20F Lupus clinical complexity EHR deidentified horcrux links to all three admissions and follow up

 Summary: 

This patient was first presented to Prof Michele Meltzer  in Jan 25, 2022 (link: https://youtu.be/X5NBa_0VVUw?feature=shared) in this CPD linked here: https://medicinedepartment.blogspot.com/2022/12/?m=1 and she first presented to the presenters in September 2022 which is recorded in the link below but to summarise it drastically, she had nephrotic glomerular proteinuria, cutaneous vasculitic lesions, CNS vasculitic lessons (investigated for altered cognition) and endocardial and pericardial inflammation (acute heart failure with pericardial effusion)that was attributed to lupus in view of a strong ANA positivity particularly of the ds-dna fraction in ELISA. https://medicinedepartment.blogspot.com/2024/08/first-admission-september-2022-20f-with.html?m=1

Second admission: She again got admitted in December 2022 with headache, altered sensorium and meningeal signs, which was associated with a minor CNS bleed on MRI was later attributed to warfarin (link:

https://drsaicharankulkarni.blogspot.com/2022/12/20f-sle.html?m=1

Her discharge after September 2022 was relatively uneventful on immunosuppressives and while her cardiac and CNS issues were the first to resolve even during admission, her proteinuria also subsided and she gradually withdrew all immunosuppressives in a year with a brief period of iatrogenic Cushing in between. Recently in June 2024, she presented with an ankle flare along with anasarca that also revealed a nephrotic relapse on evaluation of 24 hour urine protein as archived in her PaJR conversations here:https://drsaicharankulkarni.blogspot.com/2022/12/20f-sle.html?m=1

Her 3rd admission recently in July 2024 was for a right hypochondrial pleuritic pain that ultimately revealed a large hydropneumothorax along with multiple lung abscesses. Again this was possibly an iatrogenic result of the high dose immunosuppressives for just a month! There's still a persistent diagnostic uncertainty around the etiology of her lung abscesses and hydropneumothorax as her dry cough persists and her last antibiotics choice was quinolone!https://drsaicharankulkarni.blogspot.com/2022/12/20f-sle.html?m=1

4th admission PaJR update:

[27/08, 14:18]  2020 Pg: Pgs on duty this patient is at OPD please look into this. Preeented with cough

[27/08, 14:34] PaJR moderator: Please ask her to come to ICU

[27/08, 14:54] 2020 Pg: Informed them to meet you in icu sir

[27/08, 15:26] PaJR moderator: Reviewed her in ICU:

Persistent cough

Reduced weight

Anorexia nausea

Will need to be treated for tuberculosis 

We shall repeat chest X-ray, repeat sputum AFB, CBNAAT

[27/08, 15:32] 2020 Pg: Infection causing chronic systemic inflammation sir..?

[27/08, 15:36] PaJR moderator: Her pulmonary issues appear to be tuberculosis as a result of her immunosuppression for Lupus nephritis. They seem to have abruptly stopped her steroids since one month of her discharge and is currently complaining of nausea. Checking her postural BP to add weightage to a possibility of Addison's

[27/08, 15:41] Metacognitist Mover and Shaker1: Addisons mediated by TB or just Glucocorticoid mediated Adrenal Insufficiency?

[27/08, 15:44] PaJR moderator: Yes both are casting their shadows

[27/08, 15:44] PaJR moderator: BP supine 110/70

Standing 90/60

[27/08, 15:45] Metacognitist Mover and Shaker1: This fantastic review should help!

[27/08, 15:47] Metacognitist Mover and Shaker1: I would definitely consider a  9am fasting cortisol at least. Not very expensive and can be useful to diagnose adrenal insufficiency.

Putting her on Hydrocort without this would be quite risky.

[27/08, 15:50] Metacognitist Mover and Shaker1: Quick primer on what steroids can do to the immune system and which organisms can be possible culprits.

[27/08, 16:04] PaJR moderator: We can just restart low physiological dose

[27/08, 16:09] PaJR moderator: @⁨Pushed Communicator 1N22⁩ @⁨Kims PG 2023⁩ Let's start her on Tablet prednisolone 5mg morning (now) and 2.5 mg at night

[27/08, 16:09] Pushed Communicator 1N22: Ok sir

[27/08, 16:12] PaJR moderator: This is her today's chest X-ray and it's remarkably better with disappearance of prior hydropneumothorax and lung abscess shadows with some hint of a residual pleural effusion or thickening. @⁨Pushed Communicator 1N22⁩ please do her chest pleural ultrasound and share the video

[27/08, 16:13] Pushed Communicator 1N22: Okay sir

[27/08, 16:17] Pushed Communicator 1N22: Todays 👆

[27/08, 16:20] PaJR moderator: Let's hope it's all just tuberculosis!

[31/08, 10:29] PaJR moderator: Yesterday for the first time in last one month she didn't cough at night and even now since morning her cough hasn't happened. The only intervention after her admission this Tuesday was restarting her physiological dose of steroids and stopping her previous antibiotics.

She continues to be on the 50 mg azathioprine.

@⁨Pushed Communicator 1N22⁩ @⁨PG 2023⁩ please share her urine for 24 hour protein and creatinine report readied yesterday

[31/08, 10:35] PaJR moderator: Her urine for 24 hour urine protein and creatinine suggests her lupus nephritis is in remission now!

[31/08, 10:39] PaJR moderator: WBC counts since admission has also reduced! Did restarting low dose physiological steroids here have any role!

[31/08, 10:49] PaJR moderator: Just for the record she was also on azathioprine and prednisolone from September 2022 to April 2023