24-12-2024
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
Thursday, August 15, 2024
20F Lupus clinical complexity EHR deidentified horcrux links to all three admissions 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.
First admission discharge summary
Age/Gender: 21 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 27/09/2022 04:57 PM
Date of Operation MLC No
DR [SR] DR[PGY3] DR[PGY1]
Diagnosis
SYSTEMIC LUPUS ERYTHEMATOSUS WITH GLOMERULONEPHRITIC FLARE UP OF LUPUS NEPHRITIS ?CATASTROPHIC APLA SECONDARY TO SLE [LIBMAN SACKS ENDOCARDITIS
CNS THROMBO EMBOLISM, AND RENAL FAILURE]
Case History and Clinical Findings
20 YR OLD FEMALE CAME ITH C/O B/L PEDAL EDEMA SINCE 15 DAYS HYPERPIGMENTED MACULES SINCE 15 DAYS
FEVERSINCE 15 DAYS
ABDOMINAL DISTENSION SINCE 8 DAYS DRY COUGH SINCE 7 DAYS
SORE THROAT SINCE 7 DAYS DECREASED APPETITE SINCE 7 DAYS SOB SINCE 5 DAYS
DECREASED URINE OUTPUT SINCE 3 DAYS CONSTIPATION SINCE 3 DAYS
HOPI -20 YEAR OLD FEMALE CAME WITH C/O OF B/L PEDAL EDEMA EXTENDING TILL THE KNEES PITTING TYPE SINCE 15DAYS
FOR WHICH SHE GOT MEDICAL HEALTH CHECKUP AND PRESCRIBED SOME MEDICATION [UNKNOWN] THEN HER PEDAL EDEMA GOT RESOLVED ALNG WITH FEVER SHE DEVELOPED HYPER PIGMENTED MACULES ON FACE LATER THEY STOPPED MEDICATIONS AFTER 2 DAYS SHE AGAIN HAD A COMPLAINT OF B/L PEDAL EDEMA AND FEVER ABDOMINAL DISTENSION ASSOCIATED WITH DRY COUGH AND DECREASED APPETITE SHE ALSO HAS COMPLAINTS OF DECREASED URINE OUTPUT AND CONSTIPATION SINCE 3 DAYS
PASSING STOOLS ONCE IN 3-4 DAYS N/K/C/O HTN DM THYROID CAD EPILEPSY TB
PERSONAL HISTORY DIET MIXED APPETITE LOST
BOWEL AND BLADDER MOVEMENTS DECREASED
FAMILY HISTORY NOT SIGNIFICNT
O/E-
PT WAS C/C/C
ON ADMISSION VITALS BP 110/70 MMHG
PR-79 BPM RR-19 CPM TEMP -98.8 F
CVS- APEX BEAT DISPLACED LATERALLY PALPABLE THRILL IN MITRAL AREA
LOUD S2 HEARD IN ALL AREAS NO S3 HEARD
PAN SYSTOLIC MURMUR AT MITRAL AREA
RS-
BAE DECREASED
RT INFRA SCAPULAR CREPTS PRESENT P/A-
SOFT NON TENDER WITH EMBILICUS NORMAL SHAPE AND INVERTED XIPHI UMBILICAL LENGTH 15 CM
UMBILICO PUBIC LENGTH 12 CM
ON PALPATION NO ORGANOMEGALY
CNS -B/L UPPER LIMB AND LOWER LIMB
HYPER TONIA WITH EXAGERATED DTR, ABSENT ANKLE REFLEX PATELLAR CLONUS-
RT SIDE 4+
LT SIDE 3+
MOTOR POWER- 4/5 4/5
4/5 4/5
1/10/22
MMSE - DONE ON 1/10/22 ORIENTATION -
ORIENTED TO DAY, MONTH, SEASON, DATE -2 FLOOR, HOSPITAL, DISTRICT, STATE COUNTRY-4 RECALL-2/3
ATTENTION AND CALCULATION-3/4 LANGUAGE -2 OBJECTS-2 SENTENCE-1
3 STAGE COMMAND -3 READING CLOSE YOUR EYES WRITING A SENTENCE -0
MODERATE COGNITIVE IMPAIRMENT COURSE IN HOSPITAL
28/09/22-
NEPHRO REFERAL I/V/O ELEVATED RENAL PARAMETERS AND ANASARCA
REFERAL NOTES-LVTS-, OBSTRUCTION -, HEMATURIA-, PYURIA-, YELLOWIS DISCOLORATION-
NSAID ABUSE -, NATIVE MEDICATION - ADVICED TO CONTINUE THE SAME TREATMENT 28/09/22-
PULMO REFERAL I/V/O WHEEZE, XRAY CHANGES [BL PLEURAL EFFUSION] ADVICED -INJ AUGMENTIN 1.2 GM IV/TID
INJ.LASIX 40 MG IV/BD NED DUOLIN
BUDECORT 6TH HOURLY IMJ NEOMOL 1GM IV/SOS BETADINE GARGLING TAB AZITHROMYCIN
GENERAL SURGERY REFERAL I/V/O BED SORE [1/10/22]
LE- TWO SMALL ULCERS NOTED EITHER SIDE OF INTERGLUTEAL CLEFT MEASURING 1X1 CM EACH
NO ACTIVE DISCHARGE
FLOOR -GRANULATION TISSUE, NO SLOUGH
EDGE SLOPING EDGES NO SURROUNDING INDURATION MARGINS -BLACKISH
ADVICED -TO MAINTAIN HYGEINE AND KEEP THE AREA DRY OINT T BACT FOR LA
NEOSPORIN POWDER FOR LA FREQUENT POSITION CHANGE AIR BED
29/09/22-
ENT REFERRAL WAS TAKEN I/V/O DYSPHONIA REFRAL NOTES-
O/E OF ORAL CAVITY- MUCOSA PALE TONGUE IS COATED
OROPHARYNX-BL GRADE 2 TONSILLAR HYPERTROPHY, NO CONGESTION NECK-TRACHEA CENTRAL LARYNGEAL FRAMEWORK NORMAL LARYNGEAL CREPITUS+
NOSE- EXTERNAL FRAMEWORK NORMAL CAUDAL DISLOCATION-LEFT ANTERIOS MILD DNS -RIGHT
B/L NASAL MUCOSA -PALE TURBINATES AND FLOOR -NORMAL ROOMY NASAL CAVITIES
OE EAR-
B/L TYMPANIC MEMBRANE INTACT., COL+ DIAGNOSIS-DYSPHAGIA UNDER EVALUATION NO ACTIVE ENT INTERVENTION
30/09/22-
REVIEW NEPHRO REFERAL-
USG KUB SHOWING BULKY LT KIDNEY WITH ALTERED ECHOTEXTURE ADVICED TAB AUGMENTIN
TAB PAN 40 MG OD TAB DOLO 650 MG TID 4/10/22-
DVL REFERAL I/V/O HYPERPIGMENTED MACULES NOTED OVER CHEEKS AND FOREHEAD
NOSE, CHIN EAR LOBULE, RETROAURICULAR REGION [CONCHA SPARED], BOTH FOREARMS, BACK, UPPER CHEST
ORAL CAVITY- N
MULTIPLE HYPERPIGMENTED MACULES NOTED OVER BOTH THE PALMS DIAGNOSIS -POST INFLAMMATORY HYPERPIGMENTATION
ADVICED -CEBHYDRA LOTION LA/BD
REVIEW ENT REFERAL I/V/O DYSPHONIA [13/10/22]
ADVICED TO CONTINUE MEDICATION AS ADVICED BY PHYSICIAN WAIT AND WATCH
FOLLOWED BY SPEECH THERAPY
01/10/2022-
20 F WITH ANASRCA BL PEDAL EDEMA, PLEURAL EFFUSION, AND PERICARDIAL EFFUSION - RESOLVING +RASH HEALED +FEVER
SKIN- HEALED RASHES +PAINLESS EMBOLI LIKE LESIONS [JANEWAY LESIONS] PT APPEARS COMFORTABLE
FEVER SPIKES PERSIST -FEVER CHART ANALYSIS-SEPTIC PTTERN ACTION TREMOR+B/L
REDUCTION IN TACHYCARDIA[HR 148->112] LIDLAG
HEALING BEDSORE ON BACK [BUTTOCK AREA]
ON 02/10/22-
ANA PROFILE -ANTI dsDNA +++
ANTI HISTONE, ANTINUCLEOSOME, ANTI KU AG++
MRI BRAIN- MULTIPLE HYPERINTENSITIES IN BRAIN PARENCHYMA F/S/O-VASCULITIS? USG ABDOMEN -MODERATE ASCITES
SLE DAI SCORE-30 POINTS S/O ACTIVE DISEASE
ON 3/10/22-
TACHYPNEA AND TACHYCARDIA SUBSIDED ACTION TREMOR DECREASED
0N 4/10/22
INJ UNFRACTIONATED HEPARIN 5000IU /IV/STAT
FOLLOWED BY INJ UNFRACTIONATED HEPARIN 5000 IU /SC/QID FOR 3 DAYS [GIVEN FOR 3 DAYS [TILL 6//10/22]]
TAB WARFARIN 5MG /PO/OD IS STARTED
TAB LASIX 40MG PO/BD STARTED ON 12/10/22
BLOOD TRANSFUSION WAS DONE ON 13/10/22
ONE PINT OF A+VE BLOOD WAS TRANSFUSED AFTER DOING THE BLOOD GROUPING AND TYPING AND CROSS MATCHING
TRANSFUSION STARTED AT 7;30 PM AND WAS COMPLETED BY 11;20 PM
HALF AND HOURLY MONITORING OF VITALS WAS DONE DURING THE PROCESS OF TRANSFUSION
PRE TRANSFUSION VITALS AND POST TRANSFUSION VITALS WERE MONITORED, PT WAS STABLE AND NO CHILLS, RIGORS, FEVER, MYALGIA DURING THE TRANSFUSION
Investigation
USG IMPRESSION [28/09/2022] MODERATE PERICARDIAL EFFUSION BILATERAL PLEURAL EFFUSION GROSS ASCITES
MRI BRAIN PLAIN WITH CSPINE SCREENING [ON 3/10/22] IMPRESSION-
DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY
MULTIPLE SMALL ACUTE INFARCTS IN BOTH CEREBRAL HEMISPHERES-EMBOLIC SCREENING OF CERVICAL AND DORSAL SPINE APPEARS NORMAL
Treatment Given (Enter only Generic Name)
1] INJ AUGUMENTIN 1.2 GM IV/BD FOR 2 DAYS
2] INJ LASIX 40 MG IV/BD FOR 9 DAYS
3] NEB WITH DUOLIN BUDECORT
4] INJ NEOMOL 1GM IV/SOS
5] TAB AZITHROMYCIN 500 MG PO/OD FOR 2 DAYS
6] BETADINE GARGLES /TID
7] INJ DERIPHYLLINE 100 MG IV /BD FOR 7 DAYS
8] TAB PREDNISOLONE 50 MG PO/BD FOR 3 DAYS [STARTED ON 29/9/22 TO 1/10/22] TAB PREDNISOLONE 30 MG PO/BD FOR 1 DAY [STARTED ON 2/10/22]
TAB PREDNISOLONE 20 MG PO/BD FOR 11 DAYS [STARTED ON 3/10/22]
9] INJ PAN 40 MG IV/OD
10] INJ CEFTRIOXONE 1 GM IV/BD FOR 7 DAYS
11] INJ TRAMADOL 1 AMP IN 100 ML NA/IV/BD
12] INJ METHYL PREDNISOLONE 750 MG IN 100 ML NS/IV /OD FOR 3 DAYS [2/10/22 TO 4/10/22]
13] TAB HCQ 200 MG PO/OD [STARTED ON 2/10/22]
14] TAB DOLO 650 MG PO/TID
15] OINT T BACT FOR LA /BD
16] NEOSPORIN POWDER FOR LA
17] TAB AZORAN 50 MG PO/BD
18] SYP DULPHALAC 15 ML PO/TID
19] INJ UNFRATIONATED HEPARIN 5000 IU/SC/QID FOR 3 DAYS
20] TAB WARFARIN 5MG /PO/OD
21] CEBHYDRA LOTION LA /BD
Advice at Discharge
1] TAB HCQ 200 MG PER ORAL ONCE DAILY
2] TAB PREDNISOLONE 20 MG PER ORAL TWICE DAILY
3] TAB AZORAN 50 MG PER ORAL TWICE DAILY
4] TAB LASIX 40 MG PER ORAL TWICE DAILY
5] SYP SUCRALFATE 10 MLTHRICE DAILY
6] SYP DULPHLAC 15 ML PER ORAL THRICE DAILY
7] OINT TBACT LOCAL APPLICATION TWICE DAILY
8] CEBHYDRA LOTION LOCAL APPLICATION TWICE DAILY
9] NEOSPORIN LOCAL APPLICATION
Follow Up
REVIEW TO GM OPD ON TUESDAYS OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:13/10/2022 Ward:AMC Unit:GM 2
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
2nd admission discharge summary:
Age/Gender: 21 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 01/12/2022 02:17 PM
Diagnosis
1. INTRA VENTRICULAR HAEMORRHAGE SECONDARY TO WARFARIN INDUCED
2. SLE (? LUPUS NEPHRITIS)
3.? AUTOIMMUNE MENINGISM
Case History and Clinical Findings
Patient presented with flare up of SLE with Libmann Sachs endocarditis and vasculitis stroke discharged with Tab. Prednisolone 20mg BD, Tab. Azathioprine 50mg BD, Tab. HCQ 200mg OD, Tab. Warfarin 5 mg BD. On 01/12/22 patient presented to OPD with complaints of Headache, vomitings and neck pains since 2-3 days. Patient was apparently normal 3 months ago, then she had b/l pitting type of pedal oedema extending till knees which was relieved on taking medication(unknown).later she developed fever and hyperpigmented macules on face-face was high grade, later she developed b/l pitting type of pedal edema, dry cough, abdomminal distension, decreased appetite and decreased urine output. later all her complaints improved after discharge (oct 2022) and was alright till 3 days back, Then she developed Headache diffuse associated with neck pains which worsened next day following which she developed, vomiting of 3-4 episodes, non bilious and food particles as contents, she told it was not associated with pain abdomen or abdominal discomfort. No fever, no altered sensorium, No blurring of vision, No diplopia, No photophobia or phonophobia. No history of trauma. Vitals at admission: Bp 170/110mmhg Pr : 84Spo2: 99 on RARR: 18 cpm Temp : Afebrile to touch. On examination: Facial puffiness present with stary look. Previous rashes subsided. Etymotic patch noticed on Rt knee. Neck stiffness present associated with Pain. CVS: no raised JVP, Heart sounds unremarkable, previous MR murmur subsided. RS: BAE+, NVBSP/A: soft, nontender bowel sounds present. CNS: MMSE: 30/30HMF: intact Cranial nerves: normal Motor: detailed examination will be shared shortly. Exaggerated deep tendon reflexes. With I'll sustained patellar clonus. Persistent nausea and vomiting. After low dose opinoid (Tramadol) + antiemetic Persistent neck pain with stiffness. Crcl = 60ml/min For acute headache and neck pain reduction she was given Naproxen 125mg stat.3/12/22Patient developed Diplopia today. Transient Rt. LR palsy. Started in
inj. 3%NACL to decrease ICP. For 6hrs.Patient attenders counselled regarding this and advised for neurosurgical opinion but due to personal problems they continued treatment here with high risk.4/12/22Diplopia subsided and no fever spikes Neck pain and vomitings subsided. vitals at discharge: no c/o fever, vomitingpt is c/c/cafebrilebp:130/90mmhgpr:80bpmcvs:s1s2+pan systolic murmur+rs: BAE+p/a:soft,NT cns:NAD brief course in hospital was presented to opd by above given complaints .clinical examinations, MRI and other investigations were done and pt was diagnosed as INTRA VENTRICULAR HAEMORRHAGE SECONDARY TO WARFARIN INDUCED WITH
SLE (?LUPUS NEPHRITIS). 2 units of platelets were transfused and treatment was given, after that pts complaints were subsided and pt have been discharged at haemodynamically stable condition
Investigation
MRI BRAIN PLAIN:
-MILD INTRA VENTRICULAR HEMORRHAGE WITH ACUTE Hydrocephalus
-MILD DIFFUSE SUBARACHNOID HEMORRHAGE
-DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY
-GLIOTIC CHANGE IN RIGHT SUPERIOR PARIENTAL LOBULE
2D ECHO:
-MILD MR+/AR+: TRIVIAL TR+
-NO RWMA, NO AS/MS
-GOOD LV SYSTOLIC FUNCTIONS
-NO DIASTOLIC DYSFUNCTION, NO PAH/PE
BLOOD CULTURE: NO GROWTH AFTER 24 HR OF AEROBIC INTUBATION
OPHTHALMOLOGY OPINION:
NO RAISE ICT FINDING NOTED ON FUNDUS EXAMINATION
HAEMOGRAM:
ON ADMISSION:
HB:10.2 PCV:33.1 TLC:12,000 RBC:3.47 PLT:4.2 ON 7/12/22:
HB:10.4 PCV:34.7 TLC:16,800 RBC:3.54 PLT:5.40
PT; APTT
ON 1/12: >1MIN;>1MIN ON 3/12: 17SEC;35 SEC ON 4/12: 18;37
ON 5/12: 16;32
ON 7/12: 18;36
ON 9/12: 20;40
Treatment Given (Enter only Generic Name)
DAY-1:
1.T.PCM 500MG PO/TID
2.T.HCQ 200MG PO/BD
3.T. AZATHIOPRINE 50MG PO/BD
4. PREDNISOLONE 20 MG PO/BD
5. INJ.ZOFER 4MG IV/BD
6. SYP.SUCRALFATE 15ML PO/BD
7. INJ.TRAMADOL 1AMP IN 100ML NS/STAT
DAY-2
1.T.PCM 650MG PO/TID
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 50MG PO/BD
4. PREDNISOLONE 20 MG PO/BD
5. INJ.ZOFER 4MG IV/TID
6. SYP.SUCRALFATE 15ML PO/BD
7. INJ.TRAMADOL 1AMP IN 100ML NS/STAT
8. INJ.MONOCEF 2GM IV/STAT
9. INJ VIT K 10MG IV/OD
DAY-3
2 UNITS OF FFP WAS TRANSFUSED
1.T.PCM 650MG PO/TID
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 50MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/TID
6. INJ.MONOCEF 2GM IV/BD
7. INJ.TRAMADOL 1OOMG IN 100ML NS/SOS
8. INJ.VIT.K 10MG IV/OD
DAY-4
1.T.PCM 650MG PO/TID
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 50MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/TID
6. INJ.MONOCEF 2GM IV/BD
7. INJ.TRAMADOL 1OOMG IN 100ML NS/SOS
8. INJ.PANTOP 40MG IV/OD
9.T. NAPROXEN 250MG PO/SOS
10. INJ.VIT-K 10MG/IV/OD
11. INJ.TRANEXA 500MG/IV/BD
12. INJ.MANNITOL 20GM IV/BD
DAY-5
1.T.PCM 650MG PO/SOS
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 50MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/SOS
6. INJ.MONOCEF 1GM IV/BD
7. INJ.MANNITOL 20GM IV/BD
8. INJ.PAN 40MG /IV/OD
DAY-6
1.T.PCM 650MG PO/SOS
2.T.HCQ 200MG PO/OD
3.T.AZATHIOPRINE 50MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/SOS
6. INJ.MONOCEF 1GM IV/BD
7. INJ.MANNITOL 20GM IV/BD
8. INJ.PAN 40MG /IV/OD
DAY-7
1.T.PCM 650MG PO/SOS
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 50MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/SOS
6. INJ.MONOCEF 1GM IV/BD
7. INJ.MANNITOL 20GM IV/BD
8. INJ.PAN 40MG /IV/OD
DAY-8
1.T.PCM 650MG PO/SOS
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 50MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/SOS
6. INJ.MONOCEF 1GM IV/BD
7. INJ.MANNITOL 20GM IV/BD
8. INJ.PAN 40MG /IV/OD
DAY-9
1.T.PCM 650MG PO/SOS
2.T.HCQ 200MG PO/OD
3.T. AZATHIOPRINE 500MG PO/BD
4. INJ.DEXAMETHASONE 8MG IV/TID
5. INJ.ZOFER 4MG IV/SOS
6. INJ.MONOCEF 1GM IV/BD
7. INJ.MANNITOL 20GM IV/BD
8. INJ.PAN 40MG /IV/OD
Advice at Discharge
1. TAB.ACITROM 1MG PO/OD(1-X-X)
2. TAB.PREDNISOLONE 20MG PO/BD(1-X-1)
3. TAB.AZATHIOPRINE 50MG PO/BD(1-X-1)
4. TAB.HCQ 200MG PO/OD(1-X-X)
5. TAB.PCM PO/SOS
6. TAB.PAN 40MG PO/OD(1-X-X)
Follow Up
REVIEW AFTER 7 DAYS ON SATURDAY TO GENERAL MEDICINE OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:10/12/2022 Ward:MEDICAL WARD
Unit:GM 6
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. Presented 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
[08/09/2024, 20:06] PPM 1: @ Patient Advocate
మీ పేషెంట్ ఇప్పుడు ఎలా ఉన్నారు? ఆమె దగ్గు ఎలా ఉంది?
Mī pēṣeṇṭ ippuḍu elā unnāru? Āme daggu elā undi?
How's your patient now? How's her cough?
[08/09/2024, 20:08] Lupus 20F Patient Advocate: Kk sir epudu maa frnd daggu thaggindhi intlo Pani chesukuntundi
[08/09/2024, 20:18] PPM 1: 4th admission updated here:
@PPM10 please share her 4th admission discharge summary
[08/09/2024, 20:28] PPM 10: Okay sir
[23/12/2024, 12:48] PPM 1: Reviewed in OPD just now:
Complains of epigastric pain and vomiting 5 times and hasn't eaten since yesterday morning due to severe anorexia since the vomitings
[24/12/2024, 07:50] Lupus 20F Patient Advocate: Gd mrng sir nd madam yesterday ni8 vomiting 2times
[24/12/2024, 07:53] Pushed1Comm22: Usg report pettu
[24/12/2024, 09:36] PPM 1: Is she admitted?
PPM 3 - Patient suffering form pain abdomen currently am unable to answer her call. Please any volunteer or pg or intern could help her 🙏🏻
PPM 4 - Unable to call her sir. Some problem from her end I guess. Messaged her.
PPM 1 - 👍
PPM 4 - The patient came to OPD just now.
PPM 1 - Let's admit her. I can review her in the ICU AMC now.
30-12-2024
Caretaker - Good afternoon sir and madam. My patient is having pedal edema and there is swelling in her face too.
PPM 3 - Can you please share the image of her feet.
PPM 1 - Looks like her renal proteinuria may have increased.
We'll need to get her serum albumin and urine for 24 hour protein and creatinine
Let's ask her to share the image of her kidney medications
I guess she was on tablet azathioprine and prednisolone and the prednisolone dose had been brought down to the minimum.
Caretaker -
PPM 3 - This is gross.
The patient has to come to the hospital and has to be admitted for 1-2 days. We have to get done 24hr urine proteins test. This test is very essential. With this test the medication dosage will be changed.
Caretaker - Okay sir.
PPM 1 - Please ask her to share her current tablet dosages and when did she taper them off.
PPM 3 - Please share the pics of present medication of your patient. Since when is she taking the medicines?
Caretaker - This yellow tab taken in the afternoon 5mg in the morning, 2.5 in the night sir
PPM 1 - Yellow tablet packet picture to see name and dose.
Caretaker - 50 mg.
PPM 3 - AZA 50mg sir.
PPM 1 - Was she always consuming 50 mg or was it reduced after she developed the hydropneumothorax?
02-01-2025
PPM 3 - Just received a call from Patient advocate, patient is having constipation with no flatus, No urine output and Generalised body swelling. In apprehension he got a syrup to relieve her constipation but still stools not passed. He will be visiting ER in a while.
@PPM4 @PPM5 @PPM6 @PPM7 @PPM8 @PPM9 Please look into this.
PPM 1 - Yes hoping to see her soon. Will be in OPD.
They can even reach directly to our OPD.
Reviewed in OPD:
Anasarca
Other findings wnl
Anuric since morning
Constipation since morning
Plan
Admit in wards
Monitor intake output.
PPM 3 - 24h UPCR sir..?
PPM 1 - Yes once the urine comes out.
Reviewing in OPD
Currently on lowest dose prednisolone 5mg and 2.5 mg along with Azathioprine 50 mg for her Lupus nephritis
Anasarca
BP140/80
Other findings wnl
Anuric since morning
Constipation since morning
Plan
Admit in wards
Monitor
intake output
RFT
May need to watch out for RPGN.
PPM 1 - @PPM10 she passed 250 ml of urine (her estimate) spontaneously now!
PPM 10 - 👍
PPM 3 - @PPM5 @PPM4 patient is having agonising pain abdomen, her advocate is apprehensive about her abdominal distension and pain abdomen. Kindly look into this and update please.
PPM 1 - Oh just now?
She didn't have it in the morning or even afternoon?
She's likely having a post infectious IBS and can be put on Buscopan tablets tid and injection Buscopan sos.
PPM 3 - Yes sir 2 min back. He reports pain is worsening.
PPM 1 - @PPM10 share your clinical findings or ask the AMC pg to share here ASAP.
PPM 1 - @PPM11 if you are there in AMC just examine her abdomen and share the findings.
PPM 11 - Abdomen is soft and non tender sir.
PPM 1 - 👍
And how is her pain now?
PPM 11 - She is complaining of bloating of abdomen sir
She did not pass stool since yesterday
O/e : abdomen is soft and no tender
Bowel sounds present.
PPM 1 - 👍
PPM 11 - Yes sir after giving inj pantop.
PPM 3 - Thank you. Any intervention to relieve her constipation ..?
PPM 11 - Giving Enema sir.
PPM 1 - 👍
PPM 10 -
PPM 1: 👍
03-01-2025
PPM 1 - @PPM10 share the deidentified abdominal ultrasound report here.
PPM 10 -
And use our POCUS device to DIY
04-01-2025 16.20pm
PPM 1 - Reviewed in the afternoon:
Current autoimmune inflammatory indicators:
24 hour significant proteinuria 1.2 g suggestive of active glomerular inflammation
Persistent bowel symptoms in this admission and thickening on imaging suggestive of possible IBD
Reviewed the major events in the entire history from September 2022:
1st admission with altered sensorium, serositis, nephrotic proteinuria and ANA +++ suggestive of Lupus and started on high dose steroids with azathioprine as adjuvant and unfortunate anticoagulants (thinking of cardiac embolism)
December 2022
2nd admission with complications of minor IC bleed due to anticoagulant
Lost to follow up in 2023 till June 2024
Not sure if she achieved glomerular remission
Stopped all Rx in December 2023
June 2024 presented with flare of arthritis and proteinuria
Restarted steroids and adjuvants and developed pyopneumothorax because of which immunosuppressives were again quickly tapered off to prednisolone 5mg and Azathioprine 50 mg once daily with poor follow up and this time in Jan 2025 she appears to have developed glomerular injury again along with possible IBD this time!
PPM 3 - 👍
PPM 11 - She had libbmans sacks endocarditis
And once she admitted with Cushing also sir
Her PT INR APTT was also deranged back then, PT was in 100 contributed it to warfarin.
05-01-2025
PPM 1 - Libmanns sacks endocarditis is not an easy diagnosis and definitely needs histopathological confirmation and in her case as well as most cases that isn't possible and it's largely an autopsy pathology learning point.
Yes she did have side effects of steroids that are very common trade offs unlike her anticoagulant trade off where the benefit risk ratio needed to be better balanced and I would classify it as an over-testing leading to LSE and cerebral embolism diagnosis leading to overtreatment with anticoagulants
Yes the PT INR was the marker of the overtreatment delivered along with the MRI brain hemorrhages that were luckily detected early due to serendipitous sequence of events that brought her back in altered sensorium during her second admission.
PPM 11 - 👍
PPM 2 - I remember we did see some vegetations and a profound MR on the echo, first time?
PPM 1 - Unfortunately the echocardiography video wasn't archived?
PPM 2 - I believe it was archived. @PPM3 or @PPM12 should be aware.
PPM 3 -
PPM 3 - Missed video but captured this for clinical meet presentation. Her first admission echo image.
Retrieved from
PPM 1 - Thanks
Without the mitral valve Doppler it's difficult to say if the MR visible on CFM is trivial or significant.
However valvulitis is probable looking at the video. So as mentioned before it's a difficult diagnosis and the probability can only be enhanced with histopathology.
Not sure about the vegetations although again yes there is a suspicious shadow in the inner surface of pml
Fantastic to see this really!
Whatever case reports and data we capture and archive may become more valuable with the passage of time! @Case reporters.
08-01-2025
PG - Sir her BP in the morning is 160/100
1 pm - 170/100
5 pm - 170/100
Does she nedd any hypertensive sir?
PPM 1 - Yes.
Start tablet Telmisartan as it will also be available from her local PHC.
Please share her hourly BP chart.
12-01-2025
PA -
PPM 1 - Can start Tablet Lasix 40 mg once daily. Pleas share the other meds patient is taking.
PPM 1 - 👍
Caretaker - How will the pedal edema subside?
PPM 4 - Should take lasix 40mg daily.
PPM 1 - 👍
Tablet lasix to tide over the cosmetic crisis
Prednisolone and azathioprine will take a few weeks to show efficacy.
Caretaker - The patient had taken 30mg lasix in the afternoon.
PPM 1 - Start taking 40mg lasix.
16-01-2025
PPM 1 - How is the patient's pedal edema?
17-01-2025
PPM 1 - Reviewed the patient today in ICU.
Has started having severe epigastric abdominal pain again since yesterday
Along with vomiting
On examination:
Abdomen soft
Working diagnosis:
Drug induced gastritis
Plan @PPM7 @PPM8 @PPM12
Hold the tablet prednisolone for a few days
Repeat LFT
Serum creatinine
Urine for 24 hour protein and creatinine
Temporarily withhold
[17/01, 17:04]: Everytime since last few years when she developed florid proteinuria she would clinically go into remission (although not documented in 24 hour values, the nearest was probably 700 mg recently during last admission when we were battling the ravages of her pyopneumothorax) following which after the steroids were tapered due to the infection, she again developed this florid proteinuria since two weeks which doesn't seem to be responding to the 30 mg of prednisolone this time, which is on the contrary producing side effects!
18-01-2025
PPM 1 - Update from the ward.
PPM 1 - Hypoalbuminemia as expected due to her nephrotic syn flare. Steroid induced gastritis has actually made us withhold steroids at this juncture and azathioprine dose also has been reduced! @PPM5 @PPM2 this is the patient both of you managed three years back in the first encounter with us.
PPM 2 - 👍
PPM 1 - Glomerular injury predisposes to Hypertension.
PPM 2 - Are any alternatives being considered?
Does she need a pulse dosing again?
PPM 1 - This time she also appears to have an imaging finding of inflammatory bowel dose in her colon since last admission which appears to be persistent and they can't afford a colonoscopy.
Yes likely. Although iv dexa will be less taxing perhaps.
PPM 2 - I understand the imperative for this although aren't the best outcomes seen with the reliable Methylpred?
I understand each vial costs north of 1k.
PPM 1 - That's a lot.
PPM 2 - To save a kidney?
And consequently human capital?
PPM 1 - Are their studies that dexamethasone can't?
Let's try seeing if there are studies to support that imperative.
PPM 2 - Will let the treating team share.
PPM 1 - 😂
PPM 1 - 👍Which expert worth his salt would be spending time working in low resource settings treating lupus nephritis with dexa instead of MP?
We do have one such non expert generalist's notes documented possibly in tabula rasa. Will try to search and share.
PPM 2 - PPM 1.
20-01-2025
PPM 1 - Update?
Is she getting discharged?
Any repeat 24 hour protein creatinine results in this admission?
Is she on physiological doses of her previous 30 mg prednisolone that had to be withheld due to suspected gastritis?
PPM 4 - Yes sir
Planning for discharge today
Pedal edema and abd distension subsided sir
No pain abdomen nausea and vomitings
She is taking food as before
We stopped prednisolone and azathioprine for the last 3 days sir
Shall we put her back on those and discharge today sir?
PPM 1 - Calculate the actual GFR using the urinary creatinine. @PPM14 @SE can you help?
PPM 13 -
PPM 4 -
PPM 1 - 👍
PPM 7 - Creatinine is 0.8mg/dl sir.
PPM 1 - But remember for GFR calculation from urinary creatinine (this is not e GFR) you need to use the urinary creatinine, the 24 hour urinary volume and other parameters in the formula.
PPM 14 - Ok sir.
PPM 7 -
PPM 7 - Sir is this the formula, you are talking about?
PPM 1 - Yes this appears to be the one
Any more literature on how it was derived?
What's the GFR as per this formula?
21-01-2025
EMR SUMMARY
Age/Gender: 23 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 17/01/2025 03:31 PM
Name of Treating Faculty
DR Assistant Professor, DR. PG Y3, DR. PGY2
Diagnosis
1. DRUG INDUCED GASTRITIS? ORAL STEROIDS INDUCED
2. LUPUS NEPHRITIS WITH FLARE
3. INFLAMMMATORY COLITIS
4. K/C/O SYSTEMIC LUPUS ERYTHEMATOSIS [SLE] SINCE 4 YEARS
Case History and Clinical Findings
C/O PAIN ABDOMEN SINCE YESTERDAY NIGHT C/O VOMTINGS SINCE TODAY MORNING HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1DAYS AGO,THEN SHE DEVELOPED PAIN ABDOMEN SINCE YESTERDAY NIGHT AT EPIGASTRIC REGION TENDERNESS PRESENT ASSOCIATED WITH VOMITINGS SINCE TODAY MORNING THREE EPISODES, NON BILIOUS, NON PROJECTILE,NON BLOOD STAINED ,WATER AS CONTENT
NO AGGRAVATING AND RELIEVING FACTORS ASSOCIATED WITH NAUSEA
H/O PEDAL EDEMA AND FACIAL PUFFINESS SINCE 25 DAYS
NO H/O FEVER, COLD, COUGH, ALLERGIES, CHEST PAIN, PALPITATIONS, SWEATING, SOB, BURNING MICTURITION, CONSTIPATION
PAST HISTORY:
K/C/O SLE, LUPUS NEPHRITIS AND INFECTIVE COLITIS N/K/C/O DM II, TB, EPILEPSY, ASTHMA, CVA, CAD
FAMILY HISTORY:
INSIGNIFANCT PERSONAL HISTORY:
SLEEP- ADEQUATE APPETITE-NORMAL DIET-MIXED
BOWEL AND BLADDER MOVEMENTS-REGULAR ADDICTIONS-NIL
GENERAL PHYSICAL EXAMINATION:
TEMPERATURE-AFEBRILE BP-160/100MMHG
PR-156BPM RR-22CPM
SPO2-98%AT RA
MILD BILATERAL PEDAL EDEMA PRESENT [PITTING TYPE]
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION CVS - S1, S2 HEARD, NO MURMURS.
RS- B/L AE - PRESENT, NVBS, NO ADDED SOUNDS.
P/A - SOFT, TENDERNESS AT EPIGASTRIC REGION, NO ORGANOMEGALY, BOWEL SOUNDS PRESENT
CNS-NO FOCAL NEUROLOGICAL DEFICIT LOCAL EXAMINATION:
PER ABDOMENSOFT, TENDERNESS AT EPIGASTRIC REGION, BOWEL SOUNDS PRESENT, NO ORGANOMEGALY
NO GUARDING, NO RIGIDITY NO SCARS
Investigation
Anti HCV Antibodies - RAPID 17-01-2025 05:54:PM Non Reactive HBsAg-RAPID 17-01-2025 05:54:PM Negative
RBS ON 17/1/25 -70 mg/dl. HEMOGRAM ON 17/1/25
HAEMOGLOBIN 8.2 gm/dl TOTAL COUNT 9,200 cells/cumm NEUTROPHILS 84 % LYMPHOCYTES 11 % EOSINOPHILS 04 % MONOCYTES 01 % BASOPHILS 00 % PCV 24.2 vol % M C V 84.6 fl M C H 28.7 pg M C H C 33.9 % RDW-CV 15.3 % RDW-SD 47.2 fl RBC COUNT 2.86 millions/cumm
PLATELET COUNT 3.05 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia
LIVER FUNCTION TEST (LFT) 17-01-2025 05:54: PM Total Bilurubin 1.07 mg/dl 1-0 mg/dl direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl SGOT(AST) 15 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0
IU/LALKALINE PHOSPHATASE 84 IU/L 98-42 IU/LTOTAL PROTEINS 3.9 gm/dl 8.3-6.4
gm/dl ALBUMIN 2.12 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.19
COMPLETE URINE EXAMINATION (CUE) 17-01-2025 05:54:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN +++SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS 3- 4CRYSTALS Nil CASTS Nil amorphous DEPOSITS Absent OTHERS Nil
BLOOD UREA 17-01-2025 05:54:PM 49 mg/dl 42-12 mg/dl
SERUM CREATININE 17-01-2025 05:54:PM 0.8 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 17-01-2025 05:54:PMSODIUM 136 mmol/L 145-136
mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L 24 Hours Urinary Sodium ON 18/1/25 - 220 mmol/day 24 Hr URINE VOLUME : 1,700 ml
24 HOURS URINE PROTEIN ON 18/1/25- 250 mg/day. 24 HOURS URINE CREATININE-1.4 g/day RATIO 0.17URINE VOLUME 1,700 ml
24 Hr URINARYPOTASSIUM ON 18/1/25 - 45.0 mmol/day URINE VOLUME 1700 ml USG DONE ON 17/1/25
IMPRESSION:
LONG SEGMENT CIRCUMFERENTIAL WALL THICKENING OF LARGE BOWEL RIGHT ADNEXAL CYST? RIGHT OVARIAN CYST [REVIEW IN FULL BLADDER] REVIEW USG DONE ON 18/1/25
IMPRESSION:
DIFFUSE BOWEL WALL THICKENING NOTED IN ASCENDING, TRANSVERSE AND DESCENDING COLON WITH A MAXIMUM THICKNESS OF 12-13MM
MODERATE ASCITIS
B/L RAISED ECHOGENICITY OF KIDNEYS
REST OF THE FINDINGS CONSISTENT WITH THE PREVIOUS SCAN.
Treatment Given (Enter only Generic Name)
1. INJ PAN 40 MG IV /OD
2. INJ ZOFER 4 MG IV/ BD
3. INJ LASIX 40 MG IV/ BD
4. INJ. BUSCOPAN IV/SOS
5. TAB. TELMA 20 MG PO/OD/ 8 AM
6. TAB. ZYTANIX 2.5 MG PO/OD 2PM
7. SYP. MUCAINE GEL 10 ML PO/TID
8. 1 ORS SATCHET IN 1 GLASS OF WATER, DRINK 200 ML
9. OINT.THROMBOPHOBE L/A TID
10. MONITOR VITALS AND INFORM SOS
Advice at Discharge
1. TAB. PREDNISOLONE 5 MG PO/OD TO CONTINUE
2. TAB.AZATHIOPRINE 50 MG PO/OD TO CONTINUE
3. TAB. DYTOR 20 MG PO/OD TO CONTINUE
4. TAB.ZYTANIX 2.5 MG PO/OD TO CONTINUE
5. TAB.TELMA 20 MG PO/OD TO CONTINUE
6. TAB.PAN 40 MG PO/OD X 15 DAYS
7. TAB.ZOFER 4 MG PO/SOS
8. SYP. MUCAINE GEL 10 ML PO/TID X 15 DAYS
9. OINT.THROMBOPHOBE L/A TID
Follow Up
REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date: 20/1/25
Ward: FEMALE MEDICINE WARD
Unit: V
21-01-2025
PA - Sir the patient is hungry, can she eat rice?
PPM 1 - Yes that's good to hear that she's feeling hungry
And if possible let her take a balanced Harvard plate.
PA - The patient should eat Fruits, vegetables and cereals.
Can the patient eat non veg?
PPM 1 - She can eat everything like shown below.
25-01-2025
PPM 1 - Update?
What medications is she currently on?
What is her current edema like?
09-02-2025
PPM 6 - Sir the patient got admitted today morning at 6:30 am
With complains of vomitings 2 episodes at 9 pm food material as content, non bilious
Pain abdomen since 10 pm epigastric and umbilical region non radiating pain, pain is getting relieved on lying in prone position
Vitals at presentation
PR: 96/min
BP:120/70 mmHg
RR:22 cpm
Spo2:96% on RA.
PPM 1 - Pancreatitis? Steroid or azathioprine induced?
Why did they not share any updates since 21st January?
"The number of patients treated with azathioprine to cause an episode of pancreatitis was 36 (induction of remission) and 31 (maintenance of remission).The risk of pancreatitis in patients receiving azathioprine across all contexts was 3.80%, compared with a control risk of 0.2% (placebo) and 0.5% (5-aminosalicylic acid agents)."
Azathioprine induced pancreatitis usually runs a benign self limited course with rapid disappearance of signs and symptoms upon with drawl of the drug.
PPM 6 - On per abdominal examination there was tenderness in umbilical region sir
And the patient was also comfortable on lying in prone position.
USG showed this sir 👆
PPM 1 - Other than inflammatory bowel disease that we had been considering for a few weeks since her first USG few weeks back showed this bowel thickening, the other important pathology to rule out is tuberculosis. @PPM15 do they do free colonoscopy there in Gandhi medical college as this patient is not affordable?
Also @PPM6 can you share the previous latest chest X-rays and sputum AFB and CBNAAT?
Today's chest X-ray.
PPM 1 - Pain relieved by prone position was our initial cue to suspect pancreatitis.
Looks clear.
PPM 6 - Epigastric and umbilical region pain with tenderness in umbilical region along with relief of pain on lying llin prone position or lateral position made me think pancreatitis and she also told if she drinks or eats food abdominal pain is increasing itseems sir.
PPM 1 - 👍
Yes you were on the right track before the ultrasound findings added another layer of complexity
PPM 2 - Are we temporarily withdrawing the drug then?
PPM 1 -
Yes let's keep it on hold till the uncertainty is resolved @PPM14
PPM 6 - Okay sir.
10-02-2025
PPM 1 - Updat: Yesterday's history and ongoing meds reviewed.
PPM 1 - Additional Methyl Prednisolone 500 mg iv od planned by @PPM16 today
Let's review the current status of her proteinuria with a 24 hour urine protein and creatinine.
The spot protein creatinine attached here if reliable doesn't suggest an active lupus nephritis
The inflammatory bowel issue needs further investigation with a colonoscopy to rule out tuberculosis.
Let's hold the iv methyl prednisolone till then.
PPM 3 - 👍
PPM 1 - The urine output is not being monitored since admission! This is supposed to be from 9:00AM yesterday to 9:00AM today! But the patient says she voided most of it outside! @PPM6 @PPM9
PPM 16 - Sir diagnosis is clear sir..
It's mesenteric vasculitis, which is suggested by her acute presentation, favored by USG abdomen findings,delay In management can lead to complications like perforation sir...
CT abdomen is more appropriate investigation here if there is any doubt in the diagnosis sir.
PPM 1 - You mean CT angiography?
Get a CT angiography academic free if you suspect mesenteric vasculitis although a negative result will still not rule out micro vasculopathy.
PPM 16 - No sir, CT abdomen to look for signs of vasculitis..
CT angio is not giving us much information since the vessels involved are small vessels..
PPM 1 - What signs do we expect in CT abdomen?
Can we get an Abdominal x-ray to look for any signs of intestinal obstruction?
Currently she doesn't appear to have any signs of intestinal obstruction.
PPM 16 - Vessels prominence, dilated bowel loops, palisade pattern, ascites,bowel wall thickening, double halo sign.
PPM 1 - Bowel thickening present in ultrasound since last two months
Ascites absent
What is the sensitivity of others?
Can one rule out intestinal vasculitis if the CT abdomen is normal?
@PPM9 please get an AxR abdomen ap view ASAP.
PPM 9 - Yes sir.
PPM 16 - Minimal inter bowel fluid is present sir...
PPM 1 - @PPM9 get a surgery opinion ASAP. Wasn't taken by @PPM6 yesterday?
PPM 16 - Ko SF, Lee TY, Cheng TT, et al.: CT findings at lupus mesenteric vasculitis, Acta Radiol 38:115–120, 1997.
Article is not available for free sir, the question to sensitivity may be found in this article sir..
Yesterday we managed her symptoms, while thinking of possible etiologies sir....
PPM 1 - Let's establish that she has intestinal obstruction with an abdominal x-ray and take the surgeons into the loop.
Let's see if a CT abdomen can be done academic free.
PPM 9 -
PPM 1 - Thanks. Please get this reported by the radiology.
Please share the surgery notes
The abdominal x-ray doesn't look normal.
PPM 9 - Okay sir
The PG said she would look the case now and then will update sir.
PPM 1 - 👍
Evening update:
Progressive azotemia, oliguria since morning
Urea -49 to 87
Creatinine -1.1 to 2.7
PPM 16 - She had significant volume loss since the onset of illness, moreover any oral correction is not tolerated by the patient sir..
Iv volume replacement was inadequate which I have asked to do strictly...
Unless her primary cause is treated, this volume loss in the form of vomiting may continue..
This is my approach towards this case sir as of now...
PPM 1 - Agree.
Can check ivc movement in inspiration and expiration using pocus ASAP @PPM15
What is the primary cause? Unless we do a colonoscopy or CT abdomen that remains uncertain. Any luck with getting it academic free?
PPM 16 - SLE with GI vasculitis (presenting complaint)
PPM 1 - What features of the patient suggest gi vasculitis other than the fact that it's one of the differentials explaining her features of intestinal obstruction?
PPM 4 - Sir its looking like colon cut off sign?
PPM 1 - Partially.
Can't see a distinct cut off
PPM 2 - An early Rigler sign perhaps can help?
11-02-2025
PPM 1 16 - She doesn't have substrate to suspect GI obstruction sir, pseudo obstruction is better differential
She doesn't have colicky pain, abdominal distension
Moreover already USG abdomen is done it features are suggestive of vasculitis, with involvement in 2 different sites, small bowel and large bowel..
All her features are better fitting to vasculitis than obstruction sir..
PPM 1 - What USG features in her suggest vasculitis?
PPM 16 - Wall thickening, mild fluid..
PPM 1 - That can be due to any cause of inflammatory bowel
I'm writing to the MS and director in the staff group for help regarding her CT and colonoscopy.
PPM 16 - I will sponsor her CT sir @PPM9 arrange immediately for CT.
Patient shouldn't know that it's sponsored, if they come to know they expect more free aid...
Try academic free, if necessary I will come to talk...
If not possible, get it done ASAP, I will sponsor..
PPM 9 - Okay sir
PPM 1 - @PPM3 @PPM9 @PPM2 Do you recall how much high dose dexa we had given her last time for her last flare?
👆it may be there in her case reports too in the description box.
PPM 2 - I'm sure it was Methylpred?
PPM 3 - 750 mg methyl pred was given as pulse therapy followed by
Oral steroids, AZA.
PPM 2 - Does she have a lupus flare now? Is Vasculitis an indication for high dose Methylpred?
I recall we do Pred 1mg/kg here.
PPM 16 - It is sir..
PPM 2 - Alright. 👍🏼
Any literature if possible?
PPM 16 -
This is from kelley's latest edition sir.
PPM 1 -
Afternoon update and timeline by @PPM9
In bed
On iv NS 50 ml/hour and since morning received only 300 ml! Too less? @~Harika
Passed 100 ml just now!
Need
The ml graduations are well visible! Simple and nice container for measuring volume from a discarded NS bottle.
Passed some loose stools right now.
@PPM9 what about the review by Prof Sir?
Rising creatinine trends.
PPM 1 - @PPM17 any luck with the LB Nagar Gastro for colonoscopy?
@PPM3 do you know anyone there in LB Nagar who can help us with the Gastro colonoscopy there?
PPM 17 - No one is answering the call sir i will try again later sir.
PPM 1 - Can talk to NIMs Gastro and our ex UG PG
PPM 3 - One of my batchmate in KHL is now Gastro resident in NIMS sir. Will try him.
PPM 1 - Conversations with NIMs gastro resident and our ex UG PG:
[11/02, 13:12] : Can you help a 20F with intestinal obstruction with inflammatory bowel and AKI in the background of Lupus if we send her to you there just for the colonoscopy biopsy and back?
Off course if you want to admit her and go full length that also is great.
Her case report is here👇
[11/02, 13:22] NIMS Gastro KIMS UG PG: Is she having intestinal obstruction right now sir ?
[11/02, 13:32] NIMS Gastro KIMS UG PG: Sir please ask the patient to come to nims tomorrow to meet sir. I’ll give them appointment for colonoscopy on a later date. Our schedule is full for this week already.
[11/02, 14:53]: Yes since the last few days also with AKI oliguria. Just now she feels slightly better
[11/02, 14:55]: Tomorrow in your OPD? Is it only on Wednesday?
Another 20M we had discussed with you for hypersplenism and possible portal hypertension earlier went to NIMs but couldn't meet you. Not sure which day it was.
I guess I'll have to search my previous Lupus dexa records now.
PPM 1 - 👆Found this but the original udhc.co.in disappeared before we switched to blogspot and I can't access the dexa dose details! She didn't have a bad outcome from what I can recall.
PPM 1 - 👆Finally located the dexa dose we had used!
10 years back similar Lupus patient case report with extensive engagement in tabula rasa (similar to CBBLE PaJR) 👇
👆Even Prof Vivekananda Jha was a part of our CBBLE at that time!
[11/02, 15:05] NIMS Gastro Kims UG PG: This week my Opd is on Wednesday and Friday sir. And for next two weeks my Opd is on Tuesday , Thursday and Saturday. They can come on any of these days when she is stable.
[11/02, 15:46] : Our PGs will text you to coordinate.
12-02-2025
PPM 9 - 
PPM 1 - Thanks and total intake output for 11/2/25?
How many stools yesterday?
Bowel sounds?
PPM 9 - Patient was nbm yesterday
And now symptomatically feels better.
No pain abdomen no tenderness
No vomitings
Today - allowing orally
I/o -2100/500ml
Passed 1 episode of stool semi solid in consistency flatus +
Bowel sounds - present
PPM 1 - 👍
@PPM16 can we say that it's her ischemic bowel recovering without any steroid therapy?
PPM 9 - Yesterday methyl prednisolone 500mg was given sir.
PPM 1 - Given at what time? Yesterday evening?
There was nothing mentioned in the file about it when I evaluated her in the afternoon and she had already recovered by afternoon as per my findings.
Saw this note now! So even when i was evaluating her at this time yesterday the iv 500mg methyl prednisolone was started by ICU PG at 3:00PM and I wasn't even informed by ICU PG about it although both of us were seeing the patient together!
Apparently it was given from our AMC stock and out of these two options they paid 900 for the less expensive brand without a receipt.
@PPM17 discarded 500 mg in that vial after giving 500 mg from the 1000mg vial
ICU PG thinks as per his observations as ICU PG it's the forced ryles tube insertion followed by removal after 2-3 hours which made her recover.
@PPM9 and @PPM4 think it could have been a pancreatitis which has recovered spontaneously and coincidentally patient also received iv methyl pred at 3:00 PM by which time she had recovered even before the methylprednisolone.
I feel while I can agree with their hypothesis, it's still possible that her supposed intestinal vasculitis was recovering slowly and yesterday's iv methylprednisolone may have helped. Again not sure how to resolve this uncertainty except to await the macroscopic colonoscopic findings and microscopic histopathology of the intestine to check what was really going on there by sending her to NIMs and hoping for the best.
@PPM9 let's send her to NIMs on Friday👇
[11/02, 15:05] NIMS Gastro Kims UG PG: This week my Opd is on Wednesday and Friday sir.
And for next two weeks my Opd is on Tuesday , Thursday and Saturday. They can come on any of these days when she is stable .
[11/02, 15:46]: Our PGs will text you to coordinate.
13-02-2025
PPM 9 - Subjectively -patient feels better compared to yesterday
But yesterday after food intake - had abdominal pain which subsided with buscopan.
No vomitings
Passed stools yesterday afternoon.
Aki in resolving trends
Urea - 110---92
Creat -2.3 ---1.4
I/o - 2900ml/650ml
For the first time yesterday night bp-150/90mm hg
And since then bp recordings -are 160/100mmhg
PPM 1 - Thanks
3 doses of methyl prednisolone over?
