30 y female C/o cough with sputum and dyspnea. H/O multiple joint pains and long term steroid usage.
THIS IS AN 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 SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
CREDITS :
I thank Dr. Nikitha (intern) Dr. Simran (intern)
For collecting the data of the patient.
Details of patient when admitted 2 months back in a health centre in the below link:
In January
Patient came to our hospital on March 15,2022
30 years old female homemaker by occupation came to the General Medicine OPD with the
C.C:
- B/L joint pains associated with edema over legs upto knee joint including dorsum of foot since 4 days
- c/o dyspnea at rest since 4 days
-c/o cough since 4 days
H/O P.I.: Patient was apparently asymptomatic 12 months ago.
Then she developed symmetrical b/l 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 generalised 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 centre 2 months back.
Following are the clinical images when she visited health centre 2 months back:
Her X RAYS 2 MONTHS BACK:
Treatment given 2 months back:
And 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 centre for muscle biopsy.
Patient went to health centre,her ANTI NUCLEAR ANTIBODY IMMUNOFLUORESCENCE showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA, antihistones.
MYOSITIS PROFILE was done which showed MDA-5 , PL-7, Ro -52 all three were strong positive
HRCT WAS DONE ON 21/1/22
IMPRESSION: Few patchy areas of ground glass opacities in peri brochovascular 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.
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 h/o: Not a k/c/o DM, HTN, BA, epilepsy, Asthma, CVA, CAD.
Had similar complaints in the past 2 months.
Menstrual h/o: AOM- 11 years
3/25-28, regular , no pains, no clots.
Marital h/o: ML- 14 years, NCM
Primary infertility (Nulligravida)
Has recently adopted a girl from her sister-in-law.
Family h/o: No similar complaints in the family
Personal h/o:
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
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:
Vitals:
Temperature- Afebrile
BP- 150/100 mm Hg
PR- 114bpm
RR- 30cpm
SpO2- 93% @ RA
SYSTEMIC EXAMINATION:
CVS- S1, S2 sounds heard. No murmurs
RS- BAE+ NVBS heard
CNS- NAD
P/A- Soft, non tender, Bowel sounds heard
Provisional diagnosis:
DERMATOMYOSITIS TO R/O ILD
INVESTIGATIONS-
Chest X RAY-
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.
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
CUE
ALBUMIN-TRACE
SUGAR-NIL
PUS cells-2-3
EPITHELIAL cells: 2-3
TREATMENT:
1.T.SEPTRAN DS TID 1--1--1
2.TAB.FLUCONAZOLE 150 MG OD
1--X--X
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.
PFT REPORT ON 16/3/22
SOAP NOTES DAY 1
ICU BED -4
S- COMPLAINTS OF SOB WHILE TALKING ASSOCIATED WITH COUGH AND GENERALIZED WEAKNESS
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 100°F
PULSE RATE - 117BPM
BLOOD PRESSURE -
150/100MM OF HG
RESPIRATORY RATE - 30
SPO2 - 97 % AT 4 lit O2
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
RBS-312
A-DERMATOMYOSITIS TO R/O ILD
P-
1.TAB.SEPTRAN DS TID (DAY -1)
2.TAB.FLUCONAZOLE 150MG OD(DAY-1)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.WYSOLONT 50 MG OD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.NEOMOL 1GM IV SOS
SOAP NOTES DAY 2
ICU BED -4
S- COMPLAINTS OF SOB grade -2 WITH COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 101F
PULSE RATE - 107BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 35
SPO2 - 93% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
RBS-121
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
A-DERMATOMYOSITIS TO R/O ILD
P-
1.TAB.SEPTRAN DS TID (DAY -2)
2.TAB.FLUCONAZOLE 150MG OD(DAY-2)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 3
AMC BED -3
S- COMPLAINTS OF SOB grade -2 WITH COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
PALLOR present. ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 100.6F
PULSE RATE - 98BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 35
SPO2 - 91% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
GRBS-138MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
Hemogram (18/3/22)
HB:11.1
TLC:9400
N/L/E/M:89/8/1/2
PCV:32.6
MCV:82
MCH:27.8
MCHC:34
RBC:3.98
PLT:2
HBA1C:6.9
24 HOUR URINARY PROTEIN:59.9mg/dl
Total 24 hr urine volume-1900ml
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -3)
2.TAB.FLUCONAZOLE 150MG OD(DAY-3)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 4
AMC BED -3
S- COMPLAINTS OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.6F
PULSE RATE - 107BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 28
SPO2 - 94% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
GRBS-150MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -4)
2.TAB.FLUCONAZOLE 150MG OD(DAY-4)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 5
M Ward
S- OCCASIONALLY COMPLAINTS OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.6F
PULSE RATE - 107BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 24
SPO2 - 94% AT RA
GRBS-170MG/DL
SYS
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-240MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen
?Nocardia species
DERMATOMYOSITIS TO R/O ILD with pulmonary Nocardiosis?
1.TAB.SEPTRAN DS TID (DAY -6)
2.TAB.FLUCONAZOLE 150MG OD(DAY-6)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-1)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
CREDITS :
I thank Dr. Nikitha (intern) Dr. Simran (intern)
For collecting the data of the patient.
DISCUSSION
1) Latest presenting compliants cough and dyspnea are due to any underlying ILD or due to pulmonary nocardiosis?
2) Could the muscle biopsy help the patient?
3) Is it only a dermatomyositis or any overlapping syndrome SLE , MCTD ?
4) How can we improve the prognosis of this patient? Because in the absence of malignancy prognosis is generally 5 years of 93% patients.
From Manipal -
This study was a retrospective case record review of all nocardiosis cases that were diagnosed at our tertiary care hospital from January 2008 to December 2019. A total of 48 patients with a mean age of 52.2±16.28 years were included. Out of which forty one (85%) were diagnosed as pulmonary nocardiosis and seven (14.6%) as disseminated disease. Chronic lung disease 25 (52.1%), long term steroid use 22 (45.8%) followed by diabetes mellitus 11 (22.9%) were common predisposing factors. The common symptoms were fever (87.5%), cough (79.2%) and breathlessness (52.1%). The most frequent radiologic finding included consolidation in 38 (79.1%), cavitation with thickened wall in 2 (4.1%), reticulonodular shadows in 2 (4.1%), and unilateral pleural effusion in 5 (10.4%). Nocardia otitidiscaviarum (22.9%) was frequently isolated from cultures. Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was observed in 21% cases. Mortality was noted in 6 (12.5%) patients and all were with pulmonary involvement.
Definitions
Pulmonary nocardiosis was defined as the presence of clinical symptoms and signs of respiratory infection with nocardia species isolated from respiratory samples, including sputum or bronchoalveolar lavage at least once. Disseminated nocardiosis was diagnosed if the infection was present in two non-contiguous sites with or without a pulmonary focus. Long-term steroid use was defined as patients taking at least 10 mg of prednisolone per day for more than one month before the development of nocardiosis.
Various clinical samples of suspected nocardial infection were subjected to Gram staining that revealed many thin, Gram positive, branching filamentous bacteria and then confirmed with modified acid-fast staining (Kinyoun staining) with 1% sulphuric acid that showed partial acid fast filaments. These samples were cultured on 5% sheep blood agar, Sabouraud dextrose agar (SDA) and nutrient agar and incubated aerobically at 37°C under 5% CO2 for 4 weeks.
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