CONTINUATION OF THE CASE REPORT 34F SLE HEMIPARESIS OCT 2021 FROM THE BELOW LINK. 👇
Reviewing again in the OPD now:
Works as a tailor in a shop since 10 years.
She was admitted in our hospital Weakness of Left Upper Limb on 31/12/2021 at 8:14 am
Noticed as she was coming out of her washroom she was unable to use her left upper limb followed by which she developed deviation of mouth to the right side. It was associated with drooling of saliva from the right angle of mouth. She also developed paraesthesia over face and left upper limb.
Recovered complete power in two weeks and was asymptomatic from 2022-2025 but was put on prednisolone 5mg and mycofenolate mofetil 2g since then.
@PPM3 @PPM2@PPM4 was her immunosuppressives really necessary for stroke prevention since 2022? Looking forward to your sharing the evidence and then slowly tampering it off. Currently complaining of hair fall since January 2025 and painful scalp lesions thought to be pediculosis and folliculitis.
[29-08-2025 12:55] PPM 3: Of course. This is an excellent and very important clinical question. Let's break down the case, review the evidence, and formulate a plan.
### *Executive Summary*
Based on the history provided, the long-term use of prednisolone and mycophenolate mofetil (MMF) for *isolated stroke prevention* is *highly unusual and not supported by international guidelines. Their use would only be justified if a specific underlying inflammatory or autoimmune condition was diagnosed *and that condition itself required immunosuppression.
The current hair fall and scalp lesions are potential side effects of long-term immunosuppression and must be investigated.
---
### *1. Analysis of the Initial Event (Dec 2021)*
The presentation (acute onset unilateral weakness, facial deviation, sensory symptoms) is classic for an *acute ischemic stroke* (likely right middle cerebral artery territory). The fact that she recovered completely in two weeks classifies it as a *Transient Ischemic Attack (TIA)* or a *minor stroke*.
*Key Question: Why was she started on immunosuppressives?*
The standard of care for most ischemic strokes/TIAs is:
1. *Acute management:* Antiplatelets (e.g., Aspirin, Clopidogrel), statins, blood pressure control.
2. *Secondary prevention:* Identify and manage risk factors (hypertension, diabetes, cholesterol, smoking) and initiate long-term antiplatelet therapy or anticoagulation (if atrial fibrillation is found).
*Immunosuppressives (Prednisolone + MMF) are not standard stroke prevention drugs.* Their use strongly implies that her treating physicians suspected a specific *inflammatory cause* for her stroke, such as:
* *Central Nervous System (CNS) Vasculitis:* An inflammation of blood vessels in the brain, which can cause stroke. This requires immunosuppression.
* *Autoimmune Disease:* Conditions like Systemic Lupus Erythematosus (SLE), Antiphospholipid Syndrome, or Sjögren's syndrome can cause hypercoagulability or vasculitis, leading to stroke. These often require immunosuppression.
* *Vasculitis Syndromes:* Like Takayasu's arteritis or Giant Cell Arteritis (though less likely in this demographic).
*Crucial Point:* There is no mention in your history of the diagnostic workup that would justify this therapy. *The necessity of immunosuppressives hinges entirely on whether one of these conditions was definitively diagnosed.*
---
### *2. Evidence for Immunosuppression in Stroke Prevention*
The evidence is clear: immunosuppression is *not* indicated for atherosclerotic or cardioembolic strokes.
* *Guidelines:* Major guidelines from the American Heart Association (AHA) and American Stroke Association (ASA) do not list immunosuppression as a strategy for secondary stroke prevention unless a specific inflammatory condition is identified.
* *Indication-specific evidence:*
* *CNS Vasculitis:* Treatment is *mandatory* and involves high-dose steroids (e.g., prednisolone) and a steroid-sparing agent like cyclophosphamide or MMF. This is a rare condition diagnosed via angiography, MRI, or sometimes brain biopsy.
* *Antiphospholipid Syndrome (APS):* First-line treatment is *anticoagulation (e.g., Warfarin)*, not immunosuppression. Immunosuppressives may be added in refractory cases.
* *SLE:* Management is tailored. Immunosuppression is used to control the underlying SLE disease activity, which in turn reduces stroke risk.
*Conclusion:* Without a confirmed diagnosis of a condition that requires immunosuppression, the ongoing use of prednisolone and MMF since 2022 is *not evidence-based* and exposes the patient to significant unnecessary risks.
