Presented by Ravi Jain and Uzma Kamal 3rd Semester MBBS 2015
A 60 years old female patient was suffering from:
oral ulcer and oral mucosal bleeding(left side),
saliva mixed with blood,skin peeled off from mid sole,
pain and swelling in the multiple joints for 2-3 yrs
On examination:
Her RBC Count was 2.45,
Hb 5.4,
platelets 51000,
TLC 1200,
PCV 18.
She was taking methotrexate.
Assessment -
1. Pancytopenia
2. Rheumatoid arthritis.
To be supplemented by further inputs from other observers.
Conversational Clinical decision support:
A 60 years old female patient was suffering from:
oral ulcer and oral mucosal bleeding(left side),
saliva mixed with blood,skin peeled off from mid sole,
pain and swelling in the multiple joints for 2-3 yrs
On examination:
Her RBC Count was 2.45,
Hb 5.4,
platelets 51000,
TLC 1200,
PCV 18.
She was taking methotrexate.
Assessment -
1. Pancytopenia
2. Rheumatoid arthritis.
To be supplemented by further inputs from other observers.
Conversational Clinical decision support:
Comments
Uzma Kamal She is having rheumatoid arthritis since 10 years. Pain started from her left hand associated with swelling and stiffness of joints. After consulting with doctor pain and swelling subsided for some times.
Then after a month she started feeling pain on benfing knee and then pain gradually radiate towards ankle and hip joints.
Then on investigation it was diagnosed to be rheumatoid arthritis. Since then she was on medication.
Now she complainted, a month ago she felt swelling on the left side of her oral gum along with pain which aggrevates on chewing or talking. 3 days before admitting here she was having fever and bleeding from her oral mucosa.
Then after a month she started feeling pain on benfing knee and then pain gradually radiate towards ankle and hip joints.
Then on investigation it was diagnosed to be rheumatoid arthritis. Since then she was on medication.
Now she complainted, a month ago she felt swelling on the left side of her oral gum along with pain which aggrevates on chewing or talking. 3 days before admitting here she was having fever and bleeding from her oral mucosa.
Rakesh Biswas Boudhayan please share her X ray hands with Dr Nidhitomorrow. I am sure it will show some very significant erosions like our recent last patient with similar hands along with a scleroderma overlap.
Rakesh Biswas Dr Nidhi i wish our PACS system was activated and accessible online to further support such discussions.
Boudhayan Dm Has the X Ray hands been done? I have seen the Chest X Ray but not X Ray Hands . I guess the focus was different this time. Nidhi Sehgal Maam I was going through few articles on role of USG in articular diseases..... Few of my seniors in Immunology used to practice it..... How far are we applying that here ? My topic of interest( departure from this patient though) is USG of Thyroid apart from mastering other USGs( Inspired by You Sir Rakesh Biswas)
Praveen Ky Patient has inflammatory arthritis and on methotrexate.IMage is showing deformities of hands.possibilities are 1. Rheumatoid arthritis with pancytopenia probably related to methotrexate or related to feltys syndrome related to RA.Foot ulcer could be vasculitis related.
2. CONNECTIVE TISSUE DISORDERS -SLE with pancytopenia/ mixed connective tissue disease
3.Other differentials are sarcoidosis /behcets/other vasulitic disorders like PAN/ mPan/ churg Strauss
Evaluation would require
Esr/ crp
ANA profile /RA FACTOR/ anti Ccp
Uss abd for splenomegaly
ACE and c Anca/ P Anca if above tests are negative
Bone marrow examination if required
2. CONNECTIVE TISSUE DISORDERS -SLE with pancytopenia/ mixed connective tissue disease
3.Other differentials are sarcoidosis /behcets/other vasulitic disorders like PAN/ mPan/ churg Strauss
Evaluation would require
Esr/ crp
ANA profile /RA FACTOR/ anti Ccp
Uss abd for splenomegaly
ACE and c Anca/ P Anca if above tests are negative
Bone marrow examination if required
Rakesh Biswas Thanks for the detailed inputs Dr Praveen. This will definitely benefit our students. As the history taken today by our student Uzma suggests a long term course of illness for 10 years and with the classic deformities and bilaterally symmetrical hand erosions we can safely limit the diagnosis to Rheumatoid arthritis in this classic case (Prof Michele for her inputs here). She had stopped Methotrexate since the last 6 weeks and was recently on Salfasalazine and as our suspicion of her pancytopenia hovers around drug induced, currently we are thinking it could be sulfasalazine as a possible culprit for her severe anemia. Boudhayan it would be nice if you could find something around salfasalazine induced pancytpenia. Uzma can you share the image of her oral cavity with the bleeding soft tissue tumor?
Rakesh Biswas Uzma, Ravi can you share the images of her CXR pa and also let us have some more details of her cought. Her CXR pa view is suggestive of another chronic problem that usually occurs in this disease and recently we had even published one such case in the BMJ after extensive discussions here in tabula rasa Boudhayan
Uzma Kamal From day before yesterday she is having severe cough. Today she was given oxygen mask because of breathlessness.
Sorry sir i didn't asked her past histroy of cough.
Sorry sir i didn't asked her past histroy of cough.
Rakesh Biswas Uzma the patient's name is visible in both the CXRs pa that you have shared here. Please crop them and re-upload and we shall delete these.
Boudhayan Dm HRCT Thorax tomorrow Sir...... Nidhi Sehgal Maam this the patient who had this oral cavity mass and for whom we could not do CECT Head and Neck as advised by Dental because of raised Serum Creatinine
Boudhayan Dm Rakesh Biswas SIR should we add or not antibiotics...... As infective exacerbation is more common in our country than eosinophilic one .... In these context let me introduce my teacher Dr Angira Dasgupta who is a pioneer in Airway diseases in the world . Maam request you for your kind opinion. Pt has already received abt 5 days of augmentin but her cough has worsened.... More productive now with white mucoid sputum. We have budecort nebulization. Will she require Macrolides or Steroids...... Wish we had the sputum analyzer which you have set up at my Alma mater
Rakesh Biswas How do we know infective exacerbation is more common in our country (and less common in others) Boudhayan? 
:-)
:-)
Rakesh Biswas Boudhayan the nasopharynx is predominantly colonized with non-hemolytic and alpha-hemolytic Streptococci and Neisseria species with occasional carriage of Streptococcus pneumonia and Haemophilus influenzae.Determining the prevalence of bacteria in the lower respiratory tract has proved problematic due to the difficulty of obtaining lower respiratory tract samples uncontaminated by upper airway secretions.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437812/ Request, more inputs on this and the paper you shared from Sanchita and Biswaroop
Rakesh Biswas Here's another very interesting paper on this topic:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937108/
Boudhayan Dm Nidhi Sehgal Maam could u kindly discuss the Radiological findings for the UG students( X ray Hands and X ray Chest
Nidhi Sehgal I will see it tomorrow on xray moniter...and will surely discuss
Boudhayan Dm Could we ask our Radiology teachers to kindly discuss the HRCT findings
Nidhi Sehgal On hrct...there was bronchiectasis with peribronchial cuffing and patchy ground glass opacities in bilateral lower lobes...
Nidhi Sehgal These features may be pulmonary manifestions in RA...but only this much don't favour ild
Praveen Ky That finding would correlate with interstitial lung disease due to rheumatoid arthritis
Rakesh Biswas Uzma please share her HRCT findings with us here.
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