Case for Discussion: January 2017

A 32-year-old male presented with pain and swelling of small and large joints of upper and lower limbs, associated with early morning stiffness of 1 hour since one and half months. Physical examination revealed dryness of skin and mouth, excessive dandruff and scaly erythematous pruritic rashes over ears, upper eyelids, elbows and knees (Fig. 1-3). There was a history of weight loss of around 5 kg in past one month, lethargy and generalized weakness. The patient had developed breathlessness on exertion since 2 days prior to admission. There was no history of fever, weight loss, loss of appetite, dry cough, photosensitivity, oral ulcers, swallowing difficulty, Raynaud's phenomenon, loose stools, hematuria or bleed per rectum. No comorbidities were reported. The patient was an occasional smoker and not an alcoholic. No familial history of arthritis or similar complaints was present.

On examination, the patient was afebrile and comfortable at rest. His pulse rate was 90/min, regular and all peripheral pulses were palpable. Blood pressure was 110/80 mm Hg. The tip of the right index finger was mildly tender and had a bluish discoloration. All small and large joints of upper and lower limb were tender and swollen with restriction of wrists, knees and ankles. Power was  4+/5 in bilateral arms and thigh. Systemic examination including central nervous system, cardiovascular, respiratory and per abdomen was unremarkable. The results of clinical and lab investigations are given in table 1.

Fig 1: Scaly erythematosus lesions over knees

 

Fig 2: scaly erythematosus lesions over elbows

 

Fig 3: scaly erythematosus lesions over upper eyelids

 

Table 1: Results of clinical and lab investigations

Investigations

1st

visit

2nd

 visit

Hemoglobin (gm/dL)

12.4 

 

Total WBC count (cells/cumm)

6100 

 

Neutrophils (%)

75.8 

 

Basophils (%)

0.2 

 

Lymphocytes (%)

15.6 

 

Eosinophils (%)

2.8 

 

Monocytes (%)

5.6 

 

ESR (Westergren's method) (mm/hour)

60 

 

Platelet count (lakh/ cu.mm)

2.18 

 

RBC count (g/dL)

4.4 

 

Random blood sugar (mg/dL)

76 

 

S.G.O.T [A.S.T] (IU)

72 

 

S.G.P.T [A.L.T] (IU)

20 

 

Creatinine (Kinetic Jaffe) (mg/dL)

0.9 

 

ANA immunofluorescence (1:40 dilution)

Positive 1+ speckled pattern 

 

Creatinine phosphokinase (C.P.K) (Kinetic IFCC method)

 62 

 

RF-Nephelo

<20.0 

 

Hepatitis b surface antigen (HBsAg) (rapid)

Non reactive 

 

Hepatitis'c' virus antibody (rapid)

Non reactive 

 

Total bilirubin (Modified Jendrassik)

0.8 

 

Direct bilirubin (modified jendrassik)

0.3 

 

Indirect bilirubin

0.5 

 

alkaline phosphatase (kinetic)

56 

 

GAMMA GT

50 

 

Total protein

6.8 

 

Serum albumin

3.7 

 

Globulin

3.1 

 

AG ratio

1.2 

 

F-actin

 

Negative,<6.0 

HIV

 

Non reactive test value:0.1 

Anti cardiolipin antibody (IgG) ELISA

 

Negative test:3.3 

Anti cardiolipin antibody (IgM)

 

Positive test:18.4 

B2GPIGG

 

Negative test:5.5 

B2GPIGM

 

Positive test:36.5 

DIL russel viper venom time(drVVT Screen)

 

73.5 

DRVVT After dilution with normal plasma(1:1 Test : Control)

 

56.8 

DRVVT excess of phospholipid(drVVT confirm)

 

39.6 

Normalised drVVT ratio

 

1.8 

Impression

 

The above sample is positive for lupus anticoagulant.

Test

 

42.7 

Control

 

25.1 

D dimer

 

 

C3-nephelo

 

 

Complement c4

 

 

Ferritin by CLIA

 

 

QuantiFERON TB Gold In tube method

 

 

Antineutrophilic cytoplasmic antibody (ANCA) By immunofluoroscence,1:10 dilution

 

 

Anti streptolysin 'O' titre (Quantitative immunoturbidometric method)

 

 

L.D.H total

 

 

blood c/s

 

 

TEST (Mean of duplicate reading)

 

 

CONTROL

 

 

INR

 

 

Colour

Pale yellow 

 

Appearance

Clear 

 

Leucocytes

1-2/hpf 

 

RBCs

Absent 

 

Epithelial cells

1-2/hpf 

 

Casts

Absent 

 

Crystals

Absent 

 

Hematocrit (pcv)

36.4 

 

M.C.V

82.4 

 

MCH

28.1 

 

MCHC

34.1 

 

RDW

12.8 

 

PDW

10.00 

 

MPV

9.30 

 

P-LCR

19.80 

 

CRP-NEPH

16.90 

 

Reaction

6.0 (Acidic) 

 

Specific gravity

1.010 

 

Protein

Negative 

 

Sugar

Negative 

 

Ketone bodies

Negative 

 

Urobilinogen

Normal 

 

Bile pigment

Negative 

 

NIT

Negative 

 

 

Please proceed for discussing the case..