---
### *3. Current Symptoms (Hair Fall & Scalp Lesions)*
These are very likely *adverse effects* of her long-term medication:
* *Mycophenolate Mofetil (MMF):* A well-documented side effect is *dose-dependent alopecia (hair loss). It also increases the risk of **bacterial and viral infections*.
* *Prednisolone (a corticosteroid):* Can cause skin thinning, acne, and *impaired wound healing*, making her more susceptible to scalp infections like folliculitis. It also suppresses the immune system.
*Differential Diagnosis:*
1. *Drug-induced alopecia and folliculitis* (most likely).
2. *Secondary bacterial infection* (e.g., staphylococcal folliculitis) due to immunosuppression.
3. *Viral infection* (e.g., herpes zoster or simplex) on the scalp, triggered by immunosuppression.
4. *Tinea capitis* (fungal scalp infection).
5. A new manifestation of the *underlying autoimmune disease* (e.g., disco lupus), if one exists.
"Pediculosis" (lice) is possible but less likely to be directly caused by the medication, though the immunosuppression wouldn't help.
---
### *4. Recommended Plan of Action*
*Step 1: Investigate the Original Rationale*
* *Review the 2021 hospital records.* This is the most critical step. Look for:
* MRI/MRA/CTA of the brain (evidence of vasculitis? multifocal strokes?)
* Blood tests: ESR, CRP, ANA, dsDNA, Antiphospholipid antibodies (Lupus Anticoagulant, Anti-cardiolipin, Anti-β2-glycoprotein-I), ANCA.
* Echocardiogram and carotid Doppler results.
* *What was the documented diagnosis?*
*Step 2: Manage the Current Symptoms*
* *Dermatology Referral:* Essential for scalp assessment. Consider scraping and culture for bacteria/fungus.
* *Treat the infection:* Based on dermatology's input (topical/oral antibiotics for folliculitis, antifungals for tinea).
* *Do not ignore these symptoms.* They are a red flag for medication toxicity.
*Step 3: Re-evaluate Immunosuppressive Therapy & Taper*
*This must be done carefully and under close supervision.*
* *If a specific inflammatory diagnosis is confirmed (e.g., CNS Vasculitis):*
* *Consult a rheumatologist or neurologist.* The current dose may be a maintenance dose, and tapering might still be possible but must be done very slowly and cautiously to avoid relapse.
* The scalp issues may require managing the side effects while trying to maintain the lowest effective dose.
* *If no definitive diagnosis for immunosuppression is found (most likely scenario based on your question):*
1. *Start a very slow taper.* Abrupt cessation, especially of prednisolone, can cause adrenal insufficiency.
2. *Taper Prednisolone first:* Reduce by 1mg every 2-4 weeks until off. Monitor closely for any neurological symptoms.
3. *Then taper Mycophenolate:* Reduce the dose slowly (e.g., by 500mg decreases every 2-4 weeks).
4. *Initiate standard secondary stroke prevention:* Ensure she is on an antiplatelet (e.g., Clopidogrel 75mg or Aspirin 75mg + Atorvastatin 40mg) and that all vascular risk factors (BP, sugar, cholesterol) are optimally controlled.
5. *Close follow-up:* See her frequently during the taper to monitor for recurrence of symptoms and to manage adrenal insufficiency if it occurs.
*In summary, the evidence does not support the use of these drugs for general stroke prevention. The current plan should be to investigate the original reason for their use, treat the current adverse effects, and methodically taper her off these medications while implementing appropriate, evidence-based stroke prevention strategies.*
DeepSeek
[29-08-2025 13:23] PPM 1: Thanks.
Do also check out the data in her initial case reports in the description box here:
@CR do we have a PaJR case report of this patient?
[29-08-2025 13.26] CR: Yes doctor. https://pajrcasereporter.blogspot.com/2025/08/34f-sle-hemiparesis-oct-2021-telangana.html
[29-08-2025 13.40] PPM 3: Of course. Thank you for providing the additional case reports from the blogs. Having reviewed the search results and the detailed initial case reports, I can provide a more comprehensive and evidence-based analysis.
### *Executive Summary & Immediate Recommendation*
Based on the full clinical picture, the long-term use of prednisolone and mycophenolate mofetil (MMF) for *secondary stroke prevention in isolation is not evidence-based and is potentially harmful.* The therapy is only justified if a specific underlying inflammatory condition was confirmed, which the available records do not conclusively support.
