35 YEAR OLD FEMALE FEVER WITH ulcers over the body

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

35 year old female, farmer by occupation resident of aakaram came to the general medicine OPD with cheif complaints of fever and ulcers  since 5 days

HOPI:

The patient was apparently asymptomatic up until 5 days ago when she  developed low grade fever  sudden in onset , continuous in nature relived on medication h/0 of malaise not associated with chills,sweating, dizziness, fatigue and body pains, nausea, vomiting , sensitive to light 

Second day after onset of fever she went to her farm for work in the early morning and injured her left toe while spraying fertilizer . From third day she noticed progressive painful lesions appearing on both lower limbs and upper limbs chest and neck . Not associated with loss of sensation, itching, joint pains.

Difficulty in swallowing and burning sensation in the mouth post consumption of food due to small ulcers in the mouth

No complaints of headache, burning micturition, giddiness, chest pain, shortness of breath, palpitations, cough ,insomnia, loose stools, loss of appetite. 

History of usage of semecarpus anacardium for one day. Following which she went a local practitioner and was prescribed an tablet containing  deflazocort 6mg for five days itraconazole ,tofloxacin, orividazole, clobetalol propionate, and megaheal ointment for five days.

Daily activities:

wakes up at 5 am does household chores till 9am goes to farm and comes back by evