22yr old female with HEPATITIS 2° to drug induced(herbal medication?) with AUTOIMMUNE HEMOLYTIC ANEMIA? LICHEN PLANUS?

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."


ADMITTED ON 29/10/21(FRIDAY) 

A 22 YRS OLD FEMALE CAME TO THE CASUALITY WITH 1)C/O FEVER SINCE 10DAYS,
2) C/O RASHES OVER BODY WITH ITCHING SENSATION SINCE 4 DAYS

The patient was apparently asymptomatic 1 month back when she developed rashes over her legs and arms and abdomen after contact with something in her family's lemon field. For this, they visited a local doctor the next day, who prescribed her steroid ointment (halobetasol propionate) and oral medication, which she took for 10 days. The rashes subsided, however, blackish discoloration remained over the skin. 

 10DAYS AGO,THEN SHE DEVELOPED FEVER -ON AND OFF ,HIGH GRADE A/W CHILLS ,
& GENERALISED BODY PAINS+,FEVER DECREASED ON MEDICATION
ALSO HAD VOMITINGS 10DAYS AGO (NON-BILIOUS,NON-PROJECTILE) 4-5 EPISODES PER DAY FOR 2DAYS

PT WENT TO LOCAL RMP 8DAYS AGO FOR FEVER AND JAUNDICE AND WAS DIAGNOSED AS TYPHOID FOR WHICH SHE GOT TREATED SYMPTOMATICALLY

PATIENT SAYS THAT SHE HAVE TAKEN HERBAL MEDICATION(?) 5DAYS BACK ON 26/10/2021 (TUESDAY)FOR JAUNDICE 
(WENT TO HERBAL PRACTITIONER WITH C/O FEVER ON AND OFF FOR 10 DAYS AND 2 DAYS VOMITING EPISODES)
FOLLOWING WHICH SHE DEVELOPED RASHES OVER THE LIMBS /BODY NEXT DAY(4DAYS BACK)

H/O GENERALISED EDEMA ALL OVER THE BODY SINCE 3DAYS 
 
NO H/O DECREASED URINE OUTPUT AND ABDOMINAL DISTENSION
NO H/O COLD & COUGH

N/K/C/O DM,TB, ASTHMA, CVA, CAD, EPILEPSY

PERSONAL HISTORY
APPETITE: NORMAL
DIET: VEGETARIAN
REGULAR BOWEL & BLADDER MOVEMENTS
ADEQUATE SLEEP
NO ADDICTIONS

GENERAL EXAMINATION
PT IS C,C,C
PALLOR - PRESENT
ICTERUS-PRESENT
GENERALISED EDEMA -PRESENT
RASHES PRESENT ALL OVER THE BODY

NO CYANOSIS, CLUBBING, LYMPHADENOPATHY, 
VITALS-
TEMP- 101 F
PULSE- 120 bpm
RR- 20 cpm
BP- 90/70 mmHg
SPO2- 99@ROOM AIR
GRBS- 86 mg/dl

SYSTEMIC EXAMINATION
CVS: S1S2 ,NO MURMURS
RS: BAE+,NVBS+
CNS: NFD
P/A: SOFT, NON-TENDER

INVESTIGATIONS:(29/10/2021)
1)HEMOGRAM:
2)CUE:
3)BLOOD GROUP:
4)PT,INR:
5)APTT:
6)LFT:
7)RFT:
8)RBS:
9)RAPID DENGUE TEST:
10)ECG:

11)USG ABDOMEN:
-GALLBLADDER EDEMA,
-MILD SPLENOMEGALY
-MINIMAL ASCITES

12)2D-ECHO:

DVL REFERRAL DONE:
O/E: DIFFUSE ERYTHEMATOUS (NON BLANCHABLE) PURPURA OF VARIABLE SIZE ARE NOTED OVER THE BODY i.e,BOTH UPPERLIMBS,LOWER LIMBS,CHEST, ABDOMEN,BACK &GROINS
EDEMA IS NOTED(FACIAL)
NO ORAL , GENITAL MUCOSAL INVOLVEMENT.
DIAGNOSIS:DRUG RASH -(DRESS SYNDROME)
TREATMENT SUGGESTED:
1.STOP THE OFFENDING DRUG
2.TAB.ATARAX 25MG OD x 2WEEKS
3.VENUSIA MAX LOTION L/A BD x 2WEEKS

