sle grand round
TRANSCRIPT
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Practice Based Learning[ GRAND ROUND ]
PREPARED BYDr. Jafar Alsaggaf
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7 yrs old Filippino girl presented at 22-11-2014 through OPD with hx of fever and cough * 3 wks weight gain Periorbital and neck swelling
HistoryCase presentation
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The fever was on/off, responding partially to
antipyretics for 2-3 weeks The cough is productive for 2-3 wks weight gain is subjective No hx of SOB or sore throat, no hx of lower
limbs swelling or abdominal distension, no change in urine color or amount
History of Presenting Illness
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She was suspected to have ?mumps (parotitis)
2wks back (came with same persentation but still in the beginning)
Otherwise previously healthy No previous admissions she underwent dental extraction safely
Past history
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No hx of dyspnea, orthopnea or PND No vomiting, diarrhea, jaundice or steatorrhea. She’s
c/o abdominal pain (not specified) with decreased oral intake
No chest pain or night sweats There’s hx of Lt knee and Rt. Shoulder pain with
limitation in movement with no swelling of several days duration
Hx of facial rash over cheeks ?malar area for 1-2 days only prior to presentation
Many episodes of epistaxis (recent and by history)
Systemic Review
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Fhx : unremarkable Vaccination hx: she didn’t receive mumps
vaccine (4-6yrs of age) since she was in Philippine that
time but she received (MR) Perinatal hx : FT, NVD
Cont. History
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In Summary:
6yrs 10m old girl , presented with fever, cough, periorbital and neck swelling and wt. gain for 2-3 wks, with hx of facial rash and joints pain
Cont. History
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VITALS: were stable
ANTHROPOMETRIC MEASUREMENT: wt 19.25kg .. Ht 116.5 cm .. BMI 14.2 .. 18.9
percintile
She’s conscious, alert, oriented, not in pain, not in RD, pale, average body built, lying flat on bed, anxious, connected to IV line
Physical Examination
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hands: no clubbing, no Osler nodes, no Janeway
lesions Face: bilateral periorbital edema with no
redness, no central cyanosis Neck: bilateral neck edema (submandibular)
left more than rt side, soft with no redness, no scars, no clear edges, no LN enlargement
CHEST: no scars, normal abdominal breathing symmetrical, no deformity, resonant in percussion, EAE, vesicular, no added sounds
Physical Examination
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CVS: S1 + S2 + 0 Abdomen: no distention, no scars, soft, lax,
not palpable spleen, liver 2 cm BCM span: 6-7 cm
MSK: Lt knee swelling, redness, tenderness, with Limitation of movement
Lower limb: no edema
Physical Examination
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WBC 22.4 (90% NE) HB 7.2 (MCV, MCH NORMAL) RETIC >3 PLT 69 (WAS 100 the day before) CRP 64.6 ESR 140 NA 122 K 4.5 Ca 7.1 BUN 26 Crea .83 SERUM ALB 1.77 TOTAL PROTEIN 6 URIC ACID 9.6 C3 .19 C4 .03 ASO TITER <
49.9 URINE ANALYSIS: PROTEIN >300 , ERYTHROCYTE
NUMEROUS ,, BACT NUMEROUS ALB/CREA RATIO 226 = MICROALBUMINURIA (30-300) BLOOD,THROAT AND URINE C/S were taken
Admission investigation
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7 yrs old girl with edema, arthritis, ? Malar rash,
hemolytic anemia, thrombocytopenia, proteinuria, hypoalbuminemia, uremia, low C3 and low C4
? HUS ? SLE ? PIGN ? MALARIA ? Henoch-Schonlein purpura
Differential diagnosis
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While hospitalized on the Floor:
Clinically: she developed Ascitis, lower limb edema, oliguria, hematuria (tea colored)
vitally: no hypertension, normal RR, normal PR, with spikes of fever
by u/s anasarca (pleural effusion & mild pericardial effusion + ascitis) Her BUN was gradually rising and crea was up to 1.2-1.3 range ? ARF
she was receiving IV diuretics and IV albumin along with fluids restriction
HOSPITAL COURSE
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Bl c/s taken 3 times: showed S.pneumonia twice and last
one was –ve but pt was already on Abx since admission so she had Bacteremia + fever + GN+ hemolytic anemia
with conjunctival hemorrhage and positive RF ?IE so Echo was done: normal
although she is on Abx, Still she's Febrile and there's no clear source of this bacteremia +left knee arthritis though improved but still not completely back to normal ?osteomylitis – bone scan done not diagnostic for osteomyelitis
HOSPITAL COURSE
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She also had melena (occult blood in stool
analysis) then she vomited blood that’s why she was transferred to PICU ?GI bleeding
HOSPITAL COURSE
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In PICU: She was receiving blood products FFP, PLTS and PRBC along
with IV Steroids, Diuretics and oral and IV antihypertensive medications.
She had 12 hrs of oliguria then UO improved on Lasix drip with 1-2ml/kg/hr. She developed 4-5 days later gradual oxygen requirements with evidence of pulmonary hemorrhage by bronchoscopy IV cytoxan was added along with Novo 7. She was on high vent settings for 1 week// BAL positive for ESBL Klebsiella. She received 3 hemodialysis sessions for uremia, fluid overload and to decrease bleeding tendency.
She developed worsening severe subcutaneous emphysema on her last day of life.
HOSPITAL COURSE
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ANA: negative ANA: 1:320 ANA: 1:320 Anti DNA DS: -ve Anti DNA DS: 1:40 Anti DNA DS: -ve CH50 : LOW <13 (31-60) Factor VIII associated antigen: 260 (50-217) high Anti DNASE (SO) normal Anti smith (SO) 8 (<1) high Beta 2 glycoprotein Igg, Igm, IgA normal Coombs test 1-indirect –ve 2-direct weak +ve +ve RF Low c3, c4 ANCA and PANCA both negative Anti-GBM ?
Autoantibodies labs
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SLE
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Is a multisystem disorder of unknown etiology characterized by a
production of large amount of circulating autoantibodies Many of the clinical manifestations are mediated directly or
indirectly by antibody formation and the creation of immune complexes.
It mostly affects skin, joints, kidney, blood forming cells, blood vessels and CNS
SLE in children is fundamentally the same disease as in adults, with similar etiology, pathogenesis, clinical manifestations, and laboratory findings. However, the care of children and adolescents with SLE is different from that of adults because of the impact of the disease and its therapy on physical and psychologic growth and development
Definition SLE
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Childhood SLE affects girls more often than
boys (8:1) In retrospective reviews from France, Canada,
and the United Kingdom, the median age of onset of juvenile SLE was 12 to 13 years, with the disease developing in the majority of patients after eight years of age
epidemiology
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The most common initial symptoms are the
gradual onset of fever, weight loss, and malaise with general deterioration over several months, although some children have acute or even life-threatening symptoms
Clinical manifistation
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In retrospective reviews from France and Canada, the most
common presenting manifestations were as follows : Hematologic – Anemia, lymphopenia, leukopenia, and/or
thrombocytopenia Mucocutaneous – Malar rash and/or oral ulcers Musculoskeletal – Arthritis or arthralgia Fever Renal abnormalities – Nephritis and nephrotic syndrome
These manifestations, in addition to seizures and lymphadenopathy, are more common in childhood-onset lupus than adult-onset lupus, whereas Raynaud phenomenon and pleuritis are more common manifestations in patients who are adults at disease onset
Clinical manifistation
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hematologic abnormalities: will be discussed presence of autoantibodies: will be discussed markers of inflammation : high ESR, CRP vitamin D deficiency:
Avoidance of sun exposure and renal disease playing a role in that.
Some studies shows that hypovitaminosis D may have contributed to the development of active disease
Hypocomplementemia: Low C3, low C4 and, decreased complement function (CH50)C3 and C4 are used to moniter therapy effectivenessMuscle enzymes
laboratory findings
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The
Systemic Lupus International Collaborating Clinics (SLICC) group classification criteria for SLE is a revised and validated version of the American College of Rheumatology (ACR) criteria used for adults
diagnosis
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A patient is classified as having SLE if four or
more of the SLICC criteria, including at least one clinical and one immunologic criterion, are present either serially or simultaneously, during any interval of observations, in the absence of another explanation for the findings.
An alternative requirement is positive antinuclear antibodies (ANA) or anti-double-stranded DNA antibodies (anti-dsDNA) in conjunction with biopsy-proven lupus nephritis.