PPM 9 - Today is the last dose sir.
PPM 1 - 👍What about her 24 hour protein and creatinine?
PPM 9 -
PPM 1 - Even the Lupus patient in the opposite bed had the same value?!!
PPM 9 - Yes sir almost similar.
PPM 1 - If this is true then this is the closest she has come to remission!
Now how much of that was due to her azathioprine (for which pancreatitis was one of the current differentials for her abdominal pain) and how much is due to one dose of methyl prednisolone is a big head scratcher! @PPM2
PPM 16 -
PPM 1 - Please share the URL to the article.
PPM 16 - Many URL''s are there sir.. I searched for pathology of intestinal vasculitis in Lupus...
Also to prove Lupus intestinal vasculitis truly one may actually require laparoscopic biopsy of the affected vessels before they enter the intestine in the mesentery which in this particular patient will be very difficult to say the least.
However a colonoscopy to chase the USG bowel thickening is still worthwhile and if there's really a lesion there then a biopsy could tell a lot provided we a good coordination between endoscopist and pathologist.
Always share the URL to the full text of whatever screenshot you share and that's a general dictum as it helps the audience to at least check out the full text of the fragment shared in screenshot.
PPM 16 - 👍
Sir patient and attender are not affordable for ambulance all to KHL and colonoscopy charges too....
PPM 1 - Yes we were planning for NIMs @PPM9 were you able to find out from Srujan?
I talked to the father who wants to go to NIMs next week on Tuesday, Thursday or Saturday.
@PPM9 can you also get a rough estimate of the potential costs from Srujan.
PPM 9 - Yes sir I spoke with sir
He said that he will be available on Tuesday Thursday and Saturday
Since they will be discharged tomorrow
I think they can go on Tuesday sir to have an appointment for the later date
And colonoscopy would cost around 2.5k
With biopsy -rs.700 sir
Approx 3.4-4k would be an estimate sir.
PPM 1 - 👍
Please let her father know.
Can discharge her on Saturday.
PPM 9 - 👍
14-02-2025
PPM 1 - @PPM16 as a cyclic iv pulse cyclophosphamide is being planned for her under your guidance, it would be great if you can share any good RCT that shows efficacy of that regime vs other care
@PPM3 would be nice if you too could share.
Her BP spikes are an effect of iv methyl prednisolone or lupus nephritis?
PPM 16 - I'm unavailable today for discussion sir...
PPM 1 - 👍
PPM 17 - The abdomen is distended now sir visually
Yesterday the abdominal girth is 69 cms
Today eve it is 73 cms sir
She did not pass stools today.
PPM 1 - Thanks.
Let's hope we get her colonoscopy quickly before she again goes into another obstruction.
15-02-2025
PPM 16 - Our patient is having loose stools due to laxative sir, she is not feeling well, so instructed our
PG's to postpone plan for discharge and counseled the attenders too about the same sir..
Asked to shift patient to ward sir...
Goal is make her fit for colonoscopy guided biopsy on Tuesday.. @PPM1 sir.
15-02-2025EMR SUMMARY
Age/Gender: 22 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 09/02/2025 06:41 AM
Name of Treating Faculty
DR RAMJI (AP) DR HARIKA PGY2
DR TUSHARA PGY1
Diagnosis
?SLE WITH RECURRENT INTESTINAL OBSTRUCTION WITH DIFFERENTIALS:-
-SLE WITH ?MESENTERIC VASCULITIS ?IBD
-DRUG INDUCED GASTRITIS, ?PANCREATITIS
-K/C/O SLE WITH LUPUS NEPHRITIS ON IMMUNOSUPRESSION(LOW DOSE PREDNISOLONE AND AZATHIOPRINE 50MG OD)
INFECTIVE COLITIS SINCE 1 MONTH, RIGHT SIDED HYDROPNEUMOTHORAX (SEE PREVIOUS DISCHARGE)
S/P ICD PLACEMENT AND REMOVAL 1 YEAR BACK
-K/C/O HTN SINCE 2 MONTHS ACUTE KIDNEY INJURY (RENAL)
Case History and Clinical Findings
C/O PAIN ABDOMEN IN UMBILICAL REGION AND EPIGASTRIC REGION SINCE 12 HOURS HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 12 HOURS AGO AFTER WHICH PATIENT DEVELOPED PAIN ABDOMEN IN EPIGASTRIC REGION AND UMBILICAL REGION WHICH WAS
INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, NON RADIATING, NO AGGRAVATING
FACTORS, RELIEVED IN PRONE POSITION ASSOCIATED WITH VOMITINGS (6 EPISODES), NON-PROJECTILE, NON-MUCOID, NON-BILIOUS, FOOD AS CONTENT.
NO C/O SOB, PALPITATIONS, DECREASED URINE OUTPUT, FACIAL PUFFINESS, LOOSE STOOLS, CONSTIPATION, PEDAL EDEMA
NO C/O FEVER, COUGH, COLD.
H/O RIGHT SIDED HYDROPNEUMOTHORAX S/P ICD PLACEMENT AND REMOVAL 1 YEAR BACK
PAST HISTORY:-
K/C/O SLE WITH LUPUS NEPHRITIS SINCE 3 YEARS K/C/O HTN SINCE 10 DAYS
N/K/C/O DM, TB, THYROID, CVA, CAD, EPILEPSY GENERAL EXAMINATION:-
PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA BP: 120/80MMHG
PR: 86BPM RR: 18CPM
SPO2: 97% AT RA APPETITE NORMAL BOWELS REGULAR MICTURITION NORMAL NO ALLERGIES
NO ADDICTIONS SYSTEMIC EXAMINATION:-
CVS: S1,S2 +, NO MURMURS RS: BAE+, NVBS HEARD
P/A: TENDERNESS IN UMBILICAL REGION CNS: NFND
SURGERY REFERRAL DONE ON 10/2/2025:- PER ABDOMEN: INSPECTION:-
NO VISIBLY ENGORGED VEINS, PULSATIONS OR PERISTALSIS NO VISIBLE MASSES OR SWELLING PER ABDOMEN
NO VISIBLE SCARS OR SINUSES PALPATION: ABDOMEN IS SOFT
TENDERNESS + IN RIGHT LUMBAR, RIGHT ILIAC AND RIGHT UMBILICAL REGIONS NO PALPABLE MASSES/SWELLINGS PER ABDOMEN
NO GUARDING/RIGIDITY
NO HEPATOSPLENOMEGALY/ORGANOMEGALY PERCUSSION: NORMAL LIVER DULLNESS ELICITED
RIGHT OF THE ABDOMEN IS RESONANT AUSCULTATION: BS+
USG ABDOMEN AND PELVIS: CIRCUMFERENTIAL LONG SEGMENTS BOWEL WALL THICKENING NOTED
SMALL BOWEL MEASURING 5MM OF THICKNESS LARGE BOWEL MEASURING 9-10MM OF THICKNESS LIKELY INFECTIVE INFLAMMATORY ETIOLOGY
MILD PERIHEPATIC AND INTERBOWEL FREE FLUID NOTED IN PELVIS ADVICE: PROCTOGLYSIS ENEMA/STAT
CST BY PRIMARY PHYSICIAN REVIEW SOS
Investigation
LIVER FUNCTION TEST (LFT) 09-02-2025 07:11:AM Total Bilurubin 1.02 mg/dl 1-0 mg/dl Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl SGOT(AST) 16 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0
IU/LALKALINE PHOSPHATASE 126 IU/L 98-42 IU/LTOTAL PROTEINS 5.9 gm/dl 8.3-6.4
gm/dl ALBUMIN 3.06 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.08
HEMOGRAM 9/2/2025: -
HAEMOGLOBIN 9.4 gm/dl 12.0 - 15.0 Colorimetric TOTAL COUNT 12,700 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 88 % 40 - 80 Light Microscopy LYMPHOCYTES 10 % 20 - 40 Light
Microscopy EOSINOPHILS 01 % 01 - 06 Light Microscopy MONOCYTES 01 % 02 - 10 Light
Microscopy BASOPHILS 00 % 0 - 2 Light Microscopy PCV 27.6 vol % 36 - 46 Calculation M C V 81.9 fl
83 - 101 Calculation M C H 27.9 pg 27 - 32 Calculation M C H C 34.1 % 31.5 - 34.5 Calculation RDW-
CV 16.0 % 11.6 - 14.0 Histogram RDW-SD 48.4 fl 39.0-46.0 Histogram RBC COUNT 3.37
millions/cumm 3.8 - 4.8 Impedence PLATELET COUNT 4.5 lakhs/cu.mm 1.5-4.1 Impedence SMEARRBC Normocytic normochromic Light Microscopy WBC Increased in count with Neutrophilia Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic Anemia with Neutrophilic Leukocytosis
RBS 90 mg/dl. 100 - 160 GOD - POD
Anti HCV Antibodies - RAPID 09-02-2025 07:11:AM Non ReactiveHBsAg-RAPID 09-02-2025 07:11:AM Negative
HIV NEGATIVE
BLOOD UREA 09-02-2025 07:11:AM 48 mg/dl 42-12 mg/dl
SERUM CREATININE 09-02-2025 07:11:AM 1.1 mg/dl 1.1-0.6 mg/dl
SPOT URINE PROTEIN 63 mg/dl. SPOT URINE CREATININE 79.7 mg/dl. RATIO 0.79
SERUM ELECTROLYTES (Na, K, C l) 09-02-2025 07:11:AM SODIUM 140 mmol/L 145-136
mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L
T3, T4, TSH 10-02-2025 08:03:AM T3 0.54 ng/ml 1.87-0.87 ng/mlT4 8.81 micro g/dl 12.23-6.32 micro
g/dlTSH 5.60 micro-Iu/ml 5.36-0.34 micro-Iu/ml
BLOOD UREA 10-02-2025 12:29:PM 87 mg/dl 42-12 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 10-02-2025 12:29:PM SODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/L
SERUM CREATININE 10-02-2025 12:29:PM 2.7 mg/dl 1.1-0.6 mg/dl
LIPID PROFILE: -Total Cholesterol 279 mg/dl Triglycerides 295 mg/dl 0 - 150 GPO-POD With
ESPASHDL Cholesterol 72 mg/dl 40 - 65 Direct Enzymatic LDL Cholesterol 122 mg/dl. 0 - 100 Direct Enzymatic VLDL * 59 mg/dl 12-40 mg/dl Direct Enzymatic
E S R 70 mm/ 1 st hour 5 - 20 Westergren
SERUM LIPASE 24.0 IU/L 13 - 60 Colorimetric
RFT 11-02-2025 04:13:AM UREA 113 mg/dl 42-12 mg/dl CREATININE 2.9 mg/dl 1.1-0.6 mg/dl URIC ACID 8.1 mmol/L 6-2.6 mmol/LCALCIUM 9.2 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 6.4 mg/dl 4.5-2.5
mg/dl SODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
102 mmol/L 98-107 mmol/L
24 HOURS URINE PROTEIN 211 mg/day. <150 mg/day24 HOURS URINE CREATININE 0.8 g/day
1-3 gm /day RATIO 0.26URINE VOLUME 500 ml
Blood Urea 12-02-2025: 110 mg/dl 12 - 42 Urease-GLDH
Serum Creatinine 2.3 mg/dl 0.6 - 1.1 Modified Jaffe's
SODIUM 135 mmol/L 136 - 145 Ion Selective Electrode POTASSIUM 4.4 mmol/L 3.5 - 5.1 Ion
Selective Electrode CHLORIDE 101 mmol/L 98 - 107 Ion Selective Electrode CALCIUM IONIZED 1.18 mmol/L Cord Blood: 1.30 - 1.602Hrs: 1.21 - 1.4624Hrs: 1.10 - 1.363Days: 1.15 - 1.425Days: 1.22 -1.48Adults: 1.16 - 1.32 Ion Selective Electrode
COMPLETE URINE EXAMINATION 12-02-2025: -
COLOUR Pale yellow Pale Yellow Physical Examination APPEARANCE Clear Clear Physical Examination REACTION Acidic 5.0-9.0 Reagent Strip SP.GRAVITY 1.010 1.001-1.035 Reagent Strip ALBUMIN ++ Negative Reagent Strip SUGAR Nil Negative Reagent Strip BILE SALTS Nil Negative Reagent Strip BILE PIGMENTS Nil Negative Reagent Strip PUS CELLS 3-4 0-5/HPF Light Microscopy EPITHELIAL CELLS 2-3 0-5/HPF Light Microscopy RED BLOOD CELLS Nil 0-2/HPF Light Microscopy CRYSTALS Nil Nil Light Microscopy CASTS Nil Nil Light Microscopy AMORPHOUS DEPOSITS Absent Nil Light Microscopy OTHERS Nil Nil Light Microscopy
HEMOGRAM 13-02-2025: -
HAEMOGLOBIN 7.0 gm/dl 12.0 - 15.0 Colorimetric TOTAL COUNT 16,600 cells/cumm 4000 - 10000 Impedence NEUTROPHILS 92 % 40 - 80 Light Microscopy LYMPHOCYTES 05 % 20 - 40 Light Microscopy EOSINOPHILS 01 % 01 - 06 Light Microscopy MONOCYTES 02 % 02 - 10 Light
Microscopy BASOPHILS 00 % 0 - 2 Light Microscopy PCV 20.6 vol % 36 - 46 Calculation M C V 84.8 fl 83 - 101 Calculation M C H 28.8 pg 27 - 32 Calculation M C H C 34.0 % 31.5 - 34.5 Calculation RDW- CV 16.5 % 11.6 - 14.0 Histogram RDW-SD 51.0 fl 39.0-46.0 Histogram RBC COUNT 2.43
millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 2.5 lakhs/cu.mm 1.5-4.1 Impedence SMEARRBC Normocytic normochromic Light Microscopy WBC Increased on smear Light Microscopy PLATELETS Adequate in number and distribution Light microscopy hemoparasites No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia with neutrophilic leucocytosis
RFT 13-02-2025: -
UREA 92 mg/dl 12 - 42 Urease-GLDHCREATININE 1.4 mg/dl 0.6 - 1.1 Modified Jaffe's URIC ACID
7.5 mmol/L 2.6 - 6 Uricase-POD With DHBSCALCIUM 8.3 mg/dl 8.6 - 10.2 Arsenazo
IIIPHOSPHOROUS 2.8 mg/dl 2.5 - 4.5 Direct UV without reduction SODIUM 135 mmol/L 136 - 145
Ion Selective Electrode POTASSIUM 4.0 mmol/L. 3.5 - 5.1 Ion Selective Electrode CHLORIDE 104 mmol/L 98 - 107 Ion Selective Electrode
RFT 14-2-2025: -
UREA 79 mg/dl 12 - 42 Urease-GLDHCREATININE 1.2 mg/dl 0.6 - 1.1 Modified Jaffe's URIC ACID
5.7 mmol/L 2.6 - 6 Uricase-POD With DHBSCALCIUM 7.8 mg/dl 8.6 - 10.2 Arsenazo
IIIPHOSPHOROUS 2.4 mg/dl 2.5 - 4.5 Direct UV without reduction SODIUM 136 mmol/L 136 - 145
Ion Selective Electrode POTASSIUM 4.3 mmol/L. 3.5 - 5.1 Ion Selective Electrode CHLORIDE 105 mmol/L 98 - 107 Ion Selective Electrode
HEMOGRAM 15-02-2025: -
HAEMOGLOBIN 7.2 gm/dl 12.0 - 15.0 Colorimetric TOTAL COUNT 5,000 cells/cumm 4000 - 10000
Impedence NEUTROPHILS 65 % 40 - 80 Light Microscopy LYMPHOCYTES 22 % 20 - 40 Light
Microscopy EOSINOPHILS 03 % 01 - 06 Light Microscopy MONOCYTES 10 % 02 - 10 Light
Microscopy BASOPHILS 00 % 0 - 2 Light Microscopy PCV 21.0 vol % 36 - 46 CalculationM C V 83.7 fl 83 - 101 Calculation M C H 28.7 pg 27 - 32 Calculation M C H C 34.3 % 31.5 - 34.5 Calculation RDW- CV 16.2 % 11.6 - 14.0 Histogram RDW-SD 49.7 fl 39.0-46.0 Histogram RBC COUNT 2.51
millions/cumm 3.8 - 4.8 Impedence PLATELET COUNT 2.67 lakhs/cu.mm 1.5-4.1 Impedence SMEARRBC Normocytic normochromic Light Microscopy WBC With in normal limits Light Microscopy PLATELETS Adequate in number and distribution Light Microscopic parasites No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic Anemia
RFT 15-02-2025: -
UREA 56 mg/dl 12 - 42 Urease-GLDHCREATININE 1.0 mg/dl 0.6 - 1.1 Modified Jaffe's URIC ACID
4.4 mmol/L 2.6 - 6 Uricase-POD With DHBSCALCIUM 7.4 mg/dl 8.6 - 10.2 Arsenazo
IIIPHOSPHOROUS 2.0 mg/dl 2.5 - 4.5 Direct UV without reduction SODIUM 135 mmol/L 136 - 145
Ion Selective Electrode POTASSIUM 3.8 mmol/L. 3.5 - 5.1 Ion Selective Electrode CHLORIDE 104 mmol/L 98 - 107 Ion Selective Electrode
USG ABDOMEN AND PELVIS DONE ON 9/2/25:- RIGHT KIDNEY 9.4 X 4.2CM, N S/E, CMD+, PCS N LEFT KIDNEY 9.4 X 4.5CM, N S/E, CMD+, PCS N UTERUS SIZE 6.9 X 4.2CM
ENDOMETRIAL THICKNESS 6-7MM FINDINGS/IMPRESSION:-
-CIRCUMFERENTIAL LONG SEGMENT BOWEL WALL THICKENING NOTED, SMALL BOWEL WALL MEASURING 5MM AND LARGE BOWEL WALL MEASURING 9-10MM OF THICKNESS, LIKELY INFECTIVE/INFLAMMATORY ETIOLOGY.
-MILD PERIHEPATIC AND INTERBOWEL FREE FLUID NOTED IN PELVIS.
Treatment Given (Enter only Generic Name)
NBM TILL FURTHER ORDERS
IV FLUIDS NS '100ML/HR; 10%DEXTROSE WITH 1 AMP OPTINEURON INJ TRAMADOL 1AMP IN 100ML NS IV/SOS
INJ ZOFER 8MG IV/TID INJ BUSCOPAN IV/BD
INJ PAN 40MG IV/OD 1-0-0
SYP MUCAINE GEL 10MG PO/TID 1-1-1
1 ORS SACHET IN 250MLO OF WATER THRICE DAILY MONITOR VITALS AND INFORM SOS
Advice at Discharge
TO MEET DR SRUJAN GASTRO, NIMS FOR COLONOSCOPY AND BIOPSY FO COLONIC LESION WITH USG SUGGESTED BY A SONOLOGIST.
SYP MUCAINE GEL 10MG PO/TID 1-1-1
1 ORS SACHET IN 250MLO OF WATER THRICE DAILY T.WYSOLONE 10MG OD TO CONTINUE T.AZATHIOPRINE 50MG OD TO CONTINUE
Follow Up
REVIEW TO GM OPD AFTER 1 MONTH
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendant Declaration : - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:15/2/2025 Ward: FMW Unit: IV
19-02-2025
Caretaker - Good evening sir, can you please prescribe the tablets for the patient.
PPM 1 - @PPM12 @PPM9 they were supposed to visit NIMS yesterday?
Please share the tablets your patient is currently taking. Her colonoscopy is planned on Friday.
Please ask her to continue the tablets she was previously taking till we get her colonoscopy report.
@PPM2 proctologist texted. He'll also try to get her colonoscopy bill waived. They may have to pay for the pathology bill. I guess that would be great.
PPM 9 - Yes sir they visited and they are scheduled on Friday for colonoscopy
They have doubt regards what medications to continue and have cleared them sir.
PPM 1 - 👍
21-02-2025
PPM 1 - Update:
The colonoscopy mucosa appeared normal?
Could it have been an intestinal vasculitic flare up that gave rise to her intestinal obstruction symptoms then?
PPM 9 - Vasculitic flare up only supports it I think so sir.
PPM 1 - Yes! @PPM16
[21/02, 16:18] NIMS Gastro KIMS UG PG: The mucosa upto the terminal ileum was normal sir. Vasculitic flare is one possibility and the other may be small bowel strictures which cause intermittent obstruction too. As she is asymptomatic now, it would be better to get a cect enterography the next time she gets any features if obstruction. We did take biopsy just in case.
PPM 16 - Acute on Chronic vasculitis with strictures causing pseudo obstruction sir...
PPM 1 - 👍
24-02-2025
PPM 6 - Patient admitted today morning with complaints of vomitings since 4 am 4-5 episodes
1 st episode was some of the food contents and watery.
Next episodes patient complains of hematemesis - dark colored
No complaints of pain abdomen, constipation, fever
Vitals on presentation
PR: 92/min
BP: 110/70 mmHg
Spo2: 95 on RA
RR:22 cpm
P/A: soft, non-tender
PPM 16 - Have they taken any photo of haematemesis??
How sure you are it's haematemesis??
PPM 1 - Any maintenance prednisolone she was on at discharge?
PPM 6 - Yes sir
She is on prednisolone 10 mg po od, tab. Azathioprine 50 mg po od.
PPM 1 - I checked in the afternoon. Although we had written 10 they were taking 5 but I guess that's okay and may not be responsible for hypoadrenalism causing her current symptoms.
Drug induced gastritis is the other possibility for which we shall get her upper GI endoscopy tomorrow.
25-02-2025
PPM 1 - Update
BP charting since 4:00PM revealed higher spikes 140/100 to 150/100 and night 7:30 PM took Telma 40 and hourly BP monitoring slightly relented although today it's again higher before her planned upper GI endoscopy. @PPM6 we'll also need to review her 24 hour urinary protein and creatinine which for the first time had shown near remission of her lupus nephritis during last admission.
PPM 1 - upper GI endoscopy done today.
26-02-2025
PPM 1 - Current problem:
Persistent vomiting immediately after food
Invite inputs @PPM@, @PPM3, @PPM16.
PPM 16 - I shall give my inputs tomorrow sir after talking to the patient..
PPM 1 - 👍
PPM 3 - Given her complaints:
22F immunosuppressive with acute to sub acute abdominal pain and vomitings with Flare up of Lupus nephritis. With background of endocarditis
*assuming Normal UGIE attached above
Localisation -
GI -
1. Mesentric ischemia / intestinal angina
2. Lupus enteritis / Vasculitis ( sub acute ) - associated with flare up of LN
2. IBD
3. ischemic colitis (?mesentric vessels occlusion again )
? External compression of bowel or blood vessel
Renal - azotemia / ?middle molecules triggering CTZ
CNS- raised ICP ( less likely )
@PPM6 did we do her CT angio..? Or CECT abd..?
PPM 7 - Cect abd or CT angio was not done sir
PPM 2 - How would they help?
Why not drug induced? Vomiting immediately after eating?
PPM 3 - Yes sir possible. She is been on AZA which could cause pancreatitis too.
PPM 2 - Relevant bits please.
PPM 2 - Yeah. So maybe Lipase with a USG should suffice for now?
PPM 7 - One of our faculty was thinking it could be cyclic vomiting syndrome as a differential sir
PPM 2 - Isn't that a diagnosis of exclusion and is usually not sinister as seen here?
PPM 3 - Rather colonoscopy would be better.
Look for any signs of bowel inflammation or ischemia or an ulcers and take a bit for histopathology.
PPM 2 - Vomiting immediately after food intake would localise the problem much higher wouldn't it? Which means the problem is involving the digestive machinery - esophagus, stomach, hepato-pancreatico-biliary organs?
PPM 7
- 
It was done in NIMS sir
Upper GI endoscopy in our hospital. Biopsy report will be updated tomorrow sir.
PPM 3 - Correct sir here macroscopic visualisation of mucosa seems normal.
🏏
PPM 2 - I wish I had WhatsApp AI but can you please ask what is the incidence of vomiting in patients taking Azathioprine?
PPM 3 - @Meta AI incidence of vomitings in patients in chronic azathioprine
Meta AI - Azathioprine is an immunosuppressive medication commonly used to treat autoimmune diseases, prevent organ rejection in transplant patients, and manage certain inflammatory conditions.
Regarding the incidence of vomiting in patients taking chronic azathioprine, here are some findings:
- A study published in the Journal of Clinical Pharmacology found that gastrointestinal symptoms, including nausea and vomiting, occurred in approximately 12% of patients taking azathioprine (1).
- Another study published in the British Journal of Clinical Pharmacology reported that vomiting was experienced by around 5% of patients receiving azathioprine (2).
- A review of azathioprine's safety profile published in the journal Expert Opinion on Drug Safety noted that gastrointestinal adverse effects, including vomiting, are relatively common, affecting up to 20% of patients (3).
Please note that the incidence of vomiting can vary depending on factors such as:
- Dosage: Higher doses may increase the risk of gastrointestinal side effects.
- Individual tolerance: Some patients may be more susceptible to azathioprine's side effects.
- Concomitant medications: Taking other medications that can cause gastrointestinal upset may increase the risk of vomiting.
If you're experiencing persistent or severe vomiting while taking azathioprine, it's essential to consult your healthcare provider for proper evaluation and guidance.
References:
1. Journal of Clinical Pharmacology, "Azathioprine-induced gastrointestinal symptoms: a review of the literature" (2018)
2. British Journal of Clinical Pharmacology, "Adverse effects of azathioprine in patients with inflammatory bowel disease" (2015)
3. Expert Opinion on Drug Safety, "Azathioprine: a review of its safety profile" (2019)
I hope this helps! If you have further questions or concerns, feel free to ask.
PPM 2 - Please ask absolute numbers and duration of Azathioprine in study 1.
PPM 7 - @Meta AI absolute numbers and duration of Azathioprine in study 1.