OUTSIDE REPORTS:


DIAGNOSIS: DRUG RASH WITH EOSINOPHILIA and SYSTEMIC SYMPTOMS-(DRESS SYNDROME)

TREATMENT GIVEN HERE :(29/10/2021)
1.T.UDILIV 300mg PO/BD 
2.SYRUP. LACTULOSE 15ml PO/OD IN NIGHT
3.T.ATARAX 25mg PO/OD IN NIGHT
4.T.PCM 500mg PO/SOS
5.T.RIBOFLAVIN 10MG PO/BD

DAY-2:(30/10/2021)
Soap notes
S: 
Itching decreased
Rashes present 

O:
PR: 92bpm
Bp: 110/80mmhg
Temp: 98.5F
RR:18cpm
Cvs:s1,s2heard
Rs:BAE+
CNS:NFD

Generalised edema present.
Rashes present all over the body

A:
Hepatitis secondary to Drug induced(herbal medication)
INVESTIGATIONS ON DAY2(30/10/2021):
1)HEMOGRAM
2)RETICULOCYTE COUNT:
3)ABSOLUTE EOSINOPHIL COUNT:
4)LFT:
5)LDH:
6)CRP -POSITIVE
7)COOMBS -POSITIVE:
P:
1)Tab.UDILIV 300mg PO/BD
2)SYP.Lactulose 1ml/po/H/s
3)Tab.ATARAX 25mg PO/OD/Hs
4)Tab.RIBOFLAVIN 10MG PO/BD

DAY-3:(31/102021)
Soap notes
Icu 6th bed:
S: 
1 Fever spike at 4:00am
Itching decreased
Rashes present 

O:
PR: 82bpm
Bp: 120/80mmhg
Temp: 99F
RR:18cpm
Cvs:s1,s2heard
Rs:BAE+
CNS:NFD

Generalised edema present.
Rashes present all over the body

A:
Hepatitis secondary to Drug induced(herbal medication)
Investigations on day3(31/10/2021)
1)HEMOGRAM:
2)LFT:
3)S.CREATININE:0.4mg/dl


P:
1)Tab.UDILIV 300mg PO/BD
2)SYP.Lactulose 15ml/po/H/s
3)Tab.ATARAX 25mg PO/OD/Hs
4)Tab.RIBOFLAVIN 10MG PO/BD
5)Tab.PCM 500mg PO/SOS
6)Tab.Zincovit po/od
DAY-4:(01/11/2021)

Icu 6th bed:

S: 
Continuous fever spikes present whole night
Itching decreased
Rashes present 

O:
PR: 120bpm
Bp: 120/80mmhg
Temp: 98.1F@ 7am
RR:18cpm
Cvs:s1,s2heard
Rs:BAE+
CNS:NFD

Generalised edema present.
Rashes present all over the body

A:
Hepatitis secondary to Drug induced(herbal medication)

P:
1)Syp.LACTULOSE 15ml/po/H/s
2)Tab.ATARAX 25mg PO/OD/Hs
3)Tab.RIBOFLAVIN 10MG PO/BD
4)Tab.PCM 500mg PO/SOS
5)Tab.ZINCOVIT po/od
6)Inj.CEFTRIAXONE 1gm/iv/bd(D1)

DVL review done:
O/E: MULTIPLE,VIOLACEOUS,HYPERPIGMENTED PLAQUES AND PAPULES(NON TENDER) NOTED OVER ALL THE FOUR EXTREMITIES, ABDOMEN.
SCALY PLAQUES NOTED OVER THE GROIN(BOTH)
ORAL MUCOSA -PIGMENTATION(BUCCAL MUCOSA)
DIAGNOSIS:
?LICHEN PLANUS
?LICHENOID DRUG ERUPTION+DRUG RASH
ADVICE:
-CRP
-SKIN BIOPSY
TREATMENT SUGGESTED: 
1.STOP THE OFFENDING DRUG
2.VENUSIA MAX LOTION
3.Tab.ATARAX 25mg sos
DAY-5(02/11/2021):
Soap notes