DIAGNOSISSLICC CRITERIA
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Children with two or three classification
criteria may go on to develop a fourth over time. The key to proper care is to appropriately treat the manifestations present when the child is first seen and to carefully follow those who present with fewer than four criteria for the development of additional findings over time. Such progression may occur over a period of three to five years or longer
DIAGNOSISSLICC CRITERIA
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DIAGNOSTIC CRITERION (1) Acute Cutaneous Lupus OR Subacute
Cutaneous LupusAcute cutaneous lupus: lupus malar rash (do not count if malar discoid), bullous lupus, toxic epidermal necrolysis variant of SLE, maculopapular lupus rash, photosensitive lupus rash (in the absence of dermatomyositis) Subacute cutaneous lupus: nonindurated psoriaform and/or annular polycyclic lesions that resolve without scarring, although occasionally with postinflammatory dyspigmentation or telangiectasias)
DIAGNOSTIC CRITERION (2) Chronic Cutaneous LupusClassic discoid rash localized (above the neck) or generalized (above and below the neck), hypertrophic (verrucous) lupus, lupus panniculitis (profundus), mucosal lupus, lupus erythematosus tumidus, chillblains lupus, discoid lupus/lichen planus overlap
CLINICAL CRITERIA(MUCOCUTANEOUS)
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DIAGNOSTIC CRITERION (3) Oral Ulcers OR Nasal Ulcers
Oral: palate, buccal, tongueNasal ulcersIn the absence of other causes, such as vasculitis, Behcet’s disease, infection (herpesvirus), inflammatory bowel disease, reactive arthritis, and acidic foods
DIAGNOSTIC CRITERION (4) Nonscarring alopeciaDiffuse thinning or hair fragility with visible broken hairs, in the absence of other causes such as alopecia areata, drugs, iron deficiency, and androgenic alopecia
CLINICAL CRITERIA(MUCOCUTANEOUS)
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EPIDEMIOLOGY:
maculopapular rash, discoid lesions, nonscarring alopecia, cutaneous vasculitis, and Raynaud phenomenon are less common findings of skin involvement in children
CLINICAL CRITERIA(MUCOCUTANEOUS)
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DIAGNOSTIC CRITERION (5) Synovitis involving 2 or more
jointsCharacterized by swelling or effusionOR tenderness in 2 or more joints and at least 30 minutes of morning stiffness.
EPIDEMIOLOGY: the most common musculoskeletal findings in children with SLE are: arthritis and arthralgias. Bone abnormalities include osteopenia and osteonecrosis.
These findings are primarily due to glucocorticoid toxicity.
CLINICAL CRITERIAMUSCULOSKELETAL
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DIAGNOSTIC CRITERION (6) SEROSITIS
Typical pleurisy for more than 1 day OR pleural effusions OR pleural rubTypical pericardial pain (pain with recumbency improved by sitting forward) for more than 1 day OR pericardial effusion OR pericardial rub OR pericarditis by electrocardiographyIn the absence of other causes, such as infection, uremia, and Dressler’s pericarditis
CLINICAL CRITERIASEROSITIS
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EPIDEMIOLOGY (CARDIAC ABNORMALITIES):
Pericarditis is the most common cardiac abnormality in children with SLE, but other problems, such as myocarditis, valvular disease (eg, endocarditis), and coronary artery disease (CAD), can occur.
Cardiac abnormalities in children with SLE are often silent
The prevalence of clinical heart disease among children with SLE ranges in various studies from 12 to 54 percent.
CLINICAL CRITERIASEROSITIS
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EPIDEMIOLOGY (PULMONARY INVOLVEMENT):
Most reviews of childhood lupus report respiratory findings in 30 to 50 percent of cases, with pleuritis which is inflammation of the parietal and visceral pleura being the most common finding
Acute pulmonary hemorrhage and pulmonary hypertension are the most severe forms of lupus-associated pulmonary involvement, although they occur infrequently in children with SLE.
Other pulmonary manifestations of SLE in children include pneumonia, shrinking lung syndrome, pneumonitis, and pneumothorax.
CLINICAL CRITERIASEROSITIS
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DIAGNOSTIC CRITERION (7) Renal diagnostic criteria
Urine protein–to-creatinine ratio (or 24-hour urine protein) representing 500 mg protein/24 hours OR red blood cell casts
EPIDEMIOLOGY: Renal involvement in SLE may vary from the detection
of hematuria and proteinuria on routine examination to the presence of nephrotic syndrome or acute renal failure.
