Case presentation

Dr Rammohan Reddy 1st year PG, Dept of DVL,

Kamineni Institute of Medical Sciences,

Narketpally.

• Name : XXX

• Age : 33 years

• Sex : Female

• Occupation : Farmer

• IP no : 201608905

• DOA : 15-02-2016

• Marital Status : Married

Case History

A 33 year old female farmer came with complaint of multiple, red colored, raised skin lesions associated with itching and burning on exposed parts of the body since 8 years.

History of present illness:

Patient was apparently asymptomatic 8 years back. She gives history of coin shaped lesions which started initially as red colored lesions on both cheeks which gradually increased in number and reached present size in 6 months.

• Similar red colored, scaly, raised lesions appeared on bridge of nose, forehead, around mouth and on ears, exposed parts of hands, front of the neck, upper chest, upper back and right leg after 1 month.

• These small lesions coalesced to form present sized lesions over 6 months.

• H/o photosensitivity.

• No h/o oral ulcers.

• No h/o fever, fatigue.

• No h/o joint pains, stiffness, swelling.

• No h/o discoloration of fingers upon exposure to cold.

• No h/o weight loss.

• No h/o Shortness of breath, chest pain.

• No h/o headache, confusion or memory loss.

• No h/o drug intake prior to onset of these symptoms.

• No h/o dysphagia, tightening of skin.

• No h/o dry eyes and dry mouth.

• No h/o proximal muscle weakness.

• No h/o high colored urine / hematuria.

• No h/o abdominal pain.

Past history: Not a known case of Hypertension, Diabetes, Pulmonary Tuberculosis, Asthma, Epilepsy.

Family history: no h/o similar skin lesions in family.

Menstrual/obstretic –

5/30 regular, G3P3L3.

Personal history

• Diet : mixed

• Appetite : normal

• Sleep : adequate

• Bowel and bladder : regular

• Addictions : nil

Drug history

No h/o known allergies to drugs.

Patient used both topical and oral medications from local doctor on and off since 8 years (no documents available) with mild improvement to recur again.

General Examination

Patient is conscious, coherent, co operative, moderately built , moderately nourished.

No Pallor

No Icterus

No Cyanosis

No Generalised Lymphadenopathy

No Pedal edema

Vitals:

Temperature= 98.6O F

Pulse Rate= 72/minute, regular, normal volume and other peripheral pulses felt.

Blood Pressure= 110/70 mm of Hg.

Respiratory Rate= 20/ minute

Systemic Examination

• Cardio Vascular System : S1, S2 heard, no murmurs.

• Respiratory System : bilateral air entry- present, normal vesicular breath sounds, no added sounds.

• Central Nerve System : higher mental function normal. No other abnormalities are detected.

• Abdomen : soft, non tender, no organomegaly, bowel sounds heard.

Cutaneous Examination

Multiple, well defined, erythematous plaques ranging in size 2-15cm with adherent scales and hyperpigmented borders, distributed bilaterally symmetrical on face including bridge of nose, vermilion border of both upper and lower lips.

Carpet tack sign – positive.

Left Scalp, helix of ears

Right scalp, helix of ears

V-shaped area of neck, upper chest

Extensor aspect of both forearms and dorsum of hands including fingers.

Some lesions are small and coalesced to form a large plaques.

upper back and anterior aspect of right leg

Multiple depigmented lesions with atrophy and scarring

• Mucous membranes

• Oral : normal

• Genital : normal

• Conjunctiva : normal

• Hair and nails : normal

• Palms and soles : normal

Nails - normal

Provisional diagnosis Discoid Lupus Erythematosus (DLE)

Differential diagnosis

Systemic Lupus Erythematosus (SLE)

Sub Acute Cutaneous Lupus Erythematosus (SCLE)

Management

Complete blood picture• Haemoglobin – 12gr%• Total count- 4,000 /cu.mm• Neutrophils – 55 %• Lymphocytes – 40%• Eosinophils – 03%• Monocytes- 02%• Basophils - 0%• Platelets – 1.5lakhs/cu.mmPeripheral Smear: Normocytic / Normochromic.ESR – 80mm/1st hr

Complete urine examination

• Color – pale yellow• Appearance – clear• Reaction – acidic• Sp. gravity – 1.010• Albumin – trace• Sugar – nil• Bile salts – absent• Bile pigments – negative• Pus cells – 2-4/hpf

• Epitheloid cells – 2-4/hpf

• Red blood cells – nil

• Crystals – nil

• Casts – nil

• Amorphous deposits – absent

• Others – nil

• Random Blood Sugar – 89 mg/dl

Liver function tests• Total bilurubin – 0.52mg/dl• Direct bilurubin – 0.23mg/dl• AST(SGOT) -22 IU/L• ALT(10) – 10 IU/L• Alkaline phosphatase – 104 IU/L• Total proteins – 7.6gr/dl• Albumin – 3.7gr/dl• A/G ratio 0.95

Renal function tests

• Urea – 15 mg/dl

• Creatine – 0.7 mg/dl

• Uric acid – 3.7 mg/dl

• Calcium – 9.2 mg/dl

• Phosphorous – 3.5 mg/dl

• Sodium – 139 mmol/L

• Potassium – 3.8 mmol/L

• Chloride – 102mmol/L

• ECG – normal sinus rhythm.

• Chest X –ray - no abnormalities are detected.

• L E cell test – negative.

• Skin Biopsy : 4x4mm punch biopsy was taken from right hand.

histopathology features are compatible with Discoid Lupus Erythematosus (DLE)

• ANA – negative.

Final Diagnosis

Disseminated Discoid Lupus Erythematosus (DLE)

Treatment

Photoprotection: Broad spectrum Sunscreens with SPF-30

applied 30 minutes before sun exposure 3-4 times daily.

Topical therapy: Mometasone furoate cream 0.1% twice daily

on face. Halobetasol propionate cream 0.05% twice

daily on trunk, hands, legs.

Oral :

Tab Hydroxychloroquine 200mg oral BD

(after fundoscopic examination and clearance given by ophtholmology dept)

Tab levocetrizine 5mg oral OD

Before 1 month after follow up

Follow up Treatment

• Broad spectrum Sunscreens.

• Mometasone furoate cream 0.1% once daily on face.

• Halobetasol propionate cream 0.05% once daily on trunk, hands, legs.

• Tab Hydroxychloroquine 200mg oral BD.

• Follow up OP appoinment in 1 month.

Thank you