The current symptoms of hair fall and painful scalp lesions are *highly likely to be adverse effects* of this long-term immunosuppressive therapy.
The most urgent action is to *review the original diagnostic workup* from 2021. The planned slow taper of immunosuppressants is correct, but it must be done under close supervision while simultaneously initiating standard, evidence-based secondary stroke prevention.
---
### *1. Analysis of the Initial Event (Dec 2021) and Immunosuppressive Rationale*
The presentation (acute left-sided weakness, facial deviation, sensory symptoms) is classic for a right middle cerebral artery territory *ischemic stroke. The complete recovery in two weeks classifies it as a **Transient Ischemic Attack (TIA)* or *minor stroke*.
*Standard Evidence-Based Stroke Prevention (Reaffirmed from search results ):*
The cornerstone of secondary prevention for most ischemic strokes/TIAs is:
1. *Antiplatelet therapy:* Aspirin, Clopidogrel, or a combination.
2. *Statin therapy:* High-intensity statins (e.g., Atorvastatin 40-80mg).
3. *Aggressive risk factor management:* Control of hypertension, diabetes, and smoking cessation.
*Why Were Immunosuppressives Prescribed? The Critical Question*
The prescription of Prednisolone and MMF strongly suggests the treating physicians suspected a *specific inflammatory or autoimmune etiology*, such as:
* *Primary CNS Vasculitis:* An inflammation of brain blood vessels.
* *Autoimmune Disease:* Such as Systemic Lupus Erythematosus (SLE) or Antiphospholipid Syndrome (APS), which can cause stroke.
* *Vasculitis Syndromes:* Like Takayasu's arteritis.
However, *the provided case reports and your summary lack the critical diagnostic evidence* to confirm any of these conditions. There is no mention of:
* *Confirmatory serology:* Strongly positive ANA, high-titer dsDNA, Lupus Anticoagulant, Anticardiolipin antibodies, or positive ANCA.
* *Characteristic neuroimaging:* MRI/MRA/CTA findings suggestive of vasculitis (e.g., multifocal stenoses, vessel wall enhancement).
* *CSF analysis:* Elevated IgG index or oligoclonal bands suggestive of intrathecal inflammation.
*Conclusion on Immunosuppressive Necessity:* Without a documented, confirmed diagnosis of a condition that requires immunosuppression, the ongoing use of these drugs since 2022 is *not supported by international stroke guidelines* and exposes the patient to significant and unnecessary risks.
---
### *2. Evidence from Search Results Against Routine Immunosuppression for Stroke*
The search results consistently reinforce that immunosuppression is not a standard strategy for stroke prevention:
* *Stroke in Women :* This extensive review of stroke risk factors and prevention in women does not list immunosuppression as a strategy. It emphasizes hypertension control, diabetes management, and addressing women-specific factors like pregnancy and hormonal therapy.
* *Stroke in Young Adults :* This review specifically focuses on young adults and states: "Although there are no specific recommendations or guidelines for primary or secondary stroke prevention in young adults, strokes in this population are largely preventable by addressing modifiable risk factors". It discusses PFO closure, managing diabetes/hypertension, and lifestyle changes, but *makes no mention of immunosuppressives*.
---
### *3. Analysis of Current Symptoms (Hair Fall & Scalp Lesions)*
These symptoms are almost certainly *iatrogenic* (caused by the medical treatment).
* *Mycophenolate Mofetil (MMF):* A well-documented, dose-dependent side effect is *alopecia (hair loss). It also significantly increases the risk of **bacterial and viral infections* .
* *Prednisolone (a corticosteroid):* Causes skin thinning, impairs wound healing, and increases susceptibility to infections, including *folliculitis*. It can also cause steroid-induced acne and Cushing's syndrome.
*Differential Diagnosis for Scalp Lesions (from search results):*
1. *Drug-Induced Folliculitis:* The most likely cause. Immunosuppression predisposes to bacterial (e.g., Staphylococcus aureus ) and fungal folliculitis.
2. *Dissecting Cellulitis of the Scalp :* A severe inflammatory condition causing painful nodules, sinus tracts, and alopecia. It is chronic and difficult to treat, often requiring isotretinoin or extensive surgery.
3. *Underlying Autoimmune Manifestation:* If an underlying condition like SLE was present but undiagnosed, these could be cutaneous lupus lesions (e.g., DLE) .