SLE nephritis occur in 50-70% of children with SLE
CLINICAL CRITERIARENAL
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DIAGNOSTIC CRITERION (8) Neurologic diagnostic criteria
Seizures, psychosis, mononeuritis multiplex(in the absence of other known causes such as primary vasculitis), myelitis, peripheral or cranial neuropathy (in the absence of other known causes such as primary vasculitis, infection, and diabetes mellitus), acute confusional state (in the absence of other causes, including toxic/metabolic, uremia, drugs)
EPIDEMIOLOGY: Headache is a frequent complaint. Adolescents commonly present with progressive deterioration
in academic performance, withdrawal, depression, and social isolation.
More dramatic neurologic presentations of SLE include seizures, chorea, stroke, dementia, and coma.
CLINICAL CRITERIANEUROLOGICAL
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DIAGNOSTIC CRITERION (9) Hemolytic anemia
EPIDEMIOLOGY: The most common types of anemia in children
with SLE are anemia of chronic disease, iron deficiency anemia, and autoimmune hemolytic anemia (AIHA)
CLINICAL CRITERIAANEMIA
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DIAGNOSTIC CRITERION (10) Leukopenia (<4000/mm3)
OR Lymphopenia (<1000/mm3)Leucopenia at least once: In the absence of other known causes such as Felty’s syndrome, drugs, and portal hypertension. Lymphopenia at least once: in the absence of other known causes such as corticosteroids, drugs, and infection
EPIDEMIOLOGY: Leukopenia occurs in nearly two-thirds of children at some
point during the course of illness (in form of lymphopenia)
CLINICAL CRITERIALEUKOPENIA
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DIAGNOSTIC CRITERION (11) Thrombocytopenia
(<100,000/mm3)At least once in the absence of other known causes such as drugs, portal hypertension, and thrombotic thrombocytopenic purpura
EPIDEMIOLOGY: Thrombocytopenia: (ITP), usually a disease sui generis, may be
the first manifestation of SLE. This evolution occurs in up to 15 percent of patients with ITP. Thus, it is important that the clinician caring for a child with a positive ANA and ITP periodically look for evidence of SLE manifestations in other organ systems
CLINICAL CRITERIATHROMBOCYTOPENIA
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DIAGNOSTIC CRITERION (1) ANA level above laboratory reference range
EPIDEMIOLOGY: ANA: is positive in > 97% of SLE pt. -ve ANA has a high negative predictive value
for SLE
DIAGNOSTIC CRITERION(2) Anti-dsDNA antibody level above laboratory reference range (or 2-fold the reference range if tested by ELISA)
EPIDEMIOLOGY: Anti DS DNA is almost exclusively in SLE, vary with disease activity.
DIAGNOSTIC CRITERION (3) Anti-Sm: presence of antibody to Sm nuclear antigen
EPIDEMIOLOGY: Anti smith abs found in 30% of the cases and it’s specific
IMMUNOLOGIC CRITERIA
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DIAGNOSTIC CRITERION (4) Antiphospholipid antibody positivity, as determined by
Positive test for lupus anticoagulant False-positive test result for rapid plasma reagin Medium- or high-titer anticardiolipin antibody level (IgA, IgG, or
IgM) Positive test result for anti–2-glycoprotein I (IgA, IgG, or IgM)
EPIDEMIOLOGY: These are found with varying frequency and are less strongly
associated with SLE Children and adolescents with SLE who have aPL should be
presumed to have the same increased risk of developing a clotting disorder as adults with aPL
IMMUNOLOGIC CRITERIA
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DIAGNOSTIC CRITERION (5) Low complement (C3, C4,
or CH50)
DIAGNOSTIC CRITERION (6) Direct Coombs’ test (in the absence of hemolytic anemia)
IMMUNOLOGIC CRITERIA
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Corticosteroid NSAIDs for arthritis Hydroxychloroquine as maintenance and for lupus
skin dz These are not sufficient for SLE nephritis or cerebritis Cyclophosphamide is effective for the worst form of
SLE nephritis. Also CNS lupus resonds to it Steroid sparing agents – azathioprine, methotrexate
may be indicated for pt. not able to tolerate steroid tapering
TREATMENT
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Avoid sun exposure flaring of the dz Ca and Vit D (prolonged corticosteroid use) to
prevent osteopenia Early treatment of hyperlipidemia to prevent
long-term CVS complications
PREVENTION
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Thanks for: Dr. May Salem Dr.Husam Althagafi Dr.Abdulkarim Akila
Thank you