20F Lupus Nephritis Relapse 2 Weeks, Seizures and Nephritis Recovered, Telangana PaJR
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.
PPM 3 - Patient suffering form pain abdomen currently am unable to answer her call. Please any volunteer or pg o
https://08arshewarpavankumar.blogspot.com/2022/09/20-yr-female-with-bl-pedal-edema.html?m=1
r 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
BP 140/80
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 - 
PPM 1 -
Now check out figure 4 here 👇
And use our POCUS device to DIY
04-01-2025
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
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.
Please share the other medicines this patient is taking.
PA - 
PPM 2 - No quality or reliable data comparing Dexa vs MP. May have to take some expert opinions I guess.
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 @PPM13 @PPM14 @PPM15
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. @PPM16 @SE can you help?
PPM 17 - 
PPM 16 - What was her serum creatinine value??
PPM 4 - 
PPM 1 - 👍
PPM 13 - 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 16 - Ok sir.
PPM 13 - 
PPM 13 - 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
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