S: 
Fever spikes present
Itching has decreased
Rashes present 

O:
PR: 88bpm
Bp: 120/80mmhg
Temp: 103.5F @ 8am
RR:24cpm
Cvs: S1,S2 heard
Rs: BAE+
CNS:NFD

Pallor+,Icterus+
Generalised edema present.
Rashes present all over the body

A:
Hepatitis secondary to Drug induced(herbal medication)
Haemolytic anaemia
with ?lichen planus ? DRESS syndrome
Investigations on day5(02/11/2021)
1)HEMOGRAM:
2)LFT:
3)RFT:


P:
1)Syp.LACTULOSE 15ml/po/H/s to maintain 2 episodes of loose stools
2)Tab.ATARAX 25mg PO/OD/Hs
3)Tab.RIBOFLAVIN 10MG PO/BD
4)Tab.PCM 500mg PO/SOS
5)Tab.ZINCOVIT po/od
6)Inj.CEFTRIAXONE 1gm/iv /bd *day 2
7)Tab.UDILIV 300mg/BD
7)LULIFIN cream L/A BD
8) plan to start oral steroids if there is further drop in haemoglobin.
DAY-6(03/11/2021):
SOAP NOTES -
S - patient had loose stools ystd - 5 episodes.
No fever spikes ystd night .
Today Mrng -6 am -101 F 

O- icterus+ ,generalised edema + 
Rashes present all over body.
PR- 80/min , regular
BP-110/70 mmHg 
RR-18cpm 

A- ACUTE HEPATITIS -secondary to immune mediated and herbal medication .
Hemolytic anemia 
?lichen planus ? DRESS syndrome .
BLOOD C/S :


P-
1) Inj. Ceftriaxone 1gm/iv/bd
2) Inj Pan 40mg iv/od
3) Tab Dolo 500mg po Qid.
4) Tab Atarax 25mg po
5) Tab Udiliv 300mg po/Bd.
6) Tab Wysdone 60mg/Po /Od

DAY-7(04/11/2021):
Unit-5 ICU bed 6
S:
NO FEVER SPIKES 
NO FRESH COMPLAINTS 

O:
O/E
Pt c/c/c
Temp-97.6
BP- 120/80
PR- 88bpm
CVS-S1 S2 +. No murmurs 
RS- BAE + No crepts 
P/A- soft, non tender
CNS- NAD

A:
Hepatitis secondary to drug induced (?herbal medication),with ? autoimmune hemolytic anemia (secondary to herbal medication),with lichen planus
Investigations on day-7(04/11/2021)

P:
1)Inj.Ceftriaxone 1 gm/iv/BD
2)Inj.Pantop 40 mg iv/OD
3)Tab.DOLO 500 mg po /Qid
4)Tab.Atarax 25 mg HS
5)Tab.UDILIV 300g po/BD
6)Tab . Riboflavin 10 mg/po/OD
7)Tab.zincovit po/OD
8)Tab.WYSOLONE 60 mg /po/OD
9)Lulifin cream L/A BD
10) monitor vitals and inform sos
11)temp charting 4 th hourly
12) venusta max lotion

DAY-8(05/11/2021)
S:
NO FEVER SPIKES 
NO FRESH COMPLAINTS 

O:
O/E
Pt c/c/c
Temp-97.6
BP- 120/80
PR- 88bpm
CVS-S1 S2 +. No murmurs 
RS- BAE + No crepts 
P/A- soft, non tender
CNS- NAD

A:
Hepatitis secondary to drug induced (?herbal medication),with ? autoimmune hemolytic anemia (secondary to herbal medication),with lichen planus
Investigations 
HEMOGRAM:
RFT 
LFT:
P:
1)Inj.Ceftriaxone 1 gm/iv/BD
2)Inj.Pantop 40 mg iv/OD
3)Tab.DOLO 500 mg po /Qid
4)Tab.Atarax 25 mg HS
5)Tab.UDILIV 300g po/BD
6)Tab . Riboflavin 10 mg/po/OD
7)Tab.zincovit po/OD
8)Tab.WYSOLONE 60 mg /po/OD
9)Lulifin cream L/A BD
10) monitor vitals and inform sos
11)temp charting 4 th hourly
12) venusia max lotion
13)tab.doxycycline 100mg po/bd 

Skin biopsy done

Discussion:
" Is there any possibility of histopathological confirmation of the diagnosis in our patient? 

Does the sequence of events in lichen planus in general including symptomatology of events resemble that of our patient? "


Sir, we have sent for skin biopsy. 
But histopathologically lichenoid reactions and lichen planus are similar. 
Also, in this patient the rashes have occurred the next day of taking the herbal medication which presented as erythematous purpura and then later she developed the present itchy violaceous plaque and papule like lesions. 
Provisonals dx- 
1.So the initial purpura can indicate a drug rash which gradually went on to develop a lichenoid drug reaction 
OR
2.The initial one( erythematous purpura) is a drug rash and later ,
The violaceous plaques n papules can be lichen planus itself. 
Etiology of LP in this patient could be herbal medication or idiopathic like in most of the usual lichen planus cases. 
The 5Ps in LP- pruritis, purple, papule , plaque and polygonal - are satisfied in this patient. 

One cannot exactly confirm the diagnosis of whether it is lichen planus or lichenoid drug eruption, specially in this patient due to the use of herbal medication which can be either of the two, but the treatment for both is the same. 
Usual presentation of LP is random without any prior history presents with pruritic violaceous plaques and papules.
But LP can also be caused due to drugs like quinine, quinidine, penicillamine etc.


Provisional dx- 
3) both the conditions- LP AND LICHENOID DRUG ERUPTIONS can co-exist. 
4) since there was no proper documentation of the previous diagnosis of LP - we have now diagnosed the lesions as above. 
LP is an autoimmune disease. This patient has autoimmune hemolytic anemia. The autoimmunity can simply lead to an other autoimmune disease like LP. 
So it can be LP (aggravated by drug use) with a drug rash after herbal med use.


DAY-9:(06/11/2021)
Unit-5 amc, cubicle
S:
NO FEVER SPIKES 
NO FRESH COMPLAINTS 

O:
O/E
Pt c/c/c
Temp-97.6
BP- 120/80
PR- 88bpm
CVS-S1 S2 +. No murmurs 
RS- BAE + No crepts 
P/A- soft, non tender
CNS- NAD

A:
Hepatitis secondary to drug induced (?herbal medication),with ? autoimmune hemolytic anemia (secondary to herbal medication),with lichen planus
Investigations on day-9
HEMOGRAM:
LFT:


P:
1)Inj.Ceftriaxone 1 gm/iv/BD
2)Inj.Pantop 40 mg iv/OD
3)Tab.DOLO 500 mg po /Qid
4)Tab.Atarax 25 mg HS
5)Tab.UDILIV 300g po/BD
6)Tab . Riboflavin 10 mg/po/OD
7)Tab.zincovit po/OD
8)Tab.WYSOLONE 60 mg /po/OD
9)Lulifin cream L/A BD
10) monitor vitals and inform sos
11)temp charting 4 th hourly
12) venusia max lotion
13)tab.doxycycline 100mg po/bd 

DAY-10:(07/11/2021)
Ward

S:
NO FEVER SPIKES 
NO FRESH COMPLAINTS 

O:
O/E
Pt c/c/c
Temp-98.5F
BP- 110/70mmhg
PR- 86bpm
CVS-S1 S2 +. No murmurs 
RS- BAE + No crepts 
P/A- soft, non tender
CNS- NAD

A:
Hepatitis secondary to drug induced (?herbal medication),with ? autoimmune hemolytic anemia (secondary to herbal medication),with lichen planus

