1. 1. The Case of Ms. SI John Angelo Luigi S. Perez June 19, 2015 St. Luke's College of Medicine
2. 2. 48/F Right-Handed Roman Catholic Kasambahay Old Balara, QC
3. 3. Foot Numbness
4. 4. History of Present Illness 2 weeks Ascending extremity paresthesia R then L LE then UE 1 week 1 day A No headache, dizziness, slurring of speech, pain. (+) pruritus, pain
5. 5. History of Present Illness 2 weeks Ascending extremity paresthesia R > L LE > UE 1 week Ascending extremity weakness R > L LE > UE Tripping Steppage gait 1 day A No headache, dizziness, slurring of speech, pain. (+) pruritus, pain
6. 6. History of Present Illness 2 weeks Ascending extremity paresthesia R > L LE > UE 1 week Tripping Steppage gait Legs gave way (+) Fall 1 day A No headache, dizziness, slurring of speech, pain. (+) pruritus, pain Ascending extremity weakness R > L LE > UE
7. 7. Hypertensive Amlodipine, uncompliant Non-diabetic Non-asthmatic No CA Unremarkable family history
8. 8. Review of Systems Palpitations Intermittent knee pains Pruritic rashes on legs Pruritic hands
9. 9. Physical Examination Sallow skin Erythematous cheeks and nose PPC, AS Moist mucosa, (+) ulcers No CLADs SLE, CBS AP, no murmurs, regularly regular Flat, soft Normoactive, non-tender Pulses full and equal Grade 2 bipedal edema Multiple, hyperpigmented, lichenified lesions
10. 10. MMSE Cranial Nerves I II III, IV, VI V VI VII VIII IX X XI XII Neurologic Examination Cranial Nerves
11. 11. Neurologic Examination Somatic Motor 55 54 44 55 33 0 2 Good tone and bulk No fasciculations Good irritability
12. 12. Neurologic Examination Tendon Reflexes +++ + ++ 0 0 (-) Toe extensor +
13. 13. Neurologic Examination Somatic Sensory 90% 10% 60% 60% 10% 60% 100% 100% 30% 50% 50% 20% (+) Romberg's sign Cerebellum intact
14. 14. Where do we localize the lesion? Levelize? Lateralize? Localize?
15. 15. Mononeuritis Multiplex Asymmetric Asynchronous Painful Separate nerves
16. 16. Salient Features Subjective Objective 48/F 2 weeks weakness and numbness Palpitations Joint pains Pruritus Stable VS Sallow skin Facial erythema Rashes Buccal ulcers Bipedal edema Mononeuritis multiplex
17. 17. Mononeuritis Multiplex + Skin Lesions?
18. 18. We have 3 differential diagnoses Diabetic Neuropathy Guillain-Barr Syndrome (AIDP) System Lupus Erythematosus
19. 19. Diabetic Neuropathy
20. 20. Guillain-Barr Syndrome (AIDP)
21. 21. Systemic Lupus Erythematosus
22. 22. SLE is a multisystemic disease
23. 23. Neuropsychiatric SLE (NPSLE) is a recognized entity 62% 18% 8% 5% 5%1% Headache Seizures CVD Psychosis Neuropathy Movement Muscal and Brey. Neurol. Clin. 28(1) 2010
24. 24. Peripheral neuropathy attributed to SLE is rare 96% 4% SLE Related Related Florica et al. Semin. Arthritis Rheum. 41(2) 2011 Asymmetry 59% Distal weakness 34%
25. 25. Salient Features Subjective Objective 48/F 2 weeks weakness and numbness Palpitations Joint pains Pruritus Stable VS Sallow skin Facial erythema Rashes Buccal ulcers Bipedal edema Mononeuritis multiplex
26. 26. Mononeuritis Multiplex secondary to Systemic Lupus Erythematosus
27. 27. SLE is diagnosed using a set of clinical and laboratory criteria
28. 28. Various autoantibodies are useful in the SLE workup Harrison's Principles of Internal Medicine, 19th Ed.
29. 29. Complete Blood Count
30. 30. Urinalysis
31. 31. Renal Function and Electrolytes
32. 32. Our patient's 2D echo showed decreased heart function EF 43/39% Hypokinesia in inferior and inferlateral wall of LV
33. 33. Autoimmune Workup
34. 34. Autoimmune Workup
35. 35. EMG-NCV
36. 36. Our patient satisfies the SLICC criteria
37. 37. The pathogenesis of SLE is complex Harrison's Principles of Internal Medicine, 19th Ed.
38. 38. SLE is managed according to the severity of the disease
39. 39. Course in the Wards HD 1 D Guillain-Barre Syndrome HD 11 HD 5 HD 3 HD 2 HD 4 HD 7 HD 6 HD 8 HD 9 HD 10
40. 40. Course in the Wards HD 1 D Guillain-Barre Syndrome HD 11 HD 5 HD 3 HD 2 HD 4 HD 7 HD 6 HD 8 HD 9 HD 10 Given IVIg Deficits fluctuated (+) fever, pruritus
41. 41. Course in the Wards HD 1 D Guillain-Barre Syndrome HD 11 HD 5 HD 3 HD 2 HD 4 HD 7 HD 6 HD 8 HD 9 HD 10 Given IVIg Deficits fluctuated (+) fever, pruritus Rheuma: autoimmune workup (+) Hematuria Started on HCQ, prednisone
42. 42. Course in the Wards HD 1 D Guillain-Barre Syndrome HD 11 HD 5 HD 3 HD 2 HD 4 HD 7 HD 6 HD 8 HD 9 HD 10 Given IVIg Deficits fluctuated (+) fever, pruritus Rheuma: autoimmune workup (+) Hematuria Started on HCQ, prednisone Cyclo- phosphamide
43. 43. QUIZ TIME!
44. 44. A patient comes to your clinic complaining of hematuria. He also admits to joint pains, reduced appetite, fever and itchy arms. On PE, you note reddish cheeks and a mouth sore. Your impression is SLE. 1. What is the first immunologic test to confirm your impression? 2. The autoantibody above turns out positive. How will you manage your patient?
45. 45. SLE is managed according to the severity of the disease
46. 46. Enumerate the following autoantibodies: 2. Correlates with disease activity 3. Associated with drug-induced SLE 4. Associated with lupus depression or psychosis
47. 47. Various autoantibodies are useful in the SLE workup Harrison's Principles of Internal Medicine, 19th Ed.
48. 48. 5. What is the most common presentation of NPSLE? 6. Give 4 SLICC criteria that permit the diagnosis of SLE.
49. 49. Headaches are the most common presentation of NPSLE 62% 18% 8% 5% 5%1% Headache Seizures CVD Psychosis Neuropathy Movement Muscal and Brey. Neurol. Clin. 28(1) 2010
50. 50. SLE is diagnosed using a set of clinical and laboratory criteria
51. 51. Today's Learning Points
52. 52. Questions?