4. *Pemphigus Vulgaris :* An autoimmune blistering disease that can present with scalp erosions and hair loss, often associated with infection.
*Pediculosis (lice)* is possible but less likely to be the primary issue given the context of immunosuppression.
---
### *4. Synthesis with Initial Case Report Data*
The blogged case reports provide more detail on the initial presentation but *do not provide the conclusive evidence needed to justify lifelong immunosuppression*:
* *History:* The patient is a young woman with an acute neurological deficit.
* *Examination:* Confirmed left UMN facial palsy and left upper limb weakness.
* *Plausible but Unproven Autoimmune Link:* Some blogs mention a *history of Raynaud's phenomenon* and *mild anaemia. These are *red flags that could point toward an underlying connective tissue disease (e.g., SLE), but they are *not diagnostic*. Their presence justifies a more extensive workup, not the immediate and indefinite commencement of powerful immunosuppressants without a definitive diagnosis.
* *Missing Data:* Crucially, the results of the autoimmune serology (ANA, APL, etc.) are not reported in the summaries. The outcome of the MRI/MRA is also not detailed. *This is the most critical missing link.*
---
### *5. Integrated Plan of Action*
*Step 1: Immediate Diagnostic Re-evaluation*
* *Retrieve the 2021 Records:* This is non-negotiable. Obtain the full discharge summary, MRI/MRA reports, and all serological test results (ANA, dsDNA, Lupus Anticoagulant, ANCA, etc.).
* *Dermatology Referral:* Essential for scalp assessment. A *biopsy and culture* of a scalp lesion will differentiate between infective folliculitis, dissecting cellulitis , and autoimmune causes like DLE or pemphigus .
* *Baseline Labs:* CBC, LFT, KFT, fasting glucose, lipid profile, and vitamin D/B12 levels before tapering.
*Step 2: Manage Current Symptoms*
* Treat the scalp based on dermatology's input (e.g., topical/oral antibiotics for bacterial folliculitis).
*Step 3: Re-evaluate and Taper Immunosuppressive Therapy*
* *If a specific inflammatory diagnosis is confirmed (e.g., CNS Vasculitis, SLE):*
* Consult a *rheumatologist* or *neurologist*. The current dose may be a maintenance therapy.
* Tapering may still be possible but must be done very slowly and cautiously under specialist guidance to avoid disease flare.
* *If no definitive diagnosis is found (the more likely scenario):*
1. *Initiate standard secondary prevention:* Start *Aspirin 75mg + Atorvastatin 40mg* (if not already on it) and optimize BP control.
2. *Begin a slow taper:* Abrupt cessation can cause adrenal insufficiency.
* *Taper Prednisolone first:* Reduce by 1mg every 2-4 weeks until off. Monitor for headaches or neurological symptoms.
* *Then taper Mycophenolate:* Reduce the dose slowly (e.g., by 500mg decreases every 2-4 weeks).
3. *Close follow-up:* See her frequently during the taper to monitor for relapse of symptoms and to manage adrenal insufficiency.
*Step 4: Long-Term Follow-Up*
* Once off immunosuppressants, monitor her scalp condition. If the hair loss and lesions resolve, it confirms they were adverse drug reactions.
* Continue lifelong annual follow-up for standard stroke prevention.
### *Final Answer to Your Questions*
1. *"Was her immunosuppressives really necessary for stroke prevention since 2022?"*
*No.* Based on the evidence available, the use of prednisolone and mycophenolate mofetil for general stroke prevention is not supported by guidelines . Their use is only justified if a specific autoimmune condition was definitively diagnosed, for which the provided records lack evidence.
2. *"Looking forward to your sharing the evidence and then slowly tapering it off."*
The evidence from major reviews confirms that immunosuppression is not a standard of care for stroke prevention . A slow, careful taper, as you planned, is the correct course of action, but it must be done concurrently with the initiation of appropriate antiplatelet and statin therapy.
3. *"Do we have a PaJR case report of this patient?"*
Based on the information provided and the linked blogs, this case would be an *excellent candidate for a PaJR (Patient Journey Record)*. It highlights a critical learning point: the imperative to base long-term, high-risk treatments on a definitive diagnosis rather than a suspicion. The journey from an acute stroke to an unindicated treatment and subsequent iatrogenic complications is a powerful narrative for teaching rational pharmacotherapy and the importance of evidence-based practice.
No comments:
Post a Comment