FEVER FOR EVALUATIONDr N.Samatha,

(MD)INTERNAL MEDICINE

Chief complaints• Mrs Vijaya, 31 yrs female, a House wife,

Presented on 12/12/2011 with C/O

Fever : 2 monthsMalar rash : 45 daysHeadache : 45 days

History of present illness Patient was apparently asymptomatic 2 months back

when she developed fever associated with generalised body pains, rash on palms,back and arms, joint pains, anorexia, sleeplessness and headache.

• Patient presented to a local hospital, treated symptomatically, fever was relieved on medication and was discharged.

• 10-15 days later she developed malar rash,and persistent fever.

• Then, she presented to Esra hospital with fever and malar rash.

History of present illness• Fever was intermittent, low grade, on and off, no

chills/rigors, associated joint pains mostly involving large joints[non migratory and non fleeting]

• From day1 of fever, she developed macular erythema on palms, upperback and extensor aspect of arms and 10-15 days later she developed malar rash,which is slightly raised erythematous rash on cheek and nose, precipitated by sun exposure and non pruritic.

• No history S/O purpura, no orogenital eruptions or scaly lesions on anyother part of the body.

History of present illness• No past H/O exposure to C/O TB,mite bite,tick bite,or

exposure to rats or cats• No history S/O malaria,chikungunya,dengue,typhoid• No history of visual disturbances,altered sensorium & no

complaints S/O motor or sensory impairment• No H/O cough or dyspnoea• No history of drug allergy• No H/O similar complaints in the past

Personal/family history • Mixed diet,decreased appetite,decreased sleep• Bowel and bladder habits regular• Menstrual history-menarche at 13,cycles regular,4/30,no

dysmenorrhea,no clots• No similar complaints in the family

General examination• Patient is conscious, coherent, cooperative, comfortably

sitting on bed, well oriented to time, place & person• Weight - 56kgs,BMI - 158 cms• Pallor +,no icterus no cyanosis,no clubbing,no

lymphadenopathy,no pedal edema• Normal hair• Malar rash on face ,macular erythema on palms and

back,non-discoid,non blanchable• No orogenital ulcers• EYES appear normal O/E• URT normal,no congestion or secretions noted

Physical examination• Vitals ,BP 110/80, PR 80b/m,regular,normal

volume,character, all peripheral pulses felt. Temp 100F , RR 16/min

• RS-BAE+,NVBS,no ADV sounds• CVS-S1,S2 heard,no murmers• P/A-soft ,no tenderness,no organomegaly,BS+• CNS-NFND,Plantars-flexor• Muskuloskeletal system examination-no swelling or

redness or tenderness over large or small joints,no limitation of movements at joints,no pain,no stiffness

Provisional diagnosis

Pyrexia for evaluation

? Connective tissue disorder

? Granulomatous disease

? Enteric fever

? Malignancy

InvestigationsCBP - HGB:10.7gm%,WBC-1,700/cu.mm, plt-

89,000,N69,M5,L10,E2PS - Normocytic normochromic,leucopenia,lymphopeniaCUE - Pus cells-0-1,no rbc,no cystals,no castsLFT - Sr bilirubin-1.08,SGOT-134U/L,

Sr albumin- 4.3gm/dl,ALP-WNLRFT -NORMALSr electrolytes - Sr Na-146/k-3.9/Cl-100Chest xray - NormalESR -26/55mm

InvestigationsVDRL- NRWidal test- NegativeDengue NS1 Ag &IgM, IgG -NegativeHBs Ag/Anti HAV/Anti HCV /Anti HEV- NegativeHIV - NRUSG ABD/Pelvis - NormalANA - POSITIVE(2.975)Anti ds DNA Antibodies-positive(233IU/ml)

Criteria for SLE1. MALAR RASH

2. Discoid Rash

3. PHOTOSENSITIVITY4. Oral ulcers

5. Arthritis

6. Renal disorder

7. HEMATOLOGICAL DISORDER

8. Serositis

9. Neurological disorder

10. IMMUNOLOGICAL (Anti-Sm, and/or anti-phospholipid, Anti dsDNA)

11. ANTINUCLEAR ANTIBODIES-ANA POSITIVE

Diagnosis

SYSTEMIC LUPUS ERYTHEMATOSIS

ManagementSupportive therapy given,inj.methylprednisolone given,At discharge, T.azathioprine,added at 2mg/kg/day, along

with oral prednisolone,40mg bid

At follow up, patient cell counts improved, rash faded comparatively, but complained of alopecia,GI symptoms