28 /Female / Edakkalathur, Thrissur dt.Fever
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1. CASE PRESENTATION
2. 28 /Female / Edakkalathur, Thrissur dt.
Fever – 6 months
Multiple swellings over the body- 6 months
Yellowish discoloration of eyes and urine- 2 months.
Associated with chills/ rigor
4-5 days/ week
Present through out the day
Generalized body pain.
No cough with expectoration/ burning
micturition/loose stools/joint pains.
4. Multiple skin lesions over the thigh, arms and
trunk- 6 months.
Painful, red, warmth
Spontaneous resolution. No itching/ No ulceration
Yellowish discolouration of eyes and urine- 2 months.
Loss of appetite+
Loss of weight- 7-8 kgs in 5 months.
5. Past history: DECEMBER 2005- FEBRUARY 2006: Fever with urticarial rash 2 months duration, admitted and evaluated at Amala hospital, Thrissur
ESR: 40mm/hr, Mantoux- Negative
USG Abdomen: B/L PCOD, Ovarian cyst
Skin biopsy: Lobular Panniculitis
Treated with antibiotics and Dapsone.
Fever and skin lesions persisted.
6. MARCH 2006 to MAY 2006 Jubilee Mission Hospital
Raised ESR (50mm/hr), Elevated ADA,
LE cell, AntidsDNA, ANA : Negative
ASO, RA Factor: Negative C3, C4- Normal
HIV, VDRL- Negative
TB IgM – positive
Started on ATT; Wysolone. Took ATT for 2-3 weeks only. since her fever did not subside; and the skin lesion worsened, ATT was stopped.
7. June 2006 LISSY HOSPITAL- Ernakulam
Fever with loss of appetite
Non healing ulcer left gluteal region
Icterus+, Raised Liver Enzymes.
Blood culture: Sterile
Pus culture: Pseudomonas, Klebsiella
Treated with antibiotics, steroids, Thalidomide.
8. Continued Wysolone for a year, tapered and stopped in June 2007.
Asymptomatic for a long period till November 2008 when she developed fever again followed by skin lesions.
Started on high dose Wysolone (40mg/day)
No response; found to have raised liver enzymes in March 2009, came to AIMS.
10. Examination Conscious, oriented, febrile.
NO KF ring
11. GI system:
Oral cavity: N
Abdomen: Soft, Liver palpable, Non tender,
4 cm below costal margin, Firm, surface
smooth. No splenomegaly
Shifting dullness +
Chest: B/L air entry equal, normal vescicular breath
CVS:S1 S2 heard normally, No murmurs
NS: No focal neurological deficits; No neck stiffness.
Fundus: Left: Normal; Right: Medullated nerve fibres.
12. Possibilites considered were:
Erythema nodosum- ? Tubercular
Weber Christian Disease
Hepatic involvement of a systemic disease.
? Auto immune
13. TC: 3,620 N: 81%, L: 15%, M7%.
T Bil:6.2mg/dl, D: 3.9mg/dl
SGOT: 357IU/L, SGPT: 241.4IU/L, ALP: 418.4 IU/L
Albumin: 2.8g/dl, Globulin: 3.4g/dl
Na: 135.4, K:4.1, Ca: 7.9
Serum LDH: 745
14. USG abdomen:
Liver enlarged, Increased echotexture.
Dilated portal vein; measures 14 mm
Spleen enlarged ;11cm.
Pancreas, Gall bladder, Kidneys, Bladder, Uterus Normal
CXR P/A: Normal
15. Ascitic fluid study:
Total cells: 524/uL
Lymphocytes: 90%, Neutrophils: 4%.
Protein: 4.6g/dl Albumin: 2.0g/dl
Gram stain, AFB stain, Fungal stain: Negative
Ascitic fluid culture: No growth.
Cytopathology: Lymphocyte rich fluid. No atypical cells
16. AntidsDNA: Negative
Anti SM antibody: Negative.
HIV, HBV, HCV: Negative
17. Skin biopsy:
Unremarkable dermis and epidermis.
Subcutaneous tissue shows septal
panniculitis with granuloma.
18. Started on second line ATT,
Liver biopsy planned. Serum ACE, GGT levels
Deferred due to increase in INR during hospital
Fever subsided with ATT, INR normalised with
fresh frozen plasma
19. Patient requested discharge due to personal
reasons, planned to get admitted next week for
Septal panniculitis (TB/ Sarcoidosis)
Hepatocellular jaundice with ascitis (probably TB)
To r/o autoimmune causes/ sarcoidosis.
20. Erythema nodosum, a painful disorder of the subcutaneous fat, is the most common type of panniculitis.
First sign of a systemic disease such as tuberculosis, bacterial or deep fungal infection, sarcoidosis, inflammatory bowel disease, or cancer.
22. Hallmark is tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities.
Erythema nodosum does not ulcerate and usually resolves without atrophy or scarring.
Represents an inflammatory process involving the septa between subcutaneous fat lobules, with an absence of vasculitis and the presence of radial granulomas.
Bacterial - Streptococcal infections, tuberculosis,
Drugs - Sulfonamides, oral contraceptives,
24. Deep fungal - dermatophytes, coccidioidomycosis, histoplasmosis, blastomycosis
Viral/chlamydial - infectious mononucleosis, lymphogranuloma venereum, paravaccinia
Enteropathies - ulcerative colitis, Crohn's disease
Malignancies - lymphoma/leukemia, sarcoma, post radiation therapy
25. Tuberculosis and Liver Usually in miliary TB
Localised liver TB is rare
Tuberculomas, Ascitis, Cholangitis, Abscess, Porta hepatis adenopathy.
Jaundice is rare. Biliary obstruction by nodes.
Dispropotionate elevation of ALP
Marginal elevation of aminotransferases, Reversal of AG ratio
A caeseating granuloma in liver biopsy.
26. Sarcoidosis and Liver Most cases remain asymptomatic
Not associated with jaundice or PHTN
In a small subset, chronic intrahepatic cholestasis and /or portal hypertension can complicate the course of the disease. Jaundice, Hepatosplenomegaly and pruritis
ALP and GGT are very high
Raised ACE levels
Definite diagnosis: Liver biopsy. A caeseating granuloma rules out Sarcoidosis.
27. Collagen Vascular Disease and Liver PAN, Takayasu
Weber Christian Disease
a and b globulins elevated, Bil, SGOT/SGPT/ ALP: Normal or mildly elevated
28. Autoimmune chronic hepatitis Immunological factors causing liver injury
Elevated enzymes, High IgG
ANA, Anti SM antibody
Anti LKM antibody
RA factor positivity
Definite diagnosis: Liver biopsy – Inflammation characterised by mononuclear cells and plasma cells.
29. Erythema Nodosum- Management Treatment of any underlying disorders and supportive therapy, including bed rest and avoidance of contact irritation of affected areas.
Pain can be managed conservatively with nonsteroidal anti-inflammatory drugs (NSAIDs).
Oral potassium iodide prepared as a supersaturated
solution in a dosage of 400 to 900 mg per day for one month is a therapeutic option.
30. Oral prednisone at a dosage of 60 mg (1 mg per kg body weight per day) every morning is advised.
Steroids used in combination with hydroxychloroquine cyclosporin A or thalidomide have been used to treat
inflammatory bowel disease–associated erythema nodosum.
NSAIDs should be avoided in treating erythema
nodosum secondary to Crohn’s disease because they may trigger a flare-up or worsen an ongoing acute bout.