Case presentation Dr Rammohan Reddy 1 st 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, G 3 P 3 L 3.
Personal history Diet Appetite Sleep Bowel and bladder Addictions : mixed : normal : adequate : regular : 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= 98.6 O 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 entrypresent, 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.mm Peripheral Smear: Normocytic / Normochromic. ESR 80mm/1 st 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