and reflexes
• P/A- Soft and non tender, Bowel sounds heard

CHEST X-RAYS

JANUARY 2022:

15 MARCH 2022:

26 MARCH 2022:

28 MARCH 2022:

INFERENCE: RIGHT LOWER LOBE CONSOLIDATION. 

ECG:

USG ABDOMEN  ON 15/3/22:

IMPRESSION: RIGHT RENAL CORTICAL CYST WITH WALL CALCIFICATION. 

2D ECHO ON 15/3/22

EF-60%

MILD TR WITH PAH

TRIVIAL AR/MR

GOOD LV SYSTOLIC FUNCTION 

NO DIASTOLIC DYSFUNCTION. 

PFT REPORT ON 16/3/22

 

CBP

HB:9.9

TLC:9600

N/L/E/M:90/6/2/2

PCV:29.2

MCV:82

MCH:27.8

MCHC:33.9

RBC:3.56

PLT:1.77

LFT

TB-0.82

DB-0.24

AST-16

ALT-18

ALP:147

ALB-2

A/G-0.62

RFT

SR.UREA-29

SR.CREAT-0.9

NA+-137

K+-3.5

CL-:98

BGT

AB POSITIVE 

RBS

312 MG/DL

COMPLETE URINE EXAMINATION:

ALBUMIN-TRACE

SUGAR-NIL

PUS cells-2-3

EPITHELIAL cells: 2-3

SPUTUM CULTURE on 29.03.2022

 Presence of branching and filamentous thin, long, slender AFB resembling Nocardia seen under microscope from sample of both lungs.

INFERENCE: NOCARDIA SPECIES

BRONCHOSCOPY 29.03.22

https://m.youtube.com/watch?v=Q4L1HcPtI9o&feature=youtu.be

Report: 

PROVISIONAL DIAGNOSIS:

DERMATOMYOSITIS WITH RIGHT LOWER LOBE CONSOLIDATION AND PULMONARY NOCARDIOSIS.

TREATMENT

1.T.SEPTRAN DS TID 1--1--1

2.TAB.FLUCONAZOLE 150 MG OD 

3.OINT.CANDID MOUTH PAINT IN ORAL CAVITY

4.TAB.WYSOLONT 50 MG OD 1--X--X

5.TAB.FOLIC ACID 5 MG ONCE A WEEK.

TREATMENT 28.03.22

1.INJ.MEROPENEM 500MG IV BD(Day- 4 )

2.TAB.SEPTRAN DS TID (DAY -13)

3.TAB.DOXY 100MG PO BD (DAY-7)

4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY

5.TAB.AZATHIOPRINE 50 MG OD(DAY-8)

6.TAB.FOLIC ACID 5 MG ONCE WEEKLY 

7.SYP.GRILINCTRUS BM

8.TAB.METFORMIN 500MG OD

9.ZYFER GEL FOR L/A

10.TAB.DOLO 650MG PO TID

11.TAB.WYSOLONE 50 MG OD