P:
1)Inj.Ceftriaxone 1 gm/iv/BD
2)Inj.Pantop 40 mg iv/OD
3)Tab.DOLO 500 mg po /Qid
4)Tab.Atarax 25 mg HS
5)Tab.UDILIV 300g po/BD
6)Tab . Riboflavin 10 mg/po/OD
7)Tab.zincovit po/OD
8)Tab.WYSOLONE 60 mg /po/OD
9)Lulifin cream L/A BD
10) monitor vitals and inform sos
11)temp charting 4 th hourly
12) venusia max lotion
13)tab.doxycycline 100mg po/bd 



DAY-11:(08/11/2021)
Ward
S:
NO FEVER SPIKES 
NO FRESH COMPLAINTS 

O:
O/E
Pt c/c/c
Temp-98.6f
BP- 110/80
PR- 78bpm

CVS-S1 S2 +. No murmurs 
RS- BAE + No crepts 
P/A- soft, non tender
CNS- NAD

A:
Hepatitis secondary to drug induced with  autoimmune hemolytic anemia (secondary to herbal medication),with lichen planus

P:
1)Inj.Pantop 40 mg iv/OD
2)Tab.Atarax 25 mg HS
3)Tab.UDILIV 300g po/BD
4)Tab . Riboflavin 10 mg/po/OD
5)Tab.zincovit po/OD
6)Tab.WYSOLONE 60 mg /po/OD
7)Lulifin cream L/A BD
8) venusia max lotion
9)tab.doxycycline 100mg po/bd 

Plan for discharge


Comments

Post a Comment

Popular posts from this blog

60 YR OLD MALE CAME WITH C/O ABDOMEN DISTENSION SINCE 20-30 DAYS, PAIN ABDOMEN SINCE 1 WEEK, CONSTIPATION SINCE 2 DAYS, DECREASED URINE OUTPUT SINCE 2 DAYS

Image
It is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.  A 60 YR OLD MALE CAME WITH C/O ABDOMEN DISTENSION SINCE 20-30 DAYS, PAIN ABDOMEN SINCE 1 WEEK, CONSTIPATION SINCE 2 DAYS, DECREASED URINE OUTPUT SINCE 2 DAYS PATIENT WAS APPARENTLY NORMAL 1 MONTH BACK THEN HE DEVELOPED ABDOMINAL DISTENSION WHICH IS PROGRESSIVE AND ASSOCIATED WITH PAIN ABDOMEN SINCE 1 WEEK, CONSTIPATION ANS DECREASED URINE OUTPUT SINCE 2 DAYS NOT A K/C/O HTN,DM,CAD,ASTHMA,TB H/O TRAUMA TO LEFT LEG 5 YR BACK OCCASIONALLY TAKES ALCOHOL GUTKA CHEWER NON SMOKER HIS APPE
Read more

given a case of 42yr old female with multiple health events

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  You can find the entire real patient clinical problem in this link here.. https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 Following is my analysis of this patient's problem: The problems I found are 1.frequent falls to left(left limb and foot gave out) 2.migraine with aura and cognitive impairment 3.breathing difficulty  4.swelling mainly over abdomen and face 5..salt craving 6.reduced urination and reduced sweating 7.decreased exercise intolerance 8.sleep disturbances 9.increased tolerance to pain Others:-rash on face              -PCOS              -Bipolar disorder,anxiety,depression Presently having:oral ulcers and vaginal ulcers Reasons for  ▪︎
Read more

52yr old male with involuntary movements of hand and itchy skin lesions

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." Case:(22/10/2021) A 52year old male resident of bhogramguri of westbengal came to the casualty with chief complaints of involuntary movement of fingers since 6months(during resting),gradual onset,non progressive. Itching over the scalp,brows,armpits since 12yrs. Discoloration over the neck and shoulder since 12yrs , Decreased vision in both eyes since 6months(gradually progressive),  ringing sensation in the ear since 3years(on/off) No h/o. Giddiness PAST HISTORY:
Read more