Meta AI -
In Study 1, the absolute numbers and duration of Azathioprine were as follows:
- Number of patients: 40 children with inflammatory bowel disease (IBD) ¹
- Duration of Azathioprine treatment: The study doesn't explicitly state the duration, but it mentions that thiopurines can take up to 14 weeks to be fully effective ¹
- Azathioprine dose: The mean azathioprine dose was 1.3±0.4 mg/kg ¹
- Thiopurine metabolite measurement timing: Blood tests were performed 6 weeks after the initiation of therapy ¹
Meta AI
PPM 3 - @PPM2 @PPM7
Incidence of Vomiting in Chronic Azathioprine Use: A Comprehensive Analysis of Large-Scale Medical Studies
Azathioprine, a widely used immunosuppressive agent, has demonstrated clinical efficacy across various autoimmune and inflammatory conditions. However, its therapeutic benefits are often accompanied by gastrointestinal adverse effects, with vomiting representing a clinically significant concern. This report synthesizes data from multiple large-scale studies to quantify the incidence of vomiting during chronic azathioprine therapy, providing granular insights into population-specific risks, dose dependencies, and management strategies.
---
## Epidemiological Overview of Azathioprine-Associated Vomiting
The incidence of vomiting during azathioprine therapy varies substantially across patient populations and treatment protocols. A landmark study involving *622 inflammatory bowel disease (IBD) patients* revealed that *68 patients (10.9%)* discontinued treatment due to nausea and vomiting, with symptoms typically emerging within a mean of *106 days* after initiation[6]. Notably, this cohort received a mean dose of *1.77 mg/kg/day, though no direct correlation between dose intensity and emetic frequency was observed[6]. These findings align with a Korean pediatric IBD study where **27 of 174 patients (15.5%)* experienced vomiting at a mean dose of *1.38 mg/kg/day, with **10 patients (5.7% of total cohort)* requiring permanent discontinuation[3][5].
---
## Dose-Response Relationships and Temporal Patterns
Contrary to conventional pharmacokinetic expectations, vomiting incidence does not exhibit strong dose dependency. In the Korean pediatric cohort, vomiting occurred across a broad dose range (*1.38 ± 0.46 mg/kg/day), with symptom onset delayed until a mean of **10.4 months* into therapy[3]. This contrasts with adult populations where emetic episodes frequently manifest earlier, suggesting age-related differences in drug tolerance. A paradoxical observation emerged from a 14-patient gastritis study, where only *1 patient (7.1%)* developed dose-limiting nausea/vomiting despite prolonged azathioprine exposure (>2.5 months)[2], highlighting condition-specific variability in adverse effect profiles.
---
## Population-Specific Risk Stratification
### Pediatric vs. Adult Populations
Pediatric patients demonstrate heightened vulnerability, with *15.5% vomiting incidence* in Korean children[3] versus *10.9%* in mixed-age IBD cohorts[6]. This disparity may reflect developmental differences in thiopurine methyltransferase (TPMT) activity or enterohepatic recirculation patterns. Notably, pediatric data showed *37% of vomiting cases* required dose reduction, while adults predominantly required complete cessation[3][6].
### Disease-State Modifiers
IBD patients exhibit higher emetic rates (*10.9-15.5%[3][6]) compared to transplant recipients (<1%[4]). This discrepancy likely stems from baseline gastrointestinal inflammation in IBD exacerbating drug-induced mucosal irritation. A critical finding from the 622-patient IBD study revealed **64% remission rates* in Crohn's disease patients persisting beyond six months of therapy despite vomiting incidence[6], underscoring the risk-benefit calculus in chronic management.
---
## Management Algorithms and Clinical Outcomes
### Pharmacological Interventions
Proactive antiemetic use remains controversial due to potential drug interactions. The NHS guidelines recommend dietary modifications (e.g., administration with meals) as first-line management, reporting symptom resolution within one week for most patients[1]. Refractory cases often necessitate dose reduction, successful in *29.6% of pediatric patients*[3], though this risks subtherapeutic immunosuppression.
### Discontinuation Thresholds
Permanent cessation rates vary by indication:
- *5.7%* in pediatric IBD[3]
- *10.9%* in adult IBD[6]
- *7.1%* in chronic gastritis[2]
Notably, *17% of adult IBD patients* restarting azathioprine after initial intolerance achieved long-term tolerance through gradual dose escalation[6], suggesting protocolized rechallenge strategies may mitigate attrition.
---
## Mechanistic Considerations in Emetogenesis
The dual-phase vomiting pathophysiology involves:
1. *Direct mucosal irritation* via 6-thioguanine nucleotide accumulation in gut epithelium[4]
2. *Central chemoreceptor activation* through proinflammatory cytokine cross-talk (IL-6, TNF-α)[3]
Hepatic metabolism polymorphisms further modulate risk, with slow TPMT metabolizers showing *3.2-fold increased emetic propensity* in pharmacogenetic subanalyses[6]. These insights inform emerging genotype-guided dosing protocols aiming to balance efficacy and tolerability.
---
## Longitudinal Safety Data
The 622-patient cohort provided critical temporal insights:
- *42.3% of vomiting cases* occurred within 3 months
- *28.1%* manifested between 3-12 months
- *29.6%* emerged after >1 year of therapy[6]
This prolonged risk window contradicts traditional "early toxicity" paradigms, necessitating ongoing monitoring even in long-term users. Late-onset cases correlated with cumulative dose thresholds exceeding *200g*, suggesting mitochondrial toxicity mechanisms[4].
---
## Comparative Safety Profiles
While vomiting represents a predominant gastrointestinal effect, its incidence eclipses other azathioprine toxicities:
- *4.6% leukopenia*[6]
- *7.5% pancreatitis*[3]
- *2.9% hepatotoxicity*[3]
Notably, *68% of drug discontinuations* stem from vomiting/nausea compared to *4.6% for hematologic effects*[6], emphasizing its clinical impact on treatment adherence.
---
## Conclusion: Risk Mitigation in Clinical Practice
Synthesizing data from 796 patients across three continents, chronic azathioprine therapy carries a *11-15% vomiting risk, with absolute case numbers ranging from **68/622[6] to **27/174*[3] in large cohorts. Proactive genotype screening (TPMT, NUDT15), staggered dosing protocols, and early antiemetic support may reduce attrition. Future research should prioritize randomized trials of aprepitant and olanzapine as prophylactic agents in high-risk populations.
Sources
[1] Side effects of azathioprine - NHS https://www.nhs.uk/medicines/azathioprine/side-effects-of-azathioprine/
[2] The effect of azathioprine on gastric mucosal histology and acid ... https://pubmed.ncbi.nlm.nih.gov/4696531/
[3] Adverse Events Associated with Azathioprine Treatment in Korean ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3819691/
[4] Azathioprine Side Effects: Common, Severe, Long Term - Drugs.com https://www.drugs.com/sfx/azathioprine-side-effects.html
[5] [PDF] Adverse Events Associated with Azathioprine Treatment in Korean ... https://www.pghn.org/Synapse/Data/PDFData/1121PGHN/pghn-16-171.pdf
[6] The efficacy of azathioprine for the treatment of inflammatory bowel ... https://pmc.ncbi.nlm.nih.gov/articles/PMC1773162/
[7] Long -term safety and toxicity of azathioprine in patients with air ... https://ijdvl.com/long-term-safety-and-toxicity-of-azathioprine-in-patients-with-air-borne-contact-dermatitis/
[8] [PDF] Azathioprine (Imuran) https://www.cuh.hse.ie/media/pil/azathioprine-imuran-gp-sheet-2023.pdf
[9] Effect of azathioprine intolerance on outcomes of inflammatory ... https://pmc.ncbi.nlm.nih.gov/articles/PMC5369706/
[10] Hypersensitivity to azathioprine in a patient with Crohn's disease http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082017001000013
[11] Long‐term safety and effectiveness of azathioprine in the ... https://onlinelibrary.wiley.com/doi/full/10.1002/jgh3.12955
[12] azathioprine oral: Uses, Side Effects, Interactions, Pictures ... - WebMD https://www.webmd.com/drugs/2/drug-13771/azathioprine-oral/details
[13] Azathioprine (Imuran®) Drug Information Sheet https://www.hopkinsarthritis.org/patient-corner/drug-information/azathioprine-imuran/
[14] [PDF] 787fm.3 azathioprine for use in rheumatology, dermatology https://www.bucksformulary.nhs.uk/docs/Guideline_787FM.pdf
[15] Azathioprine (oral route) - Mayo Clinic https://www.mayoclinic.org/drugs-supplements/azathioprine-oral-route/description/drg-20067180
[16] Long-term Efficacy and Safety of Azathioprine in Ulcerative Colitis https://academic.oup.com/ecco-jcc/article/9/2/191/439760
[17] [PDF] updated azathioprine guidelines. - London - Whittington Hospital https://www.whittington.nhs.uk/document.ashx?id=6404
[18] Azathioprine (Imuran®) Uses and Side Effects https://www.chp.edu/our-services/transplant/liver/education/medications/azathioprine-imuran
[19] Weekly azathioprine pulse versus daily azathioprine in the treatment ... https://ijdvl.com/weekly-azathioprine-pulse-versus-daily-azathioprine-in-the-treatment-of-parthenium-dermatitis-a-non-inferiority-randomized-controlled-study/
[20] Azathioprine: Side Effects, Dosage, Uses, and More - Healthline https://www.healthline.com/health/drugs/azathioprine-oral-tablet
[21] Azathioprine - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK542190/
[22] Azathioprine: Side Effects & Treatment - Cleveland Clinic https://my.clevelandclinic.org/health/drugs/9407-azathioprine
[23] Azathioprine | Side-effects, uses, time to work - Versus Arthritis https://versusarthritis.org/about-arthritis/treatments/drugs/azathioprine/
[24] Toxicity of azathioprine: why and when? analysis of the prevalence ... https://www.scielo.br/j/ag/a/f9L5FC63GsTFFxvJsZ3TrrN/
[25] Real-World Study Finds Long-Term Azathioprine Treatment Safe ... https://www.managedhealthcareexecutive.com/view/real-world-study-finds-long-term-azathioprine-treatment-safe-effective-in-patients-with-ibd
[26] Long‐term safety and effectiveness of azathioprine in the ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10517446/
[27] Azathioprine in ulcerative colitis: Why, when, how and how long to ... https://analyticalsciencejournals.onlinelibrary.wiley.com/doi/10.1002/ddr.20481
[28] [PDF] Azathioprine for patients within adult services (non-transplant ... https://www.covwarkformulary.nhs.uk/docs/chapter01/SCA102-Azathioprine%20non%20transplant%20indications.pdf
PPM 2 - 👍
PPM 7 - According to the above study, azathioprine causes vomiting in 10-15% patients sir.
PPM 3 - Yes this could help too @PPM7
USG abd done on 24th Feb already sir.
PPM 6 - Lipase done during previous admission was normal sir.
PPM 7 - She had similar complaints at that time too sir, Lipase was normal.
27-02-2025
PPM 2 - This pretty much nails it doesn't it.
PPM 3 - 👍
PPM 1 - Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating
However having said that I guess we should stop azathioprine for now
Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission.
PPM 9 -
PPM 1 - Creatinine not done! The sample volume may have been inadequate!
Let's repeat the urine for 24 hour collection tomorrow!
[27/02, 14:35] pg: Can we plan renal biospy for her sir?!
[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.
Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today
So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!
Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!
PPM 1 - 👍
Why is the volume oliguric? Can we have the 24 hour intake output since few days that she got admitted?
PPM 9 - Yesterday -2000/400ml
PPM 1 - Day before?
Today's?
28-02-2025
PPM 17 - 1050/200 ml on 26 th sir
Today -1100/250 ml sir
PPM 1 - You mean yesterday's 24 hour urine output was 250 ml?
Last serum creatinine?
PPM 9 - Sir till evening there was no output
She is dehydrated
And after iv fluids- urine output was 250ml sir
Slightly better compared to yesterday
2 episodes of vomitings
Pain abdomen+
Tenderness in the epigastric region.
No fever spikes
Has passed stools yesterday
S.creat -1.0
PPM 1 - 👍
Yes let's monitor the urine output hourly and replenish her volume hourly as per our hourly evaluation of her ivc mobility.
@PPM3 you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @PPM18 also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.
We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @PPM5 just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet.
PPM 3 - Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.
Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir.
PPM 1 - 👍
01-03-2025
PPM 16 - 
PPM 16 - In summary, the cumulative exposure to CYC that
results in ovarian failure varies by age. To avoid
amenorrhea, female patients < 20 years old should
likely receive < 15 to 20 g of total exposure, patients
aged 20 to 30 should receive < 15 g of total exposure
and those > 30 should likely receive < 10 g of total
exposure. We did not make a recommendation for
maximum exposure to prevent infertility in patients
> 40 as this group already has a low baseline fertility
rate, worsened by disease activity. In males, the
maximum CYC exposure for patients who still wish to
conceive is lower at approximately 10 g.
We are just calculating the cost of tablets sir. Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..
PPM 1 - 👍Agree well said 👏👏. So the harms appear to be worth a try!
Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil
As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks!
[01/03, 08.31] PPM 16 - Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...
So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based...
In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....
[01/03, 08.34] PPM 16 - We are repeating lipase today sir...
Specificity of lipase is roughly 99 %...
We have to await for lipase results to say it's pancreatitis...
[01/03,08.37] PPM 16 - One thing is very clear sir, she is having disease activity, and requires immunosuppression immediately, then planned for renal biopsy for definitive decision making.
[01/03,08.48] PPM 1 - Specificity may not be as important as sensitivity here in this case who already had demonstrated normal lipase during her previous acute attack during her previous admission!
Sensitivity is more important because if it's negative we will still not be able to rule it out as it's known to have sensitivity varying from 64-100%
Here's a paper citing the same including the fact that even specificity isn't 100% for pancreatitis as IBD can often have high lipase!
[01/03,08.51] PPM 1 -Agree that she has disease activity and we have been able to suppress it using drugs in the past unfortunately that we are having to discontinue because of cumulative side effects.
In view of no definitive data toward cyclophosphamide which will also need to be discontinued after a few months, i would prefer starting mycofenolate mofetil albeit expensive
However if there is good evidence of a cyclophosphamide pulse showing complete remission without recurrence it could be worth considering. However we need to see the evidence for it. @PPM3 would you like to try perplexity again for this?
PPM 3 - 👍
[01/03,09.07] PPM 16 - Diagnostic accuracy of serum lipase and amylase as biomarkers for
acute pancreatitis
[01/03,09.09] PPM 16 - https://www.msjonline.org/index.php/ijrms/article/download/4772/3915/19147
[01/03, 09.10] PPM 16 - https://bmjopen.bmj.com/content/2/5/e001471
[01/03, 09.13] PPM 16 - I'm thinking that patient has less probability of pancreatitis sir..
Both sensitivity and specificity are high for lipase..
Helps to both rule out, as well as rule in with almost certainty....
[01/03, 09.18] PPM 1 - Sensitivity can vary from 64-100%
Negative doesn't rule out.
[01/03, 09.19] PPM 16 -
[01/03,09.19] PPM 1 - What is our alternate diagnosis for her symptoms?
[01/03, 09.20] PPM 16 - Though not meeting the cutoff, I'm convinced that patient is having pancreatitis sir...
Withholding azathioprine is justified sir...
PPM 1 - 👍
[01/03, 09.21] PPM 16 - Considering her symptoms examination findings and elevation in enzymes...
[01/03, 09.25] PPM 1 - 👍
[01/03, 09.36] PPM 6 - Previous admission lipase was 24 IU/L sir.
[01/03, 09.44] PPM 1 - 👍
An important learning point worth exploring further here in a thesis project here would be the variability of enzymatic activity in pancreatitis and how a longitudinal follow up is necessary for diagnosis rather than just a few random values? @PPM3 @PPM2
[01/03, 09.45] PPM 2 - Is this usually 2x or 3x? I remember 3x.
[01/03, 09.45] PPM 16 - 3x sir
[01/01, 09.46] PPM 2 - So if 24 is her usual count and 110 is nearly 5x, does this PaJR (highly individual centric and highly specific) number actually diagnose a pancreatitis?
PPM 1 - 👍
[01/03, 09.46] PPM 2 - Please can you give us the dates of the 24 and this 110?
@PPM6
Thanks.
[01/03, 09.49] PPM 6 - On 10th Feb sir.
[01/03, 10.00] PPM 1 - She was having an acute attack of pancreatitis when her lipase was 24
Hence it's possible that the enzyme evaluation needs to be streamlined globally and not just for this particular patient and hence the need for a thesis.
[01/03, 10.01] PPM 1 - @PPM19 thesis was the first to point us in this direction of a possibility of finding the window of enzyme rise correlating with pancreatic inflammation.
[01/03, 10.30] PPM 2 - Thanks. And when was 110?
[01/03, 10.30] PPM 2 - I'm sure there are global thesis on this issue.
[01/03, 10.31] PPM 2 - At a deeper level, it does hark back to clinical suspicion trumping all else?
[01/03, 10.32] PPM 16 - Today sir.
[01/03, 10.40] PPM 3 - Efficacy of Cyclophosphamide Pulse Therapy in Lupus Nephritis: Comparative Analysis Against Methylprednisolone and Placebo
Cyclophosphamide pulse therapy remains a cornerstone in the management of lupus nephritis (LN), demonstrating superior efficacy over methylprednisolone monotherapy and placebo in preserving renal function, inducing remission, and reducing relapse rates. High-quality evidence from randomized trials and meta-analyses supports its role as a first-line induction therapy, particularly in proliferative LN classes III/IV. This report synthesizes data on dosing strategies, combination regimens, safety profiles, and long-term outcomes to delineate cyclophosphamide’s therapeutic advantages.
Cyclophosphamide-Methylprednisolone Synergy in Induction Therapy
Superior Remission Rates with Combination Regimens
Combining cyclophosphamide pulses with intravenous methylprednisolone significantly enhances remission rates compared to methylprednisolone alone. In a 38-month observational study of 39 proliferative LN patients, 82.05% achieved remission (51.28% complete, 30.77% partial) following induction with methylprednisolone and monthly cyclophosphamide pulses (target cumulative dose: 200 mg/kg). Early initiation (<6 months from diagnosis) correlated with higher remission likelihood (P=0.04), underscoring the time-sensitive nature of aggressive immunosuppression[1]. Mechanistically, cyclophosphamide suppresses lymphocyte proliferation, complementing methylprednisolone’s anti-inflammatory effects to reduce glomerular immune complex deposition.
Head-to-Head Comparisons with Methylprednisolone Monotherapy
Methylprednisolone alone demonstrates inadequate disease control in severe LN. In refractory cases, a phase II trial comparing rituximab/cyclophosphamide (RC) versus rituximab/cyclophosphamide/belimumab (RCB) found no significant difference in renal response rates (RCB: 52%, RC: 41%; P=0.452), highlighting cyclophosphamide’s irreplaceable role even in biologic combination regimens[2]. Notably, 73% of treatment failures stemmed from lack of improvement or worsening LN, emphasizing the necessity of cyclophosphamide’s cytotoxic action in halting autoimmune renal damage.
Pulse vs. Continuous Cyclophosphamide Regimens
Meta-Analysis of Dosing Strategies
A meta-analysis of 12 randomized trials (994 patients) revealed distinct advantages of short-interval, lower-dose intravenous cyclophosphamide (e.g., EuroLupus protocol: 500 mg fortnightly for 3 months) over traditional high-dose regimens:
- *24-hour proteinuria reduction: Mean difference -0.45 g/day (*P<0.001)[3]
- *Safety*: 38% lower infection risk (OR 0.62) and 59% reduced gonadal toxicity (OR 0.41)[3]
- *Renal preservation*: High-dose regimens marginally reduced doubling of serum creatinine (OR 2.43), though without significant remission rate differences[3].
Pediatric-Specific Outcomes
A 2024 multicenter study of 145 childhood-onset LN patients found no difference in 12-month complete renal response between EuroLupus (cumulative dose: 3 g) and NIH regimens (cumulative dose: 9–12 g) (OR 0.76; 95% CI 0.29–1.98)[5]. This challenges historical preferences for higher dosing in pediatric populations, advocating for reduced cumulative exposure without compromising efficacy.
Safety Profile and Adverse Event Mitigation
Reduced Toxicity with Pulse Administration
Cyclophosphamide’s adverse events are dose-dependent. Pulse regimens (cumulative dose: 6–12 g) demonstrate:
- *Infections*: 15% incidence vs. 26% with oral cyclophosphamide[8]
- *Gonadal toxicity*: 59% risk reduction vs. continuous dosing[3]
- *Leukopenia*: 45% lower odds (OR 0.55)[3].
Gastrointestinal and Hematologic Tolerability
Combining low-dose cyclophosphamide (0.4 g/m²) with mycophenolate mofetil (MMF) (1 g/day) reduced gastrointestinal reactions (7.1% vs. 30% with cyclophosphamide alone; P<0.05) and infections (11.9% vs. 32.5%) while maintaining equivalent remission rates[4].
---
Relapse Rates and Maintenance Strategies
Post-Remission Outcomes
The EuroLupus protocol achieved 58% complete remission in Tunisian LN patients, but 38.5% relapsed within 12 months, often due to treatment withdrawal or infections[6]. This highlights the critical role of maintenance therapy:
- *Azathioprine/MMF transition*: Post-induction maintenance with azathioprine (2 mg/kg/day) or MMF (2 g/day) sustains remission in 70–80% of cases[1][6].
- *B cell monitoring: Post-rituximab/cyclophosphamide belimumab maintenance reduces naive B cell repopulation (geometric mean: 53 vs. 11 cells/μl without belimumab; *P=0.0012)[2], potentially lowering relapse risk.
---
Placebo Comparisons and Historical Context
While direct placebo-controlled trials are limited in modern LN studies due to ethical concerns, historical data contextualize cyclophosphamide’s superiority:
- Pre-cyclophosphamide eras saw <30% 5-year renal survival in proliferative LN vs. >80% with current protocols[7].
- Indirect comparisons show placebo-equivalent regimens (e.g., corticosteroids alone) fail to prevent ESRD progression, with doubling of serum creatinine in 40–60% within 5 years[1][7].
---
Cost-Effectiveness and Accessibility
Resource-Limited Settings
Oral cyclophosphamide pulse therapy offers a cost-effective alternative to IV administration (50 INR vs. 630 INR per dose) with comparable efficacy[1][7]. This expands access in regions lacking infusion infrastructure without compromising outcomes.
---
Conclusion
Cyclophosphamide pulse therapy, particularly when combined with methylprednisolone, establishes remission in >80% of proliferative LN cases, outperforming methylprednisolone monotherapy and historical placebo-equivalent approaches. The EuroLupus protocol’s efficacy parity with high-dose regimens, coupled with superior safety, positions it as the preferred induction strategy. Future research should optimize maintenance protocols integrating biologics like belimumab to address relapse rates while minimizing cumulative toxicity.
Sources
[1] The outcome of proliferative lupus nephritis with pulse ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3161432/
[2] Phase II Randomized Trial of Rituximab Plus Cyclophosphamide ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41466
[3] A Meta-Analysis of Randomized Controlled Trials - PubMed https://pubmed.ncbi.nlm.nih.gov/31702519/
[4] Efficacy and safety of cyclophosphamide combined with ... https://pmc.ncbi.nlm.nih.gov/articles/PMC4723952/
[5] Renal Response Outcomes of the EuroLupus and National Institutes ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42725
[6] AB0369 Evaluation of the eurolupus protocol in lupus nephritis ... https://ard.bmj.com/content/72/Suppl_3/A900.2
[7] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://onlinelibrary.wiley.com/doi/10.1155/2022/8345737
[8] High Dose Cyclophosphamide versus Monthly Intravenous ... https://pmc.ncbi.nlm.nih.gov/articles/PMC2911961/
[9] Randomized controlled trial of pulse intravenous cyclophosphamide ... https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1797.2005.00444.x
[10] Treatments for Lupus Nephritis: A Systematic Review and Network ... https://www.jrheum.org/content/43/10/1801
[11] [PDF] Intravenous Cyclophosphamide for lupus nephritis - Nefrología https://www.revistanefrologia.com/index.php?p=revista&tipo=pdf-simple&pii=X2013251407020823
[12] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://pmc.ncbi.nlm.nih.gov/articles/PMC9192236/
[13] Pro: Cyclophosphamide in lupus nephritis - Oxford Academic https://academic.oup.com/ndt/article/31/7/1047/1752196
[14] Lupus Nephritis Treatment & Management - Medscape Reference https://emedicine.medscape.com/article/330369-treatment
[15] [PDF] KDIGO-2024-Lupus-Nephritis-Guideline.pdf https://kdigo.org/wp-content/uploads/2024/01/KDIGO-2024-Lupus-Nephritis-Guideline.pdf
[16] Effect of Tacrolimus vs Intravenous Cyclophosphamide on Complete ... https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790507
[17] Treatment of lupus nephritis: a meta-analysis of clinical trials - PubMed https://pubmed.ncbi.nlm.nih.gov/9016889/
[18] Moderator's view: Cyclophosphamide in lupus nephritis https://academic.oup.com/ndt/article/31/7/1058/1752165
[19] Cyclophosphamide in lupus nephritis: a controlled trial - PubMed https://pubmed.ncbi.nlm.nih.gov/4104337/
[20] Calcineurin inhibitors may be a reasonable alternative to ... https://www.spandidos-publications.com/10.3892/etm.2014.1669
[21] Induction and Maintenance Treatment of Lupus Nephritis - MDPI https://www.mdpi.com/2077-0383/11/2/343
[22] Con: Cyclophosphamide for the treatment of lupus nephritis https://academic.oup.com/ndt/article/31/7/1053/1752174
[23] Mycophenolate versus Cyclophosphamide for Lupus Nephritis https://indianjnephrol.org/mycophenolate-versus-cyclophosphamide-for-lupus-nephritis/
[24] IV Cyclophosphamide Protocols for Systemic Lupus Erythematosus https://www.msdmanuals.com/professional/multimedia/table/iv-cyclophosphamide-protocols-for-systemic-lupus-erythematosus
[25] the Euro-Lupus Nephritis Trial, a randomized trial of low-dose ... https://pubmed.ncbi.nlm.nih.gov/12209517/
[26] Current and Emerging Therapies for Lupus Nephritis - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5042683/
[27] Use of EuroLupus Cyclophosphamide Dosing for the Treatment of ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10464387/
[28] The NIH pulse cyclophosphamide regime: the end of an era? https://journals.sagepub.com/doi/10.1191/0961203304lu524ed?icid=int.sj-abstract.similar-articles.8
[29] Brief Report: The Euro‐Lupus Low‐Dose Intravenous ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.40079
[01/03, 10.42] PPM 2 - Can AI simplify it with numbers laid out clearly?
[01/03, 10.49] PPM 3 - @Meta AI simplify this high quality evidence based data with laid numbers clearly so that MBBS student can understand.
[01/03, 10.50] PPM 3 -
@Meta AI simplify this high quality evidence based medical data with laid out numbers clearly so that MBBS student can understand it better. Efficacy of Cyclophosphamide Pulse Therapy in Lupus Nephritis: Comparative Analysis Against Methylprednisolone and Placebo
Cyclophosphamide pulse therapy remains a cornerstone in the management of lupus nephritis (LN), demonstrating superior efficacy over methylprednisolone monotherapy and placebo in preserving renal function, inducing remission, and reducing relapse rates. High-quality evidence from randomized trials and meta-analyses supports its role as a first-line induction therapy, particularly in proliferative LN classes III/IV. This report synthesizes data on dosing strategies, combination regimens, safety profiles, and long-term outcomes to delineate cyclophosphamide’s therapeutic advantages.
Cyclophosphamide-Methylprednisolone Synergy in Induction Therapy
Superior Remission Rates with Combination Regimens
Combining cyclophosphamide pulses with intravenous methylprednisolone significantly enhances remission rates compared to methylprednisolone alone. In a 38-month observational study of 39 proliferative LN patients, 82.05% achieved remission (51.28% complete, 30.77% partial) following induction with methylprednisolone and monthly cyclophosphamide pulses (target cumulative dose: 200 mg/kg). Early initiation (<6 months from diagnosis) correlated with higher remission likelihood (P=0.04), underscoring the time-sensitive nature of aggressive immunosuppression[1]. Mechanistically, cyclophosphamide suppresses lymphocyte proliferation, complementing methylprednisolone’s anti-inflammatory effects to reduce glomerular immune complex deposition.
Head-to-Head Comparisons with Methylprednisolone Monotherapy
Methylprednisolone alone demonstrates inadequate disease control in severe LN. In refractory cases, a phase II trial comparing rituximab/cyclophosphamide (RC) versus rituximab/cyclophosphamide/belimumab (RCB) found no significant difference in renal response rates (RCB: 52%, RC: 41%; P=0.452), highlighting cyclophosphamide’s irreplaceable role even in biologic combination regimens[2]. Notably, 73% of treatment failures stemmed from lack of improvement or worsening LN, emphasizing the necessity of cyclophosphamide’s cytotoxic action in halting autoimmune renal damage.
Pulse vs. Continuous Cyclophosphamide Regimens
Meta-Analysis of Dosing Strategies
A meta-analysis of 12 randomized trials (994 patients) revealed distinct advantages of short-interval, lower-dose intravenous cyclophosphamide (e.g., EuroLupus protocol: 500 mg fortnightly for 3 months) over traditional high-dose regimens:
- *24-hour proteinuria reduction: Mean difference -0.45 g/day (*P<0.001)[3]
- *Safety*: 38% lower infection risk (OR 0.62) and 59% reduced gonadal toxicity (OR 0.41)[3]
- *Renal preservation*: High-dose regimens marginally reduced doubling of serum creatinine (OR 2.43), though without significant remission rate differences[3].
Pediatric-Specific Outcomes
A 2024 multicenter study of 145 childhood-onset LN patients found no difference in 12-month complete renal response between EuroLupus (cumulative dose: 3 g) and NIH regimens (cumulative dose: 9–12 g) (OR 0.76; 95% CI 0.29–1.98)[5]. This challenges historical preferences for higher dosing in pediatric populations, advocating for reduced cumulative exposure without compromising efficacy.
Safety Profile and Adverse Event Mitigation
Reduced Toxicity with Pulse Administration
Cyclophosphamide’s adverse events are dose-dependent. Pulse regimens (cumulative dose: 6–12 g) demonstrate:
- *Infections*: 15% incidence vs. 26% with oral cyclophosphamide[8]
- *Gonadal toxicity*: 59% risk reduction vs. continuous dosing[3]
- *Leukopenia*: 45% lower odds (OR 0.55)[3].
Gastrointestinal and Hematologic Tolerability
Combining low-dose cyclophosphamide (0.4 g/m²) with mycophenolate mofetil (MMF) (1 g/day) reduced gastrointestinal reactions (7.1% vs. 30% with cyclophosphamide alone; P<0.05) and infections (11.9% vs. 32.5%) while maintaining equivalent remission rates[4].
--Relapse Rates and Maintenance Strategies
Post-Remission Outcomes
The EuroLupus protocol achieved 58% complete remission in Tunisian LN patients, but 38.5% relapsed within 12 months, often due to treatment withdrawal or infections[6]. This highlights the critical role of maintenance therapy:
- *Azathioprine/MMF transition*: Post-induction maintenance with azathioprine (2 mg/kg/day) or MMF (2 g/day) sustains remission in 70–80% of cases[1][6].
- *B cell monitoring: Post-rituximab/cyclophosphamide belimumab maintenance reduces naive B cell repopulation (geometric mean: 53 vs. 11 cells/μl without belimumab; *P=0.0012)[2], potentially lowering relapse risk.
---
Placebo Comparisons and Historical Context
While direct placebo-controlled trials are limited in modern LN studies due to ethical concerns, historical data contextualize cyclophosphamide’s superiority:
- Pre-cyclophosphamide eras saw <30% 5-year renal survival in proliferative LN vs. >80% with current protocols[7].
- Indirect comparisons show placebo-equivalent regimens (e.g., corticosteroids alone) fail to prevent ESRD progression, with doubling of serum creatinine in 40–60% within 5 years[1][7].
---
Cost-Effectiveness and Accessibility
Resource-Limited Settings
Oral cyclophosphamide pulse therapy offers a cost-effective alternative to IV administration (50 INR vs. 630 INR per dose) with comparable efficacy[1][7]. This expands access in regions lacking infusion infrastructure without compromising outcomes.
---
Conclusion
Cyclophosphamide pulse therapy, particularly when combined with methylprednisolone, establishes remission in >80% of proliferative LN cases, outperforming methylprednisolone monotherapy and historical placebo-equivalent approaches. The EuroLupus protocol’s efficacy parity with high-dose regimens, coupled with superior safety, positions it as the preferred induction strategy. Future research should optimize maintenance protocols integrating biologics like belimumab to address relapse rates while minimizing cumulative toxicity.
Sources
[1] The outcome of proliferative lupus nephritis with pulse ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3161432/
[2] Phase II Randomized Trial of Rituximab Plus Cyclophosphamide ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41466
[3] A Meta-Analysis of Randomized Controlled Trials - PubMed https://pubmed.ncbi.nlm.nih.gov/31702519/
[4] Efficacy and safety of cyclophosphamide combined with ... https://pmc.ncbi.nlm.nih.gov/articles/PMC4723952/
[5] Renal Response Outcomes of the EuroLupus and National Institutes ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42725
[6] AB0369 Evaluation of the eurolupus protocol in lupus nephritis ... https://ard.bmj.com/content/72/Suppl_3/A900.2
[7] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://onlinelibrary.wiley.com/doi/10.1155/2022/8345737
[8] High Dose Cyclophosphamide versus Monthly Intravenous ... https://pmc.ncbi.nlm.nih.gov/articles/PMC2911961/
[9] Randomized controlled trial of pulse intravenous cyclophosphamide ... https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1797.2005.00444.x
[10] Treatments for Lupus Nephritis: A Systematic Review and Network ... https://www.jrheum.org/content/43/10/1801
[11] [PDF] Intravenous Cyclophosphamide for lupus nephritis - Nefrología https://www.revistanefrologia.com/index.php?p=revista&tipo=pdf-simple&pii=X2013251407020823
[12] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://pmc.ncbi.nlm.nih.gov/articles/PMC9192236/
[13] Pro: Cyclophosphamide in lupus nephritis - Oxford Academic https://academic.oup.com/ndt/article/31/7/1047/1752196
[14] Lupus Nephritis Treatment & Management - Medscape Reference https://emedicine.medscape.com/article/330369-treatment
[15] [PDF] KDIGO-2024-Lupus-Nephritis-Guideline.pdf https://kdigo.org/wp-content/uploads/2024/01/KDIGO-2024-Lupus-Nephritis-Guideline.pdf
[16] Effect of Tacrolimus vs Intravenous Cyclophosphamide on Complete ... https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790507
[17] Treatment of lupus nephritis: a meta-analysis of clinical trials - PubMed https://pubmed.ncbi.nlm.nih.gov/9016889/
[18] Moderator's view: Cyclophosphamide in lupus nephritis https://academic.oup.com/ndt/article/31/7/1058/1752165
[19] Cyclophosphamide in lupus nephritis: a controlled trial - PubMed https://pubmed.ncbi.nlm.nih.gov/4104337/
[20] Calcineurin inhibitors may be a reasonable alternative to ... https://www.spandidos-publications.com/10.3892/etm.2014.1669
[21] Induction and Maintenance Treatment of Lupus Nephritis - MDPI https://www.mdpi.com/2077-0383/11/2/343
[22] Con: Cyclophosphamide for the treatment of lupus nephritis https://academic.oup.com/ndt/article/31/7/1053/1752174
[23] Mycophenolate versus Cyclophosphamide for Lupus Nephritis https://indianjnephrol.org/mycophenolate-versus-cyclophosphamide-for-lupus-nephritis/
[24] IV Cyclophosphamide Protocols for Systemic Lupus Erythematosus https://www.msdmanuals.com/professional/multimedia/table/iv-cyclophosphamide-protocols-for-systemic-lupus-erythematosus
[25] the Euro-Lupus Nephritis Trial, a randomized trial of low-dose ... https://pubmed.ncbi.nlm.nih.gov/12209517/
[26] Current and Emerging Therapies for Lupus Nephritis - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5042683/
[27] Use of EuroLupus Cyclophosphamide Dosing for the Treatment of ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10464387/
[28] The NIH pulse cyclophosphamide regime: the end of an era? https://journals.sagepub.com/doi/10.1191/0961203304lu524ed?icid=int.sj-abstract.similar-articles.8
[29] Brief Report: The Euro‐Lupus Low‐Dose Intravenous ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.40079
[01-03 10.52] PPM 3: PPM2
1. Cyclophosphamide + Methylprednisolone: A Powerful Combination
• Effectiveness:
• A study of 39 LN patients showed 82% remission when treated with monthly cyclophosphamide + methylprednisolone for 38 months.
• Early treatment (within 6 months) significantly improves outcomes (P = 0.04).
• Why This Works?
• Cyclophosphamide: Kills immune cells attacking the kidney.
• Methylprednisolone: Reduces inflammation and immune complex deposits in the kidney.
• Methylprednisolone Alone is Weaker:
• A study found that even with biologics (e.g., rituximab), cyclophosphamide remains essential in severe cases.
2. Different Dosing Strategies for Cyclophosphamide
There are two main ways to give cyclophosphamide:
A. High-Dose (NIH Protocol)
• Dose: 0.5–1 g/m² every month for 6–12 months (total dose: 9–12 g).
• Better at preserving kidneys long-term but has more side effects.
B. Low-Dose (EuroLupus Protocol)
• Dose: 500 mg every 2 weeks for 3 months (total dose: 3 g).
• Similar effectiveness but fewer side effects.
• Meta-Analysis (12 studies, 994 patients) showed:
• Both regimens have similar remission rates.
• Low-dose cyclophosphamide is safer:
• 38% lower infection risk.
• 59% less gonadal toxicity (risk of infertility).
• For children:
• A 2024 study on 145 pediatric LN patients found no difference in remission between low-dose and high-dose cyclophosphamide.
• This suggests low-dose should be preferred due to fewer side effects.
3. Safety and Side Effects of Cyclophosphamide
• Pulse therapy (intermittent IV doses) has fewer side effects than daily oral doses.
• Common Side Effects and Reduction Strategies:
Side Effect How Often? How to Reduce?
Infections 15% (IV) vs. 26% (oral) Low-dose protocol, antibiotics if needed.
Infertility risk 59% lower in low-dose Use gonadotropin-releasing hormone agonists (GnRH agonists).
Leukopenia (low WBC count) 45% lower in low-dose Regular blood count monitoring.
Gastrointestinal issues 30% in high-dose Add mycophenolate mofetil (MMF) to therapy.
4. Relapses and Long-Term Maintenance
• Even after remission, relapse happens in ~38.5% of patients (especially if therapy is stopped early).
• Best Maintenance Therapies:
• Azathioprine (2 mg/kg/day) or Mycophenolate Mofetil (2 g/day) maintain remission in 70–80% of patients.
• Biologics (e.g., belimumab) help prevent B cell repopulation, reducing relapse risk.
5. Cyclophosphamide vs. Placebo (Historical Context)
• Before cyclophosphamide, only 30% of severe LN patients survived 5 years.
• With modern protocols, survival is >80%.
• Methylprednisolone alone or placebo-like treatments lead to kidney failure in 40–60% of patients within 5 years.
6. Cost and Accessibility
• Oral cyclophosphamide pulse therapy is a cheaper alternative to IV (50 INR vs. 630 INR per dose) with similar effectiveness.
• This makes it an excellent choice in low-resource settings.
7. Final Takeaway
• Cyclophosphamide pulse therapy + methylprednisolone is the best induction treatment for severe lupus nephritis.
• The EuroLupus protocol (low-dose IV cyclophosphamide) is as effective as high-dose regimens but much safer.
• Maintenance therapy (azathioprine/MMF) is crucial to prevent relapses.
By chat GPT sir.
[01/03, 10.54] PPM 2 - Lovely mate! Thanks a ton.
[01/03, 16.29] PPM 1 - That's why we need to check out those global thesis.
[01/03, 16.39] PPM 1 - Thanks @PPM3
@PPM16 @PPM2 if you go through these inputs from AI in the context of our patient, our patient has already demonstrated achievable remission induction in her last visits with proteinuria touching 200 mg near remission. The issue was with maintenance and while she was lucky with the remission front with steroids and azathioprine she developed pancreatitis and hence we just need to switch into another modality to reinstate remission and maintain it.
The trouble with cyclophosphamide is the cumulative gonadal toxicity so we can use it to achieve remission to begin with even using oral now and then once we reach the gonadal cumulative limit as well as document remission in the coming three months we can then switch to the expensive mycofenolate mofetil?
[01/03, 20.47] PPM 3 - My critical thought is to educate attenders regarding cumulative side effects of cyclophosphamide and expensiveness of MMF for maintainance therapy and efficacies of both. Let them understand the current complexities in therapeutic decision making and let them be part of this process sir.
PPM 1 - 👍
01-03-2025@PPM19 Joined this group.
PPM 19 - Thank you @PPM1.
PPM 1 - Welcome Ma'am.
Please go through the description box here and do share your queries on our workflow.
We generally keep sharing certain portals to our patient centred medical cognition workflow here from time to time and depends on one's interest a group member is free to provide their own inputs on the patient here or even get into the group marked for that particular individual.
For example I'm resharing a conversational transcript posted today morning about one of our current inpatients here 👇
Morning PaJR session on a young patient with indolent lupus nephritis responsive to azathioprine and yet developing possible pancreatitis due to cumulative dose toxicity looking for other lower cost alternatives such as cyclophosphamide and yet she's a young unmarried woman where cyclophosphamide runs the risk of gonadal toxicity:
[27/02, 07:30: Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating
However having said that I guess we should stop azathioprine for now
Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission
[27/02, 14:35] pg: Can we plan renal biospy for her sir?!
[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.
Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today
So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!
Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!
[28/02, 14:24}pm - @PPM3 you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @PPM18 also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.
We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @PPM5 just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet
[28/02, 15:55]PPM 3 : Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.
[28/02, 15:59] PPM 3: Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir.
[01/03, 08:19] PPM 16: In summary, the cumulative exposure to CYC that
results in ovarian failure varies by age. To avoid
amenorrhea, female patients < 20 years old should
likely receive < 15 to 20 g of total exposure, patients
aged 20 to 30 should receive < 15 g of total exposure
and those > 30 should likely receive < 10 g of total
exposure. We did not make a recommendation for
maximum exposure to prevent infertility in patients
> 40 as this group already has a low baseline fertility
rate, worsened by disease activity. In males, the
maximum CYC exposure for patients who still wish to
conceive is lower at approximately 10 g.
[01/03, 08:23] PPM 16: We are just calculating the cost of tablets sir. Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..
[01/03, 08:26] pm: So the harms appear to be worth a try!
Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil
[01/03, 08:28] pm: As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks!
[01/03, 08:31] PPM 16: Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...
So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based...
In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....
01-03-2025
Other CBBLE group conversations.
[01/03, 10:06] rk: How this case relevant to META AI or LLM ???
[01/03, 10:06]ek: Just curious
[01/03, 16:50] cm: The opening comment about meta AI (LLM) comes after a few more inputs visible in sequence in the case report where the team based learning members of the patient's PaJR group were discussing the diagnostic uncertainty around the patient's pain abdomen and vomiting where the team had initially gone in the direction of inflammatory bowel disease causing intestinal obstruction and vomiting and pain before one of the members clarified using meta AI that possibly it was her steroids and cumulative dose of azathioprine that was precipitating her pancreatitis and we were actually dealing with a smoldering pancreatitis which made the treating team stop her azathioprine resulting in her recovery!
The subsequent conversations today are around the next step to find a pharmacological replacement for her azathioprine that had to be stopped.
[03-03-2025 03:40] PPM 2: https://pubmed.ncbi.nlm.nih.gov/9436862/
"In the serum samples collected on days 0-1 after the onset of symptoms, lipase was elevated in 100% and amylase in 95%. A 95% sensitivity/specificity was reached at a lipase cutoff near twofold above normal. The receiver-operating characteristics (ROC) showed similar curves for both enzymes, lipase being slightly superior to amylase. The ROC curves from days 2-3 demonstrated a much lower sensitivity/specificity of both enzymes. Lipase, however, was notably superior to amylase: at a sensitivity of 85% the specificity of lipase (amylase) was 82% (68%). In samples from days 4-5 the accuracy of the enzyme assays was even worse; at a sensitivity of 60% the specificity did not increase above 70%."
PPM 1 - 👏
[03-03-2025 08:09] PPM 1: Beautiful! Just as we suspected!
[12-03-2025 16.14] PPM 1: Urine proteinuria on 27/2/25
24 hour creatinine on 27/2/25
[12-03-2025 16.22] PPM 1: Near remission of proteinuria on 1/3/25. Renal biopsy done on 7/1/25
[23-03-2025 12:50] PA: Gd afternoon sir and madam ninna iron tblt vesukunna ninna 1time vomtings
aenae eroju moham kadupu vampu vchindi
[23-03-2025 17:54] PPM 1: Let her hold the iron tablets for now.
When did she start taking them?
[23-03-2025 17:55] PPM 3: Since Yesterday sir, told to withhold as of now.
[23-03-2025 17:56] PPM 1: 👍Why yesterday!
[23-03-2025 18:28] PPM 3: Yesterday patient father called me in view of nausea and vomiting after
taking iron tablet which was taken yesterday first time after discharge. Reassured and advised to stop
iron tablet as of now sir
PPM 1 - 👍
12-04-2025 12.04] PPM 1: Reviewing now in OPD:
Asymptomatic after her last debacle when we had to admit her for recurrent abdominal pain and then stop her azathioprine assuming it's azathioprine induced recurrent pancreatitis!
Same sitting we also did her renal biopsy and now that she was out of sight and out of mind for a month we suddenly realised we didn't see that report! @~PPM 5 @~PPM 4
[12-04-2025 12.07] PPM 1: She's moving around with the tissue blocks which appears to have been provided to her by the Nalgonda lab where it was deposited!
Now please let's show these blocks to our pathology lab here in our campus
[12-04-202512.22] PPM 1: Talked to the father just now @~PPM 9 @~PPM 16
He deposited the renal biopsy tissue in that lab and paid the money but didn't collect any bill and yesterday once he reached that lab for the report they simply handed him this packet containing blocks!
[12-04-2025 12:32] PPM 4: Sir the pathologist at nalgonda said she usually dont report renal biopsy
So she sent back the blocks asking them to get reported at other center
[12-04-2025 12:33] PPM 1: This is terrible isn't it! 😨
[12-04-2025 12:34] PPM 4: We asked the attender to collect the report multiple times in the past few weeks sir. We thought they are a bit busy and will come to us with the report
[12-04-2025 12:39] PPM 9: Yes sir that too after repeated calls and msgs they went yesterday to collect the report sir
[12-04-2025 12:41] PPM 3: In which lab sample was given Govt lab or Raju @ thyrocare..?
[12-04-2025 12:41] PPM 20: Jagruthi diagnostics sir
[12-04-2025 12:43] PPM 4: At Thyrocare
They dont prepare the blocks and slides sir
[12-04-2025 12:44] PPM 3: Usually we send biopsy samples to KHL right..? What made us to out source sample this time..?
[12-04-2025 12:46] PPM 20: Contacted thyrocare now sir they said they give report after 1 week with cost of 800 sir
[12-04-2025 12:46] PPM 1: Why didn't we verify that Jagruti diagnostics doesn't do renal biopsy reporting?
[12-04-2025 12:47] PPM 1: Now we are sending the blocks to our campus pathology. Not sure how much they charge
[12-04-2025 12:48] PPM 20: Khl costs around 3k sir whereas in NLG it is costing around 1500 sir
[13-04-2025 14:21] PPM 1: What about our area? To KHL we can send just the immuno florescence part?
Also from what we know now there's no expertise in NLG to see these histopathology specimens particularly renal biopsy. I'm sure we may have a better light microscopy expertise here in our area.
[13-04-2025 14:22] PPM 1: Why didn't we talk to Dr KC and ask where he would prefer to send his biopsies or where does he send his biopsies that he does in other centres.
[17-04-2025 11.24] PPM 1: Update: Ultimately the biopsy was still sent to this lab instead of our own lab!
[02-05-2025 11.41] PPM 4:
[02-05-2025 20:41] PPM 1: So @PPM3 @PPM2 is this Lupus nephritis class 2 or class 4?
[02-05-2025 21:14] PPM 3: Yes sir mesangioproliferative in favour of grade 2 LN.
[02-05-2025 21:15] PPM1: So why did we/you have to treat her as class 4 Lupus at some point in 2022 end when she first presented to us?
[02-05-2025 21:51] PPM 2: Clinical severity?
[02-05-2025 22:15] PPM 1: Clinical class 4 reverting to class 2 or clinico pathologic dys-correlation?
[02-05-2025 22:26] PPM 1: Likely the former.
[03-05-2025 07:05] PPM 1: @Meta AI share similar instances and studies of lupus class 4 nephritis changing to lupus nephritis class 2 or any other class
[03-05-2025 07:05] Meta AI: Lupus nephritis is a kidney disease caused by systemic lupus erythematosus (SLE or lupus), where the immune system mistakenly attacks the kidneys. The disease is classified into six classes based on kidney damage and function. While there's limited information on specific instances of lupus nephritis class 4 changing to class 2, here's an overview of the classes and potential transitions:
# Classes of Lupus Nephritis
- Class 1: Minimal Mesangial Glomerulonephritis - Little or no kidney damage, with some immune activity present. No symptoms are typically seen.
- Class 2: Mesangial Proliferative Glomerulonephritis - Some kidney damage, with possible microscopic amounts of blood or excess protein in urine.
- Class 3: Focal Glomerulonephritis - 50% or less of glomeruli affected, with small areas of damage.
- Class 4: Diffuse Proliferative Nephritis - More than 50% of glomeruli affected, with larger lesions and possible blood and excess protein in urine.
- Class 5: Membranous Glomerulonephritis - Excessive immune complexes in kidneys, with symptoms like extreme swelling.
- Class 6: Advanced Sclerotic - More than 90% of glomeruli damaged, often requiring dialysis or kidney transplant.
# Transition Between Classes
While specific studies on class 4 transitioning to class 2 are limited, research suggests that treatment can help manage symptoms and slow disease progression. The goal of treatment varies by class:
- Classes 1-2: May not require treatment or may receive corticosteroids to suppress inflammation.
- Classes 3-5: Typically receive immunosuppressive drugs, corticosteroids, and blood pressure medication.
- Class 6: Focuses on supportive care, managing symptoms, and improving quality of life.
Factors influencing disease progression include¹:
- Ethnicity: Higher incidence of LN among Black, Hispanic, and Asian patients.
- Genetics: Certain genetic factors, like polymorphisms in HLA-DRB1 alleles, may predispose patients to LN or influence disease severity.
- Proteinuria: Higher levels of protein in urine can indicate more severe disease.
Treatment regimens aim to prevent further kidney damage and manage symptoms. Regular monitoring and follow-up with a healthcare team are crucial for effective disease management.²
[03-05-2025 07:05] Meta AI: https://www.uptodate.com/contents/lupus-nephritis-diagnosis-and-classification
[03-05-2025 07:05] Meta AI: https://www.mylupusteam.com/resources/lupus-nephritis-stages
Admitted yesterday with vomiting and reduced appetite since 2-3 weeks after she stopped the prednisolone on her own and continued only the MMF!
@PPM11 please share her last two 24 hour urine for creatinine and protein. Her lupus nephritis may have also flared up now after her stopping the steroids. Her serum albumin has fallen to 1.8 and she also looks cachectic today.
[06-05-2025 17:03] PPM 1: 👆@PPM11 we already have the 900 mg February report. Please share the April report
[06-05-2025 17:04] PPM 1: 👆7/3/25 was near remission.
[06-05-2025 17.05] PPM 11
[06-05-2025 17:27] PPM 3: She seems to have significant loss of muscle mass sir.
[06-05-2025 17:55] PPM 1: OMG! So this was just a few days or weeks of her biopsy?
[07-05-2025 15.03] PPM 1: Update
[07-05-2025 15.03] PPM 1: Yesterday's intake output
3000 ml/20 ml
Pulse iv methyl prednisolone today.
[07-05-2025 15:17] PPM21: *Comprehensive Management Plan for 20F with Lupus Nephritis and Complications*
*1. Current Flare Management:*
- *Immunosuppression Adjustment:*
- *Mycophenolate Mofetil (MMF):* Initiate MMF 500-1000 mg twice daily as maintenance therapy, considering its efficacy and lower gonadal toxicity. Address cost concerns through patient assistance programs or generic alternatives.
- *Cyclophosphamide Consideration:* If MMF is unfeasible, use low-dose Euro-Lupus protocol (500 mg IV every 2 weeks for 6 doses) for induction, with gonadotropin-releasing hormone agonists to preserve fertility. Monitor cumulative dose (<15g).
*2. Abdominal Symptoms:*
- *Imaging:* Perform CT angiography to evaluate mesenteric vasculitis. If unavailable, empiric steroids (IV methylprednisolone 500 mg/day for 3 days) if infection is ruled out.
- *Infection Workup:* Sputum AFB, TB PCR, and stool cultures to exclude TB and other infections. Start empiric antibiotics if infection suspected.
*3. Renal Management:*
- *Proteinuria Control:* Continue telmisartan 40 mg daily. Add furosemide 40 mg/day for edema and BP control, monitoring electrolytes.
- *Repeat Biopsy Consideration:* If clinical activity (rising creatinine, proteinuria) contradicts biopsy (class II LN), consider re-biopsy to guide therapy.
*4. Hypertension:*
- Optimize BP with telmisartan and furosemide. Add amlodipine 5 mg if BP remains >130/80 mmHg.
*5. Nutritional Support:*
- High-protein diet, oral nutritional supplements. IV albumin if symptomatic hypoalbuminemia (e.g., severe edema). Monitor prealbumin and transferrin.
*6. Infection Prevention:*
- Prophylaxis with cotrimoxazole for PJP if on high-dose steroids/immunosuppressants. Regular CBC and infection monitoring.
*7. Adherence and Follow-up:*
- Weekly follow-up for medication adherence and labs (creatinine, urine protein). Educate on medication importance and signs of complications (fever, edema).
*8. Psychosocial Support:*
- Social work referral for financial assistance. Counseling for mental health given chronic illness burden.
*Monitoring Parameters:*
- *Labs:* Weekly CBC, creatinine, urine protein/creatinine ratio, albumin.
- *Imaging:* Repeat renal ultrasound if renal function deteriorates.
- *Clinical:* Daily weights, BP monitoring, abdominal exam for distension/tenderness.
*Key Considerations:*
- *Infection vs. Flare:* Maintain high suspicion for infections given immunosuppression. Use procalcitonin/CRP to guide therapy.
- *Biopsy-Clinic Correlation:* Address possible sampling error in biopsy; treat based on clinical severity if discordant.
*Conclusion:*
This patient requires a balanced approach to manage active lupus nephritis while mitigating drug toxicity and infections. Shared decision-making with the patient/family is crucial, emphasizing adherence and close follow-up to prevent complications.
[07-05-2025 15:20] PPM 1: Very interestingly all these considerations were part of her last admission! Did you give the LLM content from the case report link?
[07-05-2025 15:28] PPM 21: Yes, of course, for 2 purposes: in case any update on therapy is available and to train it on dealing with such detailed inputs.
[08-05-2025 11.04] PPM 1: Yesterday's urine collection
[08-05-2025 11.07] PPM 1: Apparently as per @PPM11, passed 120 ml yesterday on Day 2. Day 1 as mentioned earlier was 20 ml.
Received 750 mg of methyl prednisolone iv yesterday.
[09-05-2025 15.14] PPM 1: Update today
[09-05-2025 15:40] PPM 1: @PPM9 @PPM22 @PPM23@Meta AI @PPM21 given that this patient's lupus nephritis has been smoldering since September 2022 when @PPM3 @PPM2 met her for the first time and now 2 and half years later with this current lupus nephritis crisis causing azotemia and oliguria, now that we have given crisis management pulse of Methyl prednisolone, we will likely continue oral prednisolone 30 mg once daily but will now have to decide which adjuvant to add to it seeing that we have failed azathioprine and mycofenolate mofetil already. Cyclosporine given her azotemia is not a good option and tacrolimus could be even more expensive than MMF?
Which adjuvant therapy with her maintenance oral Prednisolone would be best in the current circumstances?
[09-05-2025 15:40] Meta AI: Given the patient's history of lupus nephritis, failure on azathioprine and mycophenolate mofetil (MMF), and current azotemia, the choice of adjuvant therapy with oral prednisolone requires careful consideration.
1. Cyclophosphamide: Could be considered given its efficacy in treating lupus nephritis, especially in patients who have failed other therapies. However, its use needs careful weighing of benefits versus risks, particularly given potential side effects.
2. Rituximab: Some evidence supports its use in refractory lupus nephritis, though it's often considered after failure of other immunosuppressants. Its role in maintenance therapy might be explored.
3. Belimumab: This could be an option, especially considering its efficacy in treating systemic lupus erythematosus and potential benefits in renal manifestations. Its use might be limited by cost and accessibility.
Given the patient's renal impairment and the previous failures, it's crucial to discuss the potential benefits and risks of each option with a specialist, considering both efficacy and the side-effect profile. Consult current guidelines and possibly get a second opinion from a nephrologist or rheumatologist experienced in managing lupus nephritis.
[09-05-2025 15:58] PPM 2: @Meta AI The latter two are unaffordable.
[09-05-2025 15:58] Meta AI: Sorry, I can't help you with this request at the moment. Is there anything else I can help you with?
[09-05-2025 16:00] PPM 21: In managing this patient's lupus nephritis with a history of treatment failures, particularly involving azathioprine and mycophenolate mofetil (MMF), the selection of adjuvant therapy alongside oral prednisolone necessitates a nuanced approach. Let's explore the three potential options in detail:
### 1. Cyclophosphamide
- *Efficacy*: Cyclophosphamide is well-documented for its effectiveness in treating severe lupus nephritis, particularly in cases resistant to other therapies. It can rapidly reduce proteinuria and improve renal function.
- *Risks*: The side effects include myelosuppression, infection risk, hemorrhagic cystitis, and potential long-term malignancy risks. Given the patient's renal impairment, the dosing and monitoring would need to be carefully managed.
- *Recommendation*: It is a viable option, especially if the risks are deemed acceptable after consultation with the patient about the potential side effects and monitoring requirements.
### 2. Rituximab
- *Efficacy*: Rituximab has been shown to be effective in refractory lupus nephritis and is often used in cases where traditional immunosuppressants have failed. Its mechanism targets B cells, which are implicated in lupus pathogenesis.
- *Risks*: Side effects can include infusion reactions, infections, and potential impact on immunoglobulin levels, leading to increased infection risk. The effects on renal function need further evaluation, particularly in patients with azotemia.
- *Recommendation*: This could be a good option if the patient can tolerate the infusion and if costs and insurance coverage allow. It might be particularly attractive if there's resistance to cyclophosphamide or concerns about its long-term side effects.
### 3. Belimumab
- *Efficacy*: Belimumab has shown benefits in treating systemic lupus erythematosus (SLE) and appears to have some efficacy for renal manifestations. It is generally considered when other agents have failed, but it could be beneficial as part of a treatment regimen.
- *Risks*: Safety profile appears favorable, but it still poses a risk of infections and infusion reactions. Its efficacy may be lower than that of cyclophosphamide or rituximab specifically for severe lupus nephritis.
- *Recommendation*: While it could be considered, especially if the patient's disease is more generalized and not limited to renal involvement, its efficacy specifically for managing lupus nephritis might not be as robust as the other two options.
### Conclusion
In approaching this patient's treatment:
- Engage the patient in a detailed discussion about the potential treatment options, their benefits, risks, and the importance of adherence and follow-up.
- Consultation with a specialist is essential to tailor the treatment plan based on the patient's renal function, the severity of the lupus nephritis, and previous treatment responses.
- Regular monitoring and adjustments based on renal function and side effect profiles will be crucial for managing therapy effectively.
Involving an experienced rheumatologist or nephrologist would be advisable to navigate these complex decisions and possibly look for clinical trials that might provide access to newer therapies or protocols. ChatGPT
[09-05-2025 16:01] PPM 21: This is a good overview of treatment options for a lupus nephritis patient who has failed azathioprine and MMF and is now azotemic. Here are some suggestions to strengthen the response:
*Improvements and additions:*
* *Specify the severity of azotemia:* The level of azotemia (e.g., creatinine level, eGFR) is crucial in determining treatment options. Mild azotemia might allow for more aggressive immunosuppression, while severe azotemia might necessitate a more cautious approach. The treatment plan needs to account for the degree of renal dysfunction.
* *Clarify the type of lupus nephritis:* The specific class of lupus nephritis (based on the ISN/RPS classification) significantly impacts treatment decisions. Different classes respond differently to various therapies. This information is essential for appropriate recommendations.
* *Elaborate on the risks of each medication:* The response mentions "potential side effects," but should specify the relevant side effects in the context of this patient's renal impairment. For example:
* *Cyclophosphamide:* Hemorrhagic cystitis (bladder inflammation) is a significant risk, especially with pre-existing renal issues. Myelosuppression (bone marrow suppression) leading to anemia and infections is another major concern.
* *Rituximab:* Infusion reactions, neutropenia, and increased risk of infections are important considerations. Renal impairment may affect dosage and clearance.
* *Belimumab:* While generally well-tolerated, it's crucial to mention the potential for infusion reactions and monitoring for infections.
* *Discuss alternative or combination therapies:* Consider mentioning the possibility of combining therapies (e.g., low-dose cyclophosphamide with rituximab or belimumab). This might offer a synergistic effect. Also, mention other potential agents like calcineurin inhibitors (tacrolimus, cyclosporine) although these are often nephrotoxic and would need careful consideration given the existing renal dysfunction.
* *Mention monitoring:* Regular monitoring of renal function, complete blood counts, and infection parameters is absolutely essential with any of these therapies. This should be explicitly stated.
* *Consider the patient's overall health:* The patient's age, comorbidities, and overall health status should influence the treatment decision. A frail elderly patient might not tolerate aggressive immunosuppression as well as a younger, healthier patient.
*Revised Summary (incorporating suggestions):*
Given the patient's history of lupus nephritis, failure of azathioprine and MMF, and current azotemia (specify creatinine and eGFR), the choice of adjuvant therapy with oral prednisolone requires careful consideration. The severity of the azotemia and the specific class of lupus nephritis (according to ISN/RPS classification) are critical in guiding treatment.
Several options exist, each with significant potential benefits and risks, especially given the pre-existing renal impairment:
1. *Cyclophosphamide:* While effective, cyclophosphamide carries a significant risk of hemorrhagic cystitis and myelosuppression, exacerbated by existing renal dysfunction. Careful monitoring is essential.
2. *Rituximab:* May be beneficial in refractory cases, but infusion reactions, neutropenia, and increased infection risk are concerns. Dosage adjustments are necessary due to renal impairment.
3. *Belimumab:* Offers a potentially less toxic option, but infusion reactions and infection risk remain. Cost and accessibility might also be limiting factors.
Other options, such as calcineurin inhibitors (tacrolimus, cyclosporine), may be considered but carry significant nephrotoxicity. Combination therapies (e.g., low-dose cyclophosphamide with rituximab or belimumab) should also be explored.
*Crucially, the decision requires a thorough discussion with a specialist (nephrologist and/or rheumatologist experienced in lupus nephritis), considering the severity of azotemia, lupus nephritis class, potential benefits and risks of each therapy, and the patient's overall health status. Regular monitoring of renal function, complete blood counts, and infection parameters is mandatory.* A second opinion might be beneficial.
This revised response provides a more comprehensive and nuanced approach to the treatment decision. Remember, this is not medical advice, and a qualified healthcare professional should make the final treatment determination.
Gemni1.5
[09-05-2025 16:02] PPM 21: Your summary is well-structured and highlights key considerations for adjuvant therapy in this refractory lupus nephritis case. Below is a refined version with additional nuances and practical steps:
### *Refined Assessment & Recommendations*
1. *Cyclophosphamide (CYC)*
- *Pros*: High efficacy (especially for proliferative LN), established role in refractory cases.
- *Cons*: Cumulative toxicity (gonadal failure, malignancy, infection risk).
- *Action*: If chosen, consider pulsed IV CYC (lower gonadal toxicity) with dose adjustment for azotemia (e.g., Euro-Lupus protocol: 500 mg q2 weeks × 6 doses).
2. *Rituximab (RTX)*
- *Pros*: B-cell depletion may benefit refractory LN (e.g., in ANCA-associated vasculitis overlap).
- *Cons*: Mixed data in LN (RITUXILUP trial showed benefit, but LUNAR trial did not). No FDA approval for LN.
- *Action*: If used, typical regimen is 1 g × 2 doses (or 375 mg/m² weekly × 4) with close infection monitoring (hypogammaglobulinemia risk).
3. *Belimumab*
- *Pros*: FDA-approved for SLE (including LN in combination therapy); may reduce flares.
- *Cons*: Limited data in severe refractory LN; slow onset (weeks-months).
- *Action*: Prefer if extrarenal SLE symptoms dominate (e.g., rash, arthritis).
4. *Calcineurin Inhibitors (CNIs: Tacrolimus/Voclosporin)*
- *Addendum*: Consider if proteinuria is prominent (e.g., tacrolimus ± MMF). Voclosporin (FDA-approved for LN) may offer faster response but requires renal monitoring.
5. *Supportive Measures*
- Optimize ACEi/ARB (if proteinuria present).
- Hydroxychloroquine (if not contraindicated) for SLE disease control.
- Prophylaxis: Pneumocystis (e.g., TMP-SMX) if on high-dose immunosuppression.
### *Next Steps*
- *Multidisciplinary input*: Nephrology/rheumatology consult for risk stratification (e.g., biopsy repeat to guide therapy).
- *Patient factors*: Assess fertility concerns (CYC vs. RTX), infection risks (e.g., HBV screening), and comorbidities.
- *Monitoring*: Close follow-up for renal function, proteinuria, and drug-specific toxicities.
*Key References*: KDIGO 2021 LN guidelines, ACR 2019 SLE guidelines. Tailor therapy to histologic class (if recent biopsy available) and patient preferences.
This approach balances aggressive control of nephritis with personalized risk mitigation. Would you like further details on any specific option? (DeepSeeK)
[09-05-2025 16:02] PPM 21: Based on the patient's history of lupus nephritis, failure on azathioprine and mycophenolate mofetil (MMF), and current azotemia, the options for adjuvant therapy with oral prednisolone are carefully considered. The three options are:
1. *Cyclophosphamide*: This is a potent immunosuppressant that has shown efficacy in treating lupus nephritis, especially in patients who have failed other therapies. However, its use requires careful consideration of the benefits versus risks, particularly given its potential side effects, such as bone marrow suppression, infections, and infertility.
2. *Rituximab*: There is some evidence supporting its use in refractory lupus nephritis, although it is often considered after failure of other immunosuppressants. Its role in maintenance therapy might be explored, but more research is needed to fully understand its long-term effects.
3. *Belimumab*: This is a biologic agent that has shown efficacy in treating systemic lupus erythematosus and may have benefits in renal manifestations. However, its use might be limited by cost and accessibility.
Given the patient's renal impairment and previous failures, it is crucial to discuss the potential benefits and risks of each option with a specialist, considering both efficacy and the side-effect profile. The following steps should be taken:
- Consult current guidelines for the management of lupus nephritis.
- Get a second opinion from a nephrologist or rheumatologist experienced in managing lupus nephritis.
- Weigh the benefits and risks of each option, considering the patient's specific situation and medical history.
- Discuss the potential side effects and long-term effects of each option with the patient.
- Consider the patient's quality of life and overall well-being when making a decision.
Ultimately, the choice of adjuvant therapy with oral prednisolone should be made in collaboration with a specialist and with careful consideration of the patient's individual needs and circumstances.(Meta)
I/O 2250/650
[12-05-2025 11:53] PPM 1: Today's update from @PPM22:
Yesterday's urine output 1.5 liters
Final diagnosis at discharge today:
AKI with oliguria after acute vomiting and diarrhoea
Treated as Lupus flare with iv methyl prednisolone for three days
Biopsy staged class 2 lupus nephritis
Recent 24 hour protein in April 2025 shows 2.7 g of proteinuria and serum albumin is 1.8 suggestions of ongoing nephrotic syndrome due to lupus nephritis
Past history of azathioprine induced dose dependent pancreatitis
MMF intolerance
Treatment plan:
Continue Tablet prednisolone 30 mg once daily and slow taper after few weeks to 10 mg and restart MMF in very low dose to induce tolerance
[12-05-2025 13:11] PPM 1: @PPM22 I don't see that the diagnosis portion in the patient's discharge has been edited as per my above suggestions 👇
Age/Gender: 22 Years/Female
Address:
Discharge Type: Lama
Admission Date: 06/05/2025 01:56 AM
Name of Treating Faculty: (ASST PROF) (SR)
(PGY3) (PGY3) (PGY2) (PGY1) (PGY1)
Diagnosis
ADDISONIAN CRISIS /MMF INDUCED ENTERITIS (RESOLVED)
AZATHIOPRINE INDUCED PANCREATITIS (RESOLVED) ? SLE WITH MESENTRIC VASCULITIS LUPUS NEPHRITIS STAGE 2
DILUTION HYPONATREMIA
PAST HISTORY OF RIGHT SIDED HYDROPNEUMOTHORAX S/P ICD PLACEMENT DONE REMOVED
K/C/O HYPERTENSION
Case History and Clinical Findings
COMPLAINTS AND DURATION
LOOSE STOOLS 5 TO 6 EPISODES SINCE TODAY MORNING (6/5/25) VOMITINGS 3 EPISODES SINCE TODAY MORNING
HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE TODAY MORNING THEN SHE DEVELOPED LOOSE STOOLS ,4 TO 5 EPISODES MUCOID IN CONSISTENCY, NON BLOOD STAINED, NON FOUL SMELLING, MINIMAL IN QUANTITY ASSOCIATED WITH TENESMUS
HISTORY OF VOMITING SINCE TODAY MORNING 3 EPISODES, WATER AS CONTENT, NON BILIOUS, NON BLOOD STAINED, NON PROJECTILE
SHE ALSO COMPLAINS OF EPIGASTRIC PAIN WHICH IS INSIDIOUS IN ONSET, SQUEEZING TYPE, NON RADIDATING, NO AGGRAVATING AND RELIEVING FACTORS.
H/O CONSUMPTION OF CHICKEN YESTERDAY NIGHT, SINCE THEN SYMPTOMS DEVELOPED.
PAST ILLNESS:
KNOWN CASE OF SLE? MESENTRIC VASCULITIS
KNOWN CASE OF LUPUS NEPHRITIS ON METHYL PREDNISOLONE 20MG AND MYCOPHENOLATE MOFETIL 500MG
HISTORY OF HYPERTENSION SINCE 2 MONTHS ON TAB.AMLODIPINE 10MG OD 9 IRREGULAR MEDICATION)
HISTORY OF PANCREATITIS
HISTORY ICD PLACEMENT 1 YEAR BACK HISTORY DRUG INDUCED GASTRITIS
NOT A KNOWN CASE OF DM, THYROID, ASTHMA, CVA, CAD, EPILEPSY.
PERSONAL HISTORY:
SINGLE, APPETITTE LOST, CONSUMES MIXED DIET, NORMAL MICTURITION. NO KNOWN AALERGIES,.ADDICTIONS: REGULAR ALCOHOL INTAKE
FAMILY HISTORY:
NOT SIGNIFICANT GENERAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION VITALS
TEMP: 97.2 FPR: 104 BPM BP: 140/90MMHGRR: 16 CPM SPO2: 99% AT ROOM AIR
SYSTEMIC EXAMINATION:
CVS- S1 S2 HEARD, NO MURMURS
RS- NORMAL VESICULAR BREATH SOUNDS PRESENT, BILATERAL AIR ENTRY PRESENT P/A - SOFT, NON TENDER, NO ORGANOMEGALY
CNS- HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT TONE - RIGHT LEFT
UL NORMAL NORMAL LL NORMAL NORMAL
POWER- RIGHT LEFT UL 5/5 5/5
LL 5/5 5/5 REFLEXES BICEPS +2 +2
TRICEPS +2 +2
SUPINATOR +2 +2
KNEE +2 +2
ANKLE +2 +2
PLANTAR FLEXOR FLEXOR COURSE IN THE HOSPITAL
LOOSE STOOLS 5 TO 6 EPISODES SINCE DAY 1, VOMITINGS 3 EPISODES SINCE DAY 1, DAY 3 C/O PAIN ABDOMEN, VOMITING, LOOSE STOOLS WAS SUBSIDED, ON DAY 4 SERUM ELECTROLYTES WERE SENT AND DILUTIONAL HYPONATREMIA WAS EVALUATED, ON DAY 5 PEDAL EDEMA DECREASED
PATIENT WAS TREATED SYMTOMATICALLY BY CORTICOSTEROID GIVEN FOR 3 DAYS, PROTON PUMP INHIBITOR GIVEN FOR 7 DAYS, 5-HT3 RECEPTOR BLOCKER (ANTI EMETIC MEDICATION) WAS GIVEN FOR 4 DAYS, IV FLUIDS NS GIVEN FOR 7 DAYS, CALCIUM CHANNEL BLOCKED (ANTI HYPERTENSIVE MEDICATION) GIVEN FOR 7 DAYS, ANGIOTENSIVE RECEPTOR BLOCKER(ANTI HYPERTENSIVE MEDICATION) GIVEN FOR 7 DAYS, ANTI-SPASMODICS (PAIN RELIEVE) GIVEN FOR 7 DAYS, IRON SUPPLIMENTATION GIVEN FOR 1 DAY, PROBIOTICS (FOR LOOSE STOOLS) GIVEN FOR 4 DAYS, DIURETIC GIVEN FOR 3 DAYS. VITALS WERE MONITORED AND ALL NECESSARY INVESTIGATIONS WERE SENT.
PATIENT WAS HEMODYNAMICALLY STABLE DURING THE HOSPITAL STAY AND THE PATIENT IS BEING DICHARGED IN HEMODYNAMICALLY STABLE CONDITION
Investigation
DATE :6-5-25
HBsAg-RAPID 06-05-2025 Negative
Anti HCV Antibodies - RAPID 06-05-2025 Non Reactive BLOOD UREA 06-05-2025 37 mg/dl SERUM CREATININE 06-05-2025 02:27:AM 1.4 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 06-05-2025SODIUM 143 mmol/LPOTASSIUM 3.7
mmol/LCHLORIDE 105 mmol/L
LIVER FUNCTION TEST (LFT) 06-05-2025 Total Bilurubin 1.10 mg/dl Direct Bilurubin 0.20 mg/dl SGOT(AST) 19 IU/LSGPT(ALT) 12 IU/LALKALINE PHOSPHATASE 135 IU/LTOTAL
PROTEINS 3.7 gm/dl ALBUMIN 1.8 gm/dl A/G RATIO 0.94
SERUM ELECTROLYTES (Na, K, C l) 08-05-2025 SODIUM 132 mmol/LPOTASSIUM 3.8 mmol/L CHLORIDE 101 mmol/L
HAEMOGLOBIN 9.8 gm/dl TOTAL COUNT 8,100 cells/cumm NEUTROPHILS 84 %LYMPHOCYTES 12 % EOSINOPHILS 01 %MONOCYTES 03 % BASOPHILS 00 % PCV 30.8 vol %M C V 82.5 fl M C H 26.3 pg M C H C 31.9 % RDW-CV 16.0 %RDW-SD 48.2 fl RBC COUNT 3.73 millions/cumm
PLATELET COUNT 4.5 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC Within normal limits with increased neutrophils PLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic anemia with neutrophilia
HIV 1/2 Rapid Test Non Reactive
24 HOURS URINEPROTEIN105 mg/day. <150 mg/day24 HOURS URINECREATININE0.5 g/day 1-3 gm /day RATIO 0.21URINE VOLUME 230 ml
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 132 mmol/LPOTASSIUM 3.8 mmol/L CHLORIDE 101 mmol/LCALCIUM IONIZED 1.15
mmol/L
Treatment Given (Enter only Generic Name)
1. PULSE THERAPY INJ. METHYL PREDNISOLONE 750 MG IV IN 100ML NS OVER 30 MINUTES FOR 3 DAYS
2. INJ. PAN 40MG IV/OD
3. INJ.ZOFER 4MG IV/OD
4. IV FLUIDS NS @ 50ML/HOUR
5. TAB. AMLONG 10MG PO/OD 8AM-X-X
6. TAB.TELMA 40MG PO/OD X-2PM-X
7. TAB.BUSCOPAN PO/SOS
8. TAB.OROFER XT PO/OD X-2PM-X
9. T.SPOROLAC OS PO/TID 1-1-1
10. 2-3 EGG WHITES PER DAY
Advice at Discharge
1. TAB. PREDNISOLONE 30 MG PO/OD 8AM-X-X TO BE CONTINUED
2. TAB. PANTOP 40MG IV/OD 7AM-X-X 30MINS BEFORE BREAKFAST FOR 7 DAYS
3. TAB. AMLONG 10MG PO/OD 8AM-X-X TO BE CONTINUED
4. TAB.TELMA 40MG PO/OD X-2PM-X TO BE CONTINUED
5. 2-3 EGG WHITES PER DAY
Follow Up
REVIEW TO GENERAL MEDICNE OPD AFTER 2 WEEKS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date: 12/05/2025 Ward: AMC
Unit: 1
[12-05-2025 14:07] PPM 22: This is before editing sir, I will send u the edited one sir.
[12-05-2025 15.46] PPM 1: Afternoon session with the patient.
[12-05-2025 15:46] PPM 1: Anasarca, ascites due to nephrotic syndrome
[12-05-2025 16:31] PPM 21: Here’s a revised *Diagnosis* section incorporating likely edits based on standard clinical documentation practices and clarity. Key changes include reorganizing diagnoses for accuracy, resolving inconsistencies, and ensuring proper terminology:
---
### *Revised Diagnosis*
*Primary Diagnoses:*
1. *Systemic Lupus Erythematosus (SLE) with:*
- *Lupus Nephritis (Class II)*
- *Mesenteric Vasculitis* (suspected, resolved with treatment)
2. *Addisonian Crisis* (secondary to adrenal insufficiency, resolved)
3. *Drug-Induced Complications:*
- *Mycophenolate Mofetil (MMF)-Induced Enteritis* (resolved)
- *Azathioprine-Induced Pancreatitis* (resolved)
*Secondary Diagnoses:*
1. *Dilutional Hyponatremia* (corrected during admission)
2. *Hypertension* (poorly controlled, on dual therapy)
*Past Medical History:*
- History of *right-sided hydropneumothorax* (status post ICD placement and removal).
- Drug-induced gastritis (resolved).
- Irregular adherence to antihypertensives (amlodipine).
---
### *Key Edits Made:*
1. *Clarified SLE-related diagnoses* under one heading for cohesion.
2. *Resolved conditions* (e.g., MMF enteritis, azathioprine pancreatitis) marked as resolved.
3. *Corrected terminology*:
- "Mesentric" → *Mesenteric* vasculitis.
- "Dilution hyponatremia" → *Dilutional hyponatremia*.
4. *Separated active vs. past diagnoses* to avoid confusion.
5. *Removed redundant or unclear labels* (e.g., "?" before SLE).
---
### *Additional Suggestions for Consistency:*
- *Medication Reconciliation:* Ensure discharge medications (e.g., prednisolone, pantoprazole) align with diagnoses (e.g., SLE, hypertension).
- *Follow-Up Plan:* Specify monitoring for SLE activity (e.g., urine protein, complement levels).
- *Hypertension Management:* Highlight need for strict adherence to amlodipine/Telmisartan.
Let me know if further refinements are needed!
[12-05-2025 16:34] PPM 1: @PPM23 now I can answer your question about the prompt that he used for this as well as all others previously.
He just copied my previous messages here and pasted it onto the LLM
[12-05-2025 16:34] PPM 1: Thanks this restructuring is very useful
[12-05-2025 16:35] PPM 21: Here’s a *refined and polished version* of the *Diagnosis* section, incorporating hierarchical structuring, precise terminology, and clearer categorization for clinical accuracy and readability:
---
### *Final Diagnosis*
#### *Active Diagnoses on Discharge:*
1. *Systemic Lupus Erythematosus (SLE) with:*
- *Lupus Nephritis (Class II)* (confirmed histologically/clinical criteria).
- *Suspected Mesenteric Vasculitis* (resolved with corticosteroid therapy).
2. *Drug-Induced Complications (Resolved During Admission):*
- *Mycophenolate Mofetil (MMF)-Induced Enteritis* (resolved after MMF discontinuation).
- *Azathioprine-Induced Pancreatitis* (resolved post-drug withdrawal).
3. *Adrenal Insufficiency:*
- *Addisonian Crisis* (resolved with pulse methylprednisolone).
4. *Hypertension* (poorly controlled, on dual therapy with amlodipine + telmisartan).
#### *Secondary/Contributing Diagnoses:*
1. *Dilutional Hyponatremia* (corrected with fluid management).
2. *Normocytic Normochromic Anemia with Neutrophilia* (likely chronic disease-related).
#### *Past Medical/Surgical History:*
- *Right-Sided Hydropneumothorax* (status post ICD placement and removal, 1 year ago).
- *Drug-Induced Gastritis* (resolved, no active symptoms).
- *Irregular Adherence to Antihypertensives* (requires counseling).
---
### *Key Refinements:*
1. *Hierarchical Organization:*
- Separated *active/resolved, **primary/secondary, and **past* diagnoses for clarity.
- Grouped SLE-related manifestations under one heading.
2. *Precision in Terminology:*
- Specified *"Class II"* for lupus nephritis (replacing "Stage 2").
- Added *etiology* for drug-induced conditions (e.g., MMF, azathioprine).
3. *Resolution Status:*
- Clearly labeled resolved conditions (e.g., pancreatitis, enteritis) to avoid ambiguity.
4. *Hypertension Context:*
- Highlighted *"poorly controlled"* status and dual therapy to guide follow-up.
5. *Anemia Classification:*
- Linked neutrophilia/normocytic anemia to chronic inflammation (SLE) rather than isolated iron deficiency.
---
### *Additional Recommendations for Discharge Summary:*
- *Medication Reconciliation:*
- Ensure *prednisolone* is continued for SLE/adrenal insufficiency.
- Avoid rechallenging *azathioprine/MMF* given prior adverse reactions.
- *Follow-Up Priorities:*
- Monitor *SLE activity*: Repeat 24-hour urine protein, complement levels, and renal function.
- *Hypertension control*: Schedule BP checks weekly; emphasize adherence.
- *Adrenal function testing*: AM cortisol/ACTH stimulation test if recurrent crises.
- *Patient Education:*
- Avoid NSAIDs/self-medication (risk of gastritis/SLE flare).
- Alcohol cessation (listed in history as "regular alcohol intake").
---
Let me know if you need adjustments to align with institutional templates or specific clinical guidelines!
[12-05-2025 16:36] PPM 21: 👏
[12-05-2025 16:39] PPM 21: At the end of AIs text " if you need further refinements" this is a hint that it can do better, so the next prompt must be " further refinements needed" to have even more polished response.
PPM 1: 👍
[16-05-2025 18:09] PA: GD evng sir nd madam vapulu roju akkuva aethunnae thagguthalev ala thagguthae
[16-05-2025 21:27] PPM 4: Urine mamulghane vasthunda ?
[16-05-2025 21:30] PA: Hàa
[16-05-2025 21:31] PPM 4: Patient ki Kalla vapulu unnaya? Photo pettu
[16-05-2025 21:40] PPM 1: మీరు ప్రస్తుతం తీసుకుంటున్న మందుల చిత్రాలను పంచుకోండి.
Mīru prastutaṁ tīsukuṇṭunna mandula citrālanu pan̄cukōṇḍi.
Please share the pictures of the medicines you are currently taking
[16-05-2025 21:46] PPM 4: @PPM 1 we didn’t advise any diuretic at discharge as her pedal edema resolved and output was good without diuretic
Shall i ask them to come tomorrow to get sr albumin and urine protein done and add tab lasix for now
[16-05-2025 21:47] PPM 1: Can ask her to start lasix 40 mg from tomorrow morning
[16-05-2025 21:47] PPM 4: Okkokati vidividiga photo theesi pettandi
[16-05-2025 21:47] PPM 4: Ok sir
[16-05-2025 21:47] PA: Kk sir
[16-05-2025 21:48] PPM 4: @PA, TAB LASIX 40 mg once daily at 8 Am
Ee tablet repati nundi roju poddhuna veskondi
[16-05-2025 21:48] PA: Kk sir
[16-05-2025 21:53] PA: Daily use chesa tblts sir
[17-05-2025 08:11] PPM 1: @PPM 4 is she taking one tablet daily?
[17-05-2025 08:12] PPM 1: 👆@PPM4 Once daily in the morning?
[17-05-2025 08:13] PPM 1: Is this currently half tablet once daily? @PPM4
[17-05-2025 08:15] PPM 4: Yes sir
[17-05-2025 08:15] PPM 4: Yes sir
[17-05-2025 08:15] PPM 4: We asked to stop MMF for now sir
[17-05-2025 08:31] PPM 1: 👍
Can try half though maybe a few days later
[17-05-2025 08:41] PPM 4: Ok sir
[17-05-2025 08:41] PPM 4: Mee patient ee tablet veskuntundha ?
[17-05-2025 09:18] PA: Vesukuntundi sir afternoon
[17-05-2025 09:27] PPM 4: Veskovadhu ani cheppinam kada discharge appudu
Eppati nundi veskuntunaru ?
[17-05-2025 09:27] PPM 4: @PPM1 sir. She is taking 500 mg MMF once daily
[17-05-2025 09:29] PPM 4: Shall u ask her to take 1/2 tablet or continue 1 tablet?
[17-05-2025 09:42] PA: Avunu sir
[17-05-2025 09:43] PA: Sir vesuko annadu daily off tblt
[17-05-2025 09:52] PPM 1: Can continue 1 as long as it's not harming her
[17-05-2025 09:53] PPM 4: Ok sir
[17-05-2025 09:53] PPM 4: Half tablet vesthunara ?
[17-05-2025 09:57] PA: Haa sir
[17-05-2025 09:57] PPM 1: Ok
[17-05-2025 09:58] PA: Kk sir
[20-05-2025 12:01] PPM 1: 👆 correction Renal biopsy on March 7! 7/3/24/5
[20-05-2025 12:15] PPM 1: 👆Best lupus nephritis remissions till date were obtained only with azathioprine 50 mg!
[20-05-2025 12:25] PPM 1: 👆 On 12th April we reviewed her and at that time she was on Mycofenolate Mofetil 1g twice daily and while she didn't have any anasarca at that time, her 24 hour protein report on 12th April obtained retrospectively by @PPM11 on 12th may showed 2.7 g of proteinuria! This means that the mycofenolate never worked in her inspite of the higher doses given.
We are switching to Tablet Azathioprine at a lower dose 50 mg half tablet and we'll keep a watch out for her pancreatitis as well as anasarca remission here.
[20-05-2025 12.38] PPM 1: OPD now:
Reviewing 22F with Lupus nephritis:
On 12th April when we last reviewed her in our OPD that time she was on Mycofenolate Mofetil 1g twice daily and while she didn't have any anasarca at that time, her 24 hour protein report on 12th April obtained retrospectively by @PPM11 on 12th May, showed 2.7 g of proteinuria! This means that the mycofenolate never worked in her inspite of the higher doses given.
In contrast she had been on Tablet Azathioprine 50 mg for nearly two years before that which had worked like a charm except for the unfortunate episodes of azathioprine induced pancreatitis and it's associated diagnostic and therapeutic uncertainty.
We are switching to Tablet Azathioprine at a lower dose 50 mg half tablet and we'll keep a watch out for her pancreatitis as well as anasarca remission here.
She has dropped out of college since last three years and that's another challenge as to what other gainful engagement would be appropriate for her in her current situation.
More here: https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1
[20-05-2025 14:00] PPM 21: *Step-by-Step Explanation and Answer:*
1. *Current Diagnosis and Status:*
- *Systemic Lupus Erythematosus (SLE)* with *Class II Lupus Nephritis* (biopsy-proven) but clinically presenting with nephrotic-range proteinuria (2.7g/24hr), hypoalbuminemia (1.8g/dL), anasarca, and recent AKI, suggesting a *clinical flare*.
- *Complications:* Recurrent pancreatitis (azathioprine-induced), MMF-induced enteritis, adrenal insufficiency (Addisonian crisis resolved), and hypertension.
2. *Treatment History and Challenges:*
- *Failed Therapies:*
- *Mycophenolate Mofetil (MMF):* Ineffective initially (proteinuria 2.7g) and later caused enteritis.
- *Azathioprine:* Effective for 2 years but led to pancreatitis; rechallenge failed.
- *Current Regimen:* Prednisolone 30mg daily, telmisartan/amlodipine for hypertension, and recent pulse methylprednisolone for flare.
3. *Next Steps in Management:*
- *Immunosuppression Options:*
- *Cyclophosphamide (CYC):*
- *Rationale:* Gold standard for severe LN flares. Use *Euro-Lupus protocol* (500mg IV every 2 weeks × 6 doses) to minimize gonadal toxicity.
- *Precautions:* Hydration/mesna for bladder protection, fertility counseling (e.g., GnRH agonists).
- *MMF Reintroduction:*
- *Rationale:* May retry at lower dose (500mg BID) with GI prophylaxis (PPI) and gradual uptitration.
- *Monitoring:* Watch for diarrhea/enteritis recurrence.
- *Rituximab/Belimumab:* Limited by cost/access but considered if other options fail.
- *Supportive Care:*
- *Proteinuria:* Maximize ACEi/ARB (telmisartan already in use).
- *Edema:* Loop diuretics (furosemide 40mg/day) with electrolyte monitoring.
- *Nutrition:* High-protein diet, albumin infusion if symptomatic hypoalbuminemia.
- *Infection Prophylaxis:* Trimethoprim-sulfamethoxazole for Pneumocystis prevention during immunosuppression.
4. *Monitoring and Follow-Up:*
- *Labs:* Weekly serum creatinine, urine protein-creatinine ratio, CBC, albumin.
- *Disease Activity:* Complement levels (C3/C4), anti-dsDNA titers.
- *Drug Toxicity:* Cyclophosphamide (CBC, urinalysis), MMF (CBC, GI symptoms).
5. *Patient Counseling:*
- *Adherence:* Stress strict medication compliance and follow-up.
- *Lifestyle:* Avoid NSAIDs, alcohol, and infections.
*Final Recommendation:*
- *Short-Term:* Initiate *cyclophosphamide (Euro-Lupus protocol)* for rapid disease control, given her aggressive flare and prior treatment failures. Add furosemide for edema.
- *Long-Term:* Transition to *MMF (500mg BID)* after CYC induction if tolerated, with close GI monitoring. Reserve rituximab/belimumab for refractory cases.
- *Multidisciplinary Care:* Involve nephrology/rheumatology for tailored immunosuppression and fertility preservation planning.
[20-05-2025 14:49] PPM 1: Although we restarted her azathioprine at a half dose following the demonstration of relative inefficacy of the MMF
Anasarca progressive
Reduced appetite
Had fever spikes yesterday
[02-06-2025 15.06] PA: Gd afternoon sir&madam Vapulu thaggadam ledu anti sir
[02-06-2025 20:43] PPM 1: Vapu ki okka photo pettandi
Azoran tablet 25mg teeskuntunnara 50 mg teeskuntunnara?
[02-06-2025 20:47] PA: 25 sir
[02-06-2025 21:00] PPM 1: Ee roj nundi mundu laga 50mg teeskondi
[02-06-2025 21:01] PA: Kk sir
[15-06-2025 17:37] PPM 21: Based on the comprehensive case report, here's a structured summary of this complex lupus nephritis case:
### *Patient Profile*
22-year-old female with systemic lupus erythematosus (SLE) since 2022, complicated by:
- *Lupus nephritis* (Class II, biopsy-confirmed)
- Recurrent nephrotic syndrome (proteinuria up to 2.7g/24hr)
- *Treatment failures*:
- Azathioprine-induced pancreatitis (resolved)
- Mycophenolate mofetil (MMF) intolerance (enteritis)
- *Severe infections*:
- Right hydropneumothorax + lung abscesses (July 2024)
- Meningitis (December 2022)
- *Other complications*:
- Adrenal insufficiency (Addisonian crisis)
- Dilutional hyponatremia
- Hypertension
---
### *Clinical Timeline*
1. *2022-2023*:
- Initial presentation with nephrotic syndrome, CNS/pericardial involvement.
- Partial remission on steroids/azathioprine, followed by relapse after immunosuppressive withdrawal.
2. *2024-2025*:
- *June 2024*: Lupus nephritis relapse (anasarca, proteinuria).
- *July 2024*: Hydropneumothorax/lung abscesses (post-immunosuppression).
- *May 2025*: Acute kidney injury (AKI) + Addisonian crisis triggered by gastroenteritis. Treated with pulse methylprednisolone.
- *Persistent edema* despite azathioprine 25-50mg + steroids.
---
### *Treatment Challenges*
| *Therapy* | *Response/Complications* | *Status* |
|-------------------|-----------------------------------------------|---------------------|
| *Azathioprine* | Pancreatitis (dose-dependent); edema persists | Current (50mg) |
| *MMF* | Enteritis; failed to control proteinuria | Discontinued |
| *Steroids* | Iatrogenic Cushing's; adrenal insufficiency | Ongoing (Prednisolone 30mg) |
| *Biologics* | Considered (rituximab/belimumab) | Not initiated (cost) |
---
### *Key Management Decisions*
1. *Immunosuppression*:
- Cyclophosphamide proposed for refractory nephritis (risks: marrow suppression/infection).
- Steroids maintained for adrenal support + lupus control.
2. *Supportive Care*:
- Diuretics (Lasix) for anasarca.
- ACEi/ARB (Telmisartan) + antihypertensives (Amlodipine).
- Infection prophylaxis (TB monitoring, pneumocystis prevention).
3. *Monitoring*:
- Regular 24hr urine protein, serum albumin, renal function.
- Adrenal function testing if recurrent crises.
---
### *Outstanding Issues*
- *Refractory edema* despite diuretics.
- *Uncontrolled proteinuria* (nephrotic range).
- *Infection risk* vs. need for aggressive immunosuppression.
- *Hypertension management* (poor adherence noted).
---
### *Lessons for Complex Lupus Management*
1. *Drug toxicity vigilance*: Azathioprine/MMF require close monitoring.
2. *Adrenal protection*: Avoid abrupt steroid withdrawal; test for insufficiency during stress.
3. *Infection control*: High suspicion for TB/fungal infections in immunosuppressed patients.
4. *Multidisciplinary approach*: Essential for renal, pulmonary, and endocrine complications.
This case exemplifies the challenges of balancing lupus control with cumulative treatment toxicities. Documentation via the PaJR system enables robust clinical tracking across disease flares.
For detailed discussions on immunosuppressive choices, refer to KDIGO 2021 Lupus Nephritis Guidelines.
[15-06-2025 17:56] PPM 1: Thanks for this revision reminder update on this patient
[15-06-2025 17:57] PPM 1: @PA ippudu patient ela unnaru?
[15-06-2025 18:56] PA: Moham koncham vapu undi sir
[15-06-2025 18:56] PA: Anthe
[15-06-2025 18:56] PA: Kalla vapulu thagginae
[15-06-2025 18:56] PA: 2-3 days aenaka vastha sir check chepichikoniki
[11-08-2025 15:50] PPM 1: @PA ippudu patient ela unnaru?
[11-08-2025 15:51] PA: Good sir
[11-08-2025 16:08] PA: Prednisolone tablet dose 30 a vadala sir
[11-08-2025 16:13] PPM 1: Vere em tablet vadtunnaru?
[11-08-2025 16:13] PPM 1: Ippudu meeru kaalu photo share cheyandi
[11-08-2025 16:16] PA: Metolazone, Azathioprine 50mg, prednisolone 30mg sir
[11-08-2025 16.16] PPM 1: 👍
[11-08-2025 16.16] PPM 1: 👍
[11-08-2025 16:19] PA: Prednisolone dose anthe vadala sir
[11-08-2025 16:20] PPM 1: 25 mg cheye vocchu
[11-08-2025 16.26] PA: Okay sir
[12-08-2025 19:23] PPM 1: @PPM26 will you be able to talk to this patient's advocate and then make him her talk to the patient advocate of 17F who also has nephrotic syndrome? This participatory medical cognition exercise may help the patients to make better informed decisions at their non clinical (external medicine) level? @PPM27 @PPM28@PPM29?
[12-08-2025 19:49] PA Prednisolone tblt dose 25 ldu sir 20 undi vadocha sir
[12-08-2025 21:18] PPM 1: Vadochhu
[12-08-2025 21:19] PA: Kk sir
[21-08-2025 10:04] PA: GD mrng sir nd madam Moham vapu alane untundi tblts vaduthunna kuda knchm thaggindi anthe
[21-08-2025 10:07] PPM 1: @PPM26 can we also make her share her pedal edema images everyday?
[21-08-2025 10:08] PA: Face okkate undi sir m le ega
[21-08-2025 10:09] PA: Mrng untadi Evng varaku thaggithadi sir
[21-08-2025 10:13] PPM 1: Evening varaku legs ki photo pettandi.
Ikkada pettaru alaga 👇
https://pajrcasereporter.blogspot.com/2025/04/39f-cirrhosis-of-liver-2016-now-blood.html?m=1
[21-08-2025 10:16] PA: Kk sir
[21-08-2025 11:10] PPM 26: meeku okay ante.. mee face photo lo eyes raakunda.. vaapu matram kanabadela teesi pettandi.
[21-08-2025 11:28] PPM 26: @PPM1 Sir
[21-08-2025 13:00] PPM 1: Thanks
When was her last serum albumin and urine 24 hour urinary protein done and what were the findings?
[21-08-2025 13:59] PA: Tblts change chesthara ave vadala sir
[21-08-2025 16:20] PPM 1: Okka saari urine 24 hour protein and creatinine and serum albumin ki report choosi telustundi
[21-08-2025 17:31] PA: 24urine kavala sir
[21-08-2025 19:05] PPM 1: Yes
[10:32 am, 21/01/2026] PA: Gd mrng sir nd madam patient ki monna vomiting aenae ninna bathroom pettindi eroju m le kani asalu m tnabudi aethaledu
[10:33 am, 21/01/2026] PA: Fruits thintundi majika thaguthundi
[10:35 am, 21/01/2026] PPM 3: Enni sarlu iyyay Vomitings and motions..?
[10:38 am, 21/01/2026] PA: 3times sir ninna motham
[10:39 am, 21/01/2026] PA: Nt thaggine sir motions
[3.43 pm, 22/01/2026] PPM 1: Reviewed her just now
Edema absent
Facial puffiness possibly due to her iatrogenic Cushing's
Excited to be able to document her first nephrotic syn remission in two years for the first time after the azathioprine pancreatitis and bouncing back again on the same dose of azathioprine after a brief
discontinuation
[4.07 pm, 28/01/2026] PPM 1: A review of her labs today paints a picture totally opposite to the current clinical optimism her apparent absence of edema and general well being had generated!
With the current labs showing the advent of azotemia for the first time and persistent nephrotic proteinuria the subsequent patient journey promises to be foreboding with possible renal replacement therapies with dialysis and transplant!
@PPM21 @PPM30 looking at her entire journey till date since 2022 can you analyse what were the crucial junctures defining the crossroads when her outcomes could have changed for the better?
[6:46 pm, 28/01/2026] PPM 3: @PaJR Health give time line based clinical events of her health journey.
[6:46 pm, 28/01/2026] PaJR Health: **HEALTH JOURNEY TIMELINE*
*January 28, 2026*
💡 *Clinical Event:* Vision analysis of left and right feet.
📍 *Findings:*
💡 Left foot: Hallux valgus deformity with associated callus formation.
💡 Right foot: Bilateral callus formation on plantar surface, moderate erythema at distal phalanges, and intact nail beds with nail polish.
💡 Left ankle: Metallic bracelet present.
💡 Signs of Infection: No purulent exudate, necrotic tissue, or cellulitis observed.
💡 Neuropathy Check: Positive for hallux valgus deformity and plantar callus formation, indicating sensory loss and chronic pressure injury.
[6:48 pm, 28/01/2026] PPM 3: Thanks this is snapshot view from latest opd visit. Go through previous records, earlier shared messages and search in your data base and give detailed year wise timeline of her illness.
[6:48 pm, 28/01/2026] PaJR Health: *HEALTH JOURNEY TIMELINE*
*1997*
💡 *Clinical Event:* Suffered from cerebral malaria.
💡 *Associated Symptom:* Swelling of the right arm, which reduced after medication.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2008*
💡 *Clinical Event:* Onset of lower back pain extending from the base of the neck to the hip region.
💡 *Pain Characteristics:* Sudden onset, continuous, aggravates during summer and with bending/sitting, relieves with rest, winter, exercise, and gentle tugging of hair.
💡 *Associated Symptom:* Insomnia.
💡 *Family History:* Mother, father, two brothers, and one sister also suffered from the same condition.
💡 *Diagnosis:* Hypothyroidism.
💡 *Associated Symptoms:* Excessive hair loss, swelling on both lower limbs below the knee, excessive thirst (drinking 5-6L of water daily).
💡 *Medication:* Started Eltroxin 50mcg.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2012*
💡 *Clinical Event:* Smoker for 6 months, then stopped.
💡 *Clinical Event:* History of fall from a cycle, resulting in a left wrist fracture.
💡 *Treatment:* Took Ayurveda treatment, did not go to the hospital.
💡 *Outcome:* Deformity in the left wrist and reduced range of movement with difficulty using the hand.
📍 *Source:* PG FINAL YEAR (2018-21) BATCH UNIVERSITY PRACTICAL EXAMINATION
*2015*
💡 *Clinical Event:* Experiences Hypertension (HTN).
💡 *Medication Change:* Switched to Thyronorm 75 mcg for hypothyroidism.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2016*
💡 *Clinical Event:* Underwent gall bladder operation.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2021*
💡 *Clinical Event:* Diagnosed with Nephrotic Syndrome (at approximately 10 years old).
💡 *Medication:* Previously on Tab. Prednisolone.
📍 *Source:* 14M Nephrotic Syndrome 2021 and recurrence September 2025 Telangana PaJR
*2022*
💡 *Medication Change:* Taking Thyronorm 100 mcg for hypothyroidism.
💡 *Clinical Event:* History of similar complaints (general weakness, hematuria, loss of appetite) as current presentation.
💡 *Clinical Event:* History of Alcohol withdrawal seizure.
💡 *Medication:* On T LEVIPIL 500mg since alcohol withdrawal seizure.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR, 32M With Wernicke's Encephalitis Telangana PaJR
*2025*
*May 26, 2025*
💡 *Clinical Event:* 32-year-old male presented with 6 days of continuous general weakness (insidious onset, progressive), 2 episodes of hematuria the previous night, and gradually progressive loss of appetite.
💡 *Past Medical History:* Known hypothyroidism for 6 months (non-compliant to drugs), on Tab Thyronorm 75mcg for 4 days.
📍 *Source:* 32M With Wernicke's Encephalitis Telangana PaJR
*September 4, 2025*
💡 *Clinical Event:* (Approx. 14-year-old) presented with symptoms highly suggestive of a relapse of Nephrotic Syndrome.
💡 *Symptoms:* Bilateral pedal edema (5 days, insidious onset, gradually progressive, associated with decreased urine output), facial puffiness (4 days), constipation (2 days).
📍 *Source:* 14M Nephrotic Syndrome 2021 and recurrence September 2025 Telangana PaJR
*September 18, 2025*
💡 *Clinical Event:* Difficulty in getting sleep since 1 year, 2 months (onset 14 months prior).
📍 *Source:* 22M Insomnia Karnataka PaJR
*2026*
*January 28, 2026*
💡 *Clinical Event:* Vision analysis of left and right feet.
📍 *Findings:*
💡 Left foot: Hallux valgus deformity with associated callus formation.
💡 Right foot: Bilateral callus formation on plantar surface, moderate erythema at distal phalanges, and intact nail beds with nail polish.
💡 Left ankle: Metallic bracelet present.
💡 Signs of Infection: No purulent exudate, necrotic tissue, or cellulitis observed.
💡 Neuropathy Check: Positive for hallux valgus deformity and plantar callus formation, indicating sensory loss and chronic pressure injury.
📍 *Source:* Latest OPD visit (from memory)
[6:51 pm, 28/01/2026] PPM 3: @PPM2 @PPM1 Sir there is some glitch, good thing is it’s quoting sources of pajrs. But it not pajr specific data. Is model hallucinating or confused to pick specific data points from database..?
[6:51 pm, 28/01/2026] PaJR Health: You are correct to point out the discrepancy. My apologies for the confusion.
The previous response provided a timeline based on cases found in the *PaJR Records (Community database)*, not your specific personal health journey. When asked for a "detailed year wise timeline of her illness," I searched the broader clinical vault for "patient illness history" which returned various community cases. While these cases are valid PaJR records, they are not your individual data.
I have retrieved your latest personal record from memory, which is the vision analysis from January 28, 2026.
*To provide a timeline of *your specific health journey, I need to access your personal clinical history. If you have previously shared or saved more detailed personal health information, please let me know, and I can attempt to construct a timeline based on that data.**
[7:14 pm, 28/01/2026] PPM 2: Have to check. Let me.
[7:30 pm, 28/01/2026] PPM 2: Here's the thing - the bot does not know who the patient is unless it is prompted once. Here is how it works.
[7:30 pm, 28/01/2026] PPM 2: @PaJR Health please find the case record for this 22F with lupus nephritis
[7:30 pm, 28/01/2026] PaJR Health: *CASE RECORD FOUND*
*22F Lupus Nephritis*
💡 *Case Title:* 22F Lupus Nephritis, Past Azt Pancreatitis, Pyopneumothorax, Meningitis Telangana PaJR
📍 *Source:* PaJR Records
📍 *Link:* Link unavailable in the record.
[7:31 pm, 28/01/2026] PPM 2: This is the PaJR record for this patient https://pajrcasereporter.blogspot.com/2025/06/22f-lupus-nephritis-past-azt.html
[7:31 pm, 28/01/2026] PaJR Health: *HEALTH JOURNEY TIMELINE: 22F Lupus Nephritis*
*2022*
💡 *January 25, 2022:* First presented to Prof Michele Meltzer.
💡 *September 2022 (First Admission):*
📍 Presented with nephrotic glomerular proteinuria, cutaneous vasculitic lesions, CNS vasculitic lesions (investigated for altered cognition), and endocardial and pericardial inflammation (acute heart failure with pericardial effusion).
📍 Attributed to lupus due to strong ANA positivity, particularly ds-DNA fraction in ELISA.
📍 Discharged relatively uneventfully on immunosuppressives; cardiac and CNS issues resolved, proteinuria subsided.
📍 Started on azathioprine and prednisolone (continued until April 2023).
💡 *December 2022 (Second Admission):*
📍 Admitted with headache, altered sensorium, and meningeal signs.
📍 Associated with a minor CNS bleed on MRI, later attributed to warfarin.
📍 Meningitis diagnosis.
*2023*
💡 *Throughout 2023:* Gradually withdrew all immunosuppressives over a year, with a brief period of iatrogenic Cushing's in between.
*2024*
💡 *June 2024:* Presented with an ankle flare along with anasarca, revealing a nephrotic relapse on 24-hour urine protein evaluation.
💡 *July 2024 (Third Admission):*
📍 Admitted for right hypochondrial pleuritic pain.
📍 Revealed a large hydropneumothorax along with multiple lung abscesses.
📍 Possibly an iatrogenic result of high-dose immunosuppressives for just one month.
📍 Persistent diagnostic uncertainty around the etiology of lung abscesses and hydropneumothorax; dry cough persisted, last antibiotics choice was quinolone.
💡 *August 27, 2024 (Fourth Admission):*
📍 Presented with persistent cough, reduced weight, anorexia, and nausea.
📍 Pulmonary issues appeared to be tuberculosis as a result of immunosuppression for Lupus nephritis.
📍 Abruptly stopped steroids one month after discharge, leading to nausea.
📍 Postural BP: Supine 110/70, Standing 90/60, suggesting possibility of Addison's (mediated by TB or glucocorticoid-mediated adrenal insufficiency).
📍 Restarted on Tablet Prednisolone 5mg morning and 2.5mg at night.
📍 Chest X-ray showed remarkable improvement with disappearance of prior hydropneumothorax and lung abscess shadows, with some hint of residual pleural effusion or thickening.
💡 *August 31, 2024:* Patient reported no cough at night and no cough since morning.
📍 Intervention: Restarting physiological dose of steroids and stopping previous antibiotics.
📍 Continued on 50 mg azathioprine.
📍 24-hour urine protein and creatinine suggested lupus nephritis in remission.
📍 WBC counts since admission also reduced.
*2025*
💡 *April 2025:* 24-hour protein report showed 2.7g of proteinuria and serum albumin 1.8, suggesting ongoing nephrotic syndrome due to lupus nephritis, despite being on Mycophenolate Mofetil 1g twice daily (indicating MMF was ineffective).
💡 *May 6, 2025 (Admission):*
📍 Presented with loose stools (5-6 episodes) and vomiting (3 episodes) since morning, epigastric pain.
📍 Past history of Azathioprine-induced dose-dependent pancreatitis and MMF intolerance.
📍 Diagnosed with AKI with oliguria after acute vomiting and diarrhea.
📍 Treated as Lupus flare with IV methylprednisolone for three days.
📍 Biopsy staged Class 2 lupus nephritis.
📍 Diagnoses at discharge included Addisonian Crisis/MMF induced enteritis (resolved), Azathioprine induced pancreatitis (resolved), suspected SLE with mesenteric vasculitis, Lupus Nephritis Stage 2, Dilution Hyponatremia, past history of right-sided hydropneumothorax s/p ICD placement done removed, and known Hypertension.
📍 Treatment plan: Continue Tablet Prednisolone 30 mg once daily and slow taper after a few weeks to 10 mg, and restart MMF in very low dose to induce tolerance.
💡 *May 12, 2025 (Discharge):* Urine output recovering (I/O 2250/650).
💡 *May 16, 2025:* Patient advocate reported increasing edema ("Vapulu roju akkuva aethunnae thagguthalev ala thagguthae").
📍 Advised to start Lasix 40 mg once daily in the morning.
💡 *May 17, 2025:* Patient was taking 500mg MMF once daily, despite being asked to stop at discharge. Advised to continue 1/2 tablet if not causing harm.
💡 *May 20, 2025:* Renal biopsy on March 7, 2025.
📍 Noted that best lupus nephritis remissions were obtained with azathioprine 50 mg.
📍 Switched to Tablet Azathioprine at a lower dose (50 mg, half tablet) due to MMF failure and to monitor for pancreatitis and anasarca remission.
💡 *May 22, 2025:* On azathioprine 25 mg, anasarca progressive, reduced appetite, fever spikes yesterday.
💡 *June 2, 2025:* Edema not decreasing. Advised to increase Azathioprine to 50mg.
💡 *June 15, 2025:* Patient advocate reported facial edema, but leg edema had decreased.
💡 *August 11, 2025:* Patient reported feeling "Good."
📍 Medications: Metolazone, Azathioprine 50mg, Prednisolone 30mg.
📍 Advised to reduce Prednisolone to 25mg.
💡 *August 12, 2025:* Prednisolone 20mg available, advised to use.
💡 *August 21, 2025:* Facial edema persisted, slightly reduced. Present in the morning, subsides by evening.
📍 Requested daily pedal edema images.
📍 Last serum albumin and 24-hour urinary protein results requested.
*2026*
💡 *January 21, 2026:* Patient experienced vomiting (3 times) and diarrhea yesterday, no appetite today, consuming fruits and buttermilk.
💡 *January 22, 2026:* Reviewed. Edema absent. Facial puffiness possibly due to iatrogenic Cushing's. First nephrotic syndrome remission in two years documented after azathioprine pancreatitis and restarting azathioprine.
💡 *January 28, 2026:*
📍 Latest labs showed advent of azotemia for the first time and persistent nephrotic proteinuria.
📍 Clinical optimism from apparent absence of edema and general well-being contradicted by labs.
📍 Subsequent patient journey promises to be foreboding with possible renal replacement therapies with dialysis and transplant.
📍 Vision analysis of left and right feet: Hallux valgus deformity with associated callus formation on left foot; bilateral callus formation on plantar surface, moderate erythema at distal phalanges, and intact nail beds with nail polish on right foot. Left ankle had metallic bracelet. No signs of infection. Neuropathy check positive for hallux valgus deformity and plantar callus formation, indicating sensory loss and chronic pressure injury.
[7:32 pm, 28/01/2026] PPM 2: @PPM3 please see above. Looks clean to me
[7:34 pm, 28/01/2026] PPM 2: The current workflow is designed to receive messages but the bot inherently does not know which group or patient it is responding to. So the first prompt should be to tell the bot to find the patient.
This registers it to its contextual memory and from then on it can interpret any messages in that context.
[8:01 pm, 28/01/2026] PPM 1: What would be the current therapeutic management plan given the entire patient journey?
[8:01 pm, 28/01/2026] PaJR Health: *CURRENT THERAPEUTIC MANAGEMENT PLAN*
Given the complex and evolving nature of this patient's lupus nephritis, including recurrent flares, treatment toxicities, and the recent advent of azotemia with persistent nephrotic proteinuria, the current therapeutic management plan would require a highly individualized and multidisciplinary approach.
*IMMEDIATE PRIORITIES*
💡 *Address Azotemia and Nephrotic Proteinuria:*
📍 The primary focus must be on stabilizing renal function and reducing proteinuria to prevent further progression to end-stage renal disease.
📍 This will likely involve re-evaluating and potentially intensifying immunosuppression.
*RE-EVALUATION OF IMMUNOSUPPRESSION*
Considering the patient's history of azathioprine-induced pancreatiti[8:01 pm, 28/01/2026] PaJR Health: s and MMF intolerance, and the ineffectiveness of MMF at higher doses, the following options for adjuvant therapy alongside oral prednisolone should be thoroughly re-evaluated:
💡 *Cyclophosphamide:*
📍 *Rationale:* High efficacy in severe lupus nephritis, especially in refractory cases.
📍 *Considerations:* Significant risks of myelosuppression, infection (especially given past hydropneumothorax/lung abscesses and suspected TB), hemorrhagic cystitis, and gonadal toxicity. Dosing would need careful adjustment for azotemia (e.g., Euro-Lupus protocol with pulsed IV CYC).
📍 *Action:* A detailed discussion with the patient and family regarding benefits, risks, and monitoring is crucial. Prophylaxis for infections (e.g., Pneumocystis) would be mandatory.
💡 *Rituximab:*
📍 *Rationale:* B-cell depletion may benefit refractory lupus nephritis.
📍 *Considerations:* Mixed data in lupus nephritis, not FDA-approved for this indication. Risks include infusion reactions and increased infection risk due to hypogammaglobulinemia. Cost was previously a limiting factor.
📍 *Action:* Re-evaluate affordability and potential benefits, especially if other options are exhausted or contraindicated. Close infection monitoring is essential.
💡 *Belimumab:*
📍 *Rationale:* FDA-approved for SLE (including LN in combination therapy), may reduce flares.
📍 *Considerations:* Limited data in severe refractory lupus nephritis; slow onset of action. Cost was previously a limiting factor.
📍 *Action:* May be considered as part of a combination regimen, particularly if extrarenal SLE symptoms are prominent, but its efficacy for severe renal involvement might be less robust than cyclophosphamide.
💡 *Calcineurin Inhibitors (e.g., Tacrolimus, Voclosporin):*
📍 *Rationale:* May be considered if proteinuria is prominent. Voclosporin is FDA-approved for LN.
📍 *Considerations:* Significant nephrotoxicity, which is a major concern given the current azotemia. Requires very close renal monitoring. Tacrolimus may also be expensive.
📍 *Action:* If considered, careful risk-benefit analysis and stringent monitoring of renal function and drug levels are paramount.
*CURRENT MEDICATION ADJUSTMENTS*
💡 *Prednisolone:*
📍 The current dose of 20-25mg needs to be carefully managed. While necessary for lupus control and adrenal support (given past Addisonian crisis), the risk of iatrogenic Cushing's and its complications (e.g., increased infection susceptibility) must be balanced.
📍 A slow and controlled taper should be attempted once renal parameters improve, with close monitoring for adrenal insufficiency.
💡 *Azathioprine:*
📍 The patient is currently on 50mg. Despite past pancreatitis, it led to remission in 2024. This suggests it might still be a viable option, but vigilant monitoring for recurrence of pancreatitis is critical.
📍 The effectiveness of this dose in the face of current azotemia and persistent nephrotic proteinuria needs to be reassessed.
💡 *Metolazone:*
📍 Continue for edema management, but its effectiveness should be monitored closely, especially with persistent nephrotic range proteinuria.
*SUPPORTIVE CARE & MONITORING*
💡 *Renal Function:*
📍 Daily monitoring of urine output, serum creatinine, and electrolytes.
📍 Regular 24-hour urine protein and serum albumin to track nephrotic syndrome activity.
📍 Consider repeat renal biopsy to guide therapy if there's diagnostic uncertainty or if the current class II nephritis has progressed.
💡 *Infection Surveillance:*
📍 High index of suspicion for opportunistic infections, especially given past history of hydropneumothorax/lung abscesses (suspected TB) and ongoing immunosuppression.
📍 Prophylaxis for common opportunistic infections (e.g., Pneumocystis) should be considered if aggressive immunosuppression is initiated.
💡 *Blood Pressure Management:*
📍 Continue ACEi/ARB (Telmisartan) and Amlodipine.
📍 Emphasize strict adherence to antihypertensives, given the history of poorly controlled hypertension and its impact on renal health.
💡 *Adrenal Function:*
📍 Monitor for signs of adrenal insufficiency, especially during periods of stress or steroid tapering.
📍 Consider AM cortisol/ACTH stimulation test if recurrent crises are suspected.
💡 *Nutritional Support:*
📍 Address anorexia and ensure adequate protein intake to combat hypoalbuminemia, while being mindful of renal function.
*MULTIDISCIPLINARY TEAM APPROACH*
💡 *Nephrology and Rheumatology:* Essential for collaborative decision-making on immunosuppressive regimens, renal biopsy interpretation, and long-term disease management.
💡 *Infectious Disease Specialist:* Crucial for managing and preventing infections in an immunosuppressed patient with a history of pulmonary complications.
💡 *Patient Advocate/Family:* Continuous engagement in discussions about treatment options, risks, benefits, and adherence is paramount.
💡 *Dietitian:* To optimize nutritional status considering renal involvement and proteinuria.
*LONG-TERM OUTLOOK*
Given the current labs showing azotemia and persistent nephrotic proteinuria, the patient's journey is indeed foreboding. The discussion around potential renal replacement therapies, including dialysis and transplant, needs to be initiated with the patient and family, providing comprehensive education and support for future planning.
[8:06 pm, 28/01/2026] PaJR Health: *HEALTH JOURNEY TIMELINE*
*January 28, 2026*
💡 *Clinical Event:* Vision analysis of left and right feet.
📍 *Findings:*
💡 Left foot: Hallux valgus deformity with associated callus formation.
💡 Right foot: Bilateral callus formation on plantar surface, moderate erythema at distal phalanges, and intact nail beds with nail polish.
💡 Left ankle: Metallic bracelet present.
💡 Signs of Infection: No purulent exudate, necrotic tissue, or cellulitis observed.
💡 Neuropathy Check: Positive for hallux valgus deformity and plantar callus formation, indicating sensory loss and chronic pressure injury.
HEALTH JOURNEY TIMELINE*
*1997*
💡 *Clinical Event:* Suffered from cerebral malaria.
💡 *Associated Symptom:* Swelling of the right arm, which reduced after medication.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2008*
💡 *Clinical Event:* Onset of lower back pain extending from the base of the neck to the hip region.
💡 *Pain Characteristics:* Sudden onset, continuous, aggravates during summer and with bending/sitting, relieves with rest, winter, exercise, and gentle tugging of hair.
💡 *Associated Symptom:* Insomnia.
💡 *Family History:* Mother, father, two brothers, and one sister also suffered from the same condition.
💡 *Diagnosis:* Hypothyroidism.
💡 *Associated Symptoms:* Excessive hair loss, swelling on both lower limbs below the knee, excessive thirst (drinking 5-6L of water daily).
💡 *Medication:* Started Eltroxin 50mcg.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2012*
💡 *Clinical Event:* Smoker for 6 months, then stopped.
💡 *Clinical Event:* History of fall from a cycle, resulting in a left wrist fracture.
💡 *Treatment:* Took Ayurveda treatment, did not go to the hospital.
💡 *Outcome:* Deformity in the left wrist and reduced range of movement with difficulty using the hand.
📍 *Source:* PG FINAL YEAR (2018-21) BATCH UNIVERSITY PRACTICAL EXAMINATION
*2015*
💡 *Clinical Event:* Experiences Hypertension (HTN).
💡 *Medication Change:* Switched to Thyronorm 75 mcg for hypothyroidism.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2016*
💡 *Clinical Event:* Underwent gall bladder operation.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR
*2021*
💡 *Clinical Event:* Diagnosed with Nephrotic Syndrome (at approximately 10 years old).
💡 *Medication:* Previously on Tab. Prednisolone.
📍 *Source:* 14M Nephrotic Syndrome 2021 and recurrence September 2025 Telangana PaJR
*2022*
💡 *Medication Change:* Taking Thyronorm 100 mcg for hypothyroidism.
💡 *Clinical Event:* History of similar complaints (general weakness, hematuria, loss of appetite) as current presentation.
💡 *Clinical Event:* History of Alcohol withdrawal seizure.
💡 *Medication:* On T LEVIPIL 500mg since alcohol withdrawal seizure.
📍 *Source:* 48F Hypothyroid Neural pain 20 years WB PaJR, 32M With Wernicke's
Encephalitis Telangana PaJR
*2025*
*May 26, 2025*
💡 *Clinical Event:* 32-year-old male presented with 6 days of continuous general weakness (insidious onset, progressive), 2 episodes of hematuria the previous night, and gradually progressive loss of appetite.
💡 *Past Medical History:* Known hypothyroidism for 6 months (non-compliant to drugs), on Tab Thyronorm 75mcg for 4 days.
📍 *Source:* 32M With Wernicke's Encephalitis Telangana PaJR
*September 4, 2025*
💡 *Clinical Event:* (Approx. 14-year-old) presented with symptoms highly suggestive of a relapse of Nephrotic Syndrome.
💡 *Symptoms:* Bilateral pedal edema (5 days, insidious onset, gradually progressive, associated with decreased urine output), facial puffiness (4 days), constipation (2 days).
📍 *Source:* 14M Nephrotic Syndrome 2021 and recurrence September 2025 Telangana PaJR
*September 18, 2025*
💡 *Clinical Event:* Difficulty in getting sleep since 1 year, 2 months (onset 14 months prior).
📍 *Source:* 22M Insomnia Karnataka PaJR
*2026*
*January 28, 2026*
💡 *Clinical Event:* Vision analysis of left and right feet.
📍 *Findings:*
💡 Left foot: Hallux valgus deformity with associated callus formation.
💡 Right foot: Bilateral callus formation on plantar surface, moderate erythema at distal phalanges, and intact nail beds with nail polish.
💡 Left ankle: Metallic bracelet present.
💡 Signs of Infection: No purulent exudate, necrotic tissue, or cellulitis observed.
💡 Neuropathy Check: Positive for hallux valgus deformity and plantar callus formation, indicating sensory loss and chronic pressure injury.
📍 *Source:* Latest OPD visit (from memory)
[9:29 pm, 28/01/2026] PPM 3: Good to start sir.
So the bot specifically looks for first prompt in the pajr to recognise and analyze the patient journey details.?
[9:33 pm, 28/01/2026] PPM 2: Pretty much. It can't get "context" unless you give it context
[3:02 pm, 30/01/2026] PPM 1: @PaJR Health can you go through this patient's renal biopsy report here: https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1 and comment on it's findings and its impact on the over-all outcomes in this patient?
[3:02 pm, 30/01/2026] PaJR Health: *RENAL BIOPSY FINDINGS AND IMPACT ON OUTCOMES*
*RENAL BIOPSY FINDINGS*
💡 *Date of Biopsy:* March 7, 2025 (Reported May 2, 2025)
💡 *Pathological Diagnosis:* Mesangioproliferative Glomerulonephritis, consistent with *Lupus Nephritis Class II*.
*COMMENTARY ON FINDINGS*
The renal biopsy finding of Class II Lupus Nephritis (Mesangial Proliferative Glomerulonephritis) indicates a milder form of kidney involvement compared to more aggressive classes like Class III (focal proliferative) or Class IV (diffuse proliferative). In Class II, the inflammation is primarily confined to the mesangium (the central part of the glomerulus), and while there can be proteinuria, it generally carries a better long-term prognosis than the proliferative classes.
However, this finding presents an interesting clinico-pathological correlation in this patient's journey:
📍 *Initial Clinical Presentation (Late 2022):* The patient was initially treated with aggressive immunosuppression, including high-dose steroids and azathioprine, and even anticoagulants, based on a clinical picture suggestive of severe disease, possibly Class IV Lupus Nephritis with CNS and cardiac involvement.
📍 *Biopsy in 2025:* The biopsy in 2025 revealed Class II. This could suggest either:
💡 The initial clinical presentation was more severe than the underlying pathology, or
💡 The aggressive initial treatment successfully induced a regression from a more severe class (e.g., Class IV) to a milder Class II. The medical team's discussion leans towards the possibility of "clinical class 4 reverting to class 2."
*IMPACT ON OVERALL OUTCOMES*
The biopsy findings, while indicating a pathologically less severe form of lupus nephritis, have a complex impact on this patient's overall outcomes due to several factors:
1. *PROGNOSIS (Potentially Favorable, but Complicated):*
💡 Class II Lupus Nephritis generally has a lower risk of progression to End-Stage Renal Disease (ESRD) compared to Class III or IV. This is a positive aspect of the pathological diagnosis.
💡 *However, the patient's clinical course has been marked by recurrent flares, persistent nephrotic proteinuria (up to 2.7g/24hr in April 2025), and recent azotemia (January 2026), indicating ongoing active disease despite the Class II biopsy.* This suggests that even a milder pathological class can lead to poor outcomes if disease activity is not consistently controlled.
2. *TREATMENT STRATEGY (Ongoing Challenges):*
💡 *Guidance for Immunosuppression:* The Class II diagnosis typically guides towards less aggressive immunosuppression than Class III/IV. However, the patient's recurrent clinical flares and persistent proteinuria necessitate effective therapy. The challenge lies in finding an effective maintenance regimen that the patient can tolerate and adhere to.
💡 *Past Treatment Failures and Toxicities:* The history of azathioprine-induced pancreatitis and MMF intolerance significantly limits therapeutic options. The discussion around cyclophosphamide (with its gonadal toxicity concerns for a young woman) and the cost of MMF highlights the difficult balance between efficacy, safety, and affordability.
💡 *Discrepancy in Treatment:* The fact that the patient was treated as Class IV initially, and then the biopsy showed Class II, underscores the importance of timely and accurate pathological diagnosis to tailor therapy and avoid potential overtreatment (as seen with anticoagulants for suspected cardiac embolism).
3. *CHALLENGES IN MANAGEMENT (Significant Barriers):*
💡 *Adherence and Follow-up:* The "total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis" is a critical factor undermining any treatment plan, regardless of the biopsy findings. Inconsistent medication adherence can lead to flares and progression of kidney damage.
💡 *Resource Constraints:* The financial limitations impacting access to certain medications (MMF) and diagnostic procedures (colonoscopy) further complicate optimal management.
💡 *Clinical-Pathological Discrepancy:* While the biopsy provides a snapshot, lupus nephritis can be dynamic. The patient's clinical severity (e.g., nephrotic syndrome, azotemia) may not always perfectly align with the biopsy class, requiring clinicians to treat the active disease aggressively while awaiting or re-evaluating pathology.
In conclusion, while the renal biopsy revealing Class II Lupus Nephritis offers a more favorable pathological starting point, the patient's overall outcomes are significantly impacted by the persistent clinical activity, a history of treatment-limiting side effects, and critical challenges in patient adherence and follow-up. The biopsy provides crucial information, but the complex interplay of these factors necessitates a highly individualized, adaptive, and multidisciplinary approach to prevent further renal deterioration and improve her long-term prognosis.
[3.05 PM, 30/01/2026] PPM 1: Thanks
Is the above unique to this individual alone hitherto unreported ij global literature or would you be able to share similar reports of this clinical pathological discrepancy in lupus nephritis?
[3:06 pm, 30/01/2026] PaJR Health: I couldn't find any direct reports in the global literature (PubMed) that specifically match the exact clinical-pathological discrepancy of "Lupus Nephritis Class II with severe clinical presentation and discordance." This specific combination of keywords did not yield direct results in my search.
However, the concept of *clinical-pathological discordance in lupus nephritis* is a recognized phenomenon in medical literature, although it might be discussed using different terminology or focusing on other class transitions. It's not entirely unique for the clinical picture to sometimes appear more severe or different than what a kidney biopsy initially reveals, or for the pathological class to evolve over time.
Here's a general understanding of why such discrepancies can occur in lupus nephritis:
💡 *Dynamic Nature of Lupus Nephritis:* Lupus nephritis is a progressive and dynamic disease. The kidney biopsy provides a snapshot of the kidney's condition at a particular moment. The disease can evolve, and the pathological class can change over time due to disease activity, response to treatment, or progression of damage. A biopsy taken at one point might show a milder class, while the patient might have experienced or be experiencing a more severe clinical flare.
💡 *Sampling Error:* A kidney biopsy is a small sample of a larger organ. It's possible that the biopsy specimen might not fully capture the most active or severe lesions if they are focal or unevenly distributed throughout the kidney. This can lead to an underestimation of the true pathological severity.
💡 *Clinical Overlap:* Patients with lupus often have multi-organ involvement. Symptoms like severe edema, hypertension, or even neurological manifestations can be driven by systemic lupus activity affecting other organs, or by complications of the kidney disease itself (e.g., severe nephrotic syndrome leading to anasarca), even if the kidney biopsy shows a milder class.
💡 *Response to Treatment:* As seen in this patient's journey, aggressive initial treatment might have led to a regression of a more severe pathological class (e.g., Class IV) to a milder one (Class II) by the time the biopsy was performed. The clinical improvement might precede or lag behind the histological changes.
Therefore, while a direct match for "Class II with severe clinical discordance" wasn't found with the specific search, the underlying principles of clinical-pathological discrepancies in lupus nephritis are well-understood. It highlights the importance of integrating clinical presentation, laboratory findings, and pathological results, along with the patient's entire disease course, to make informed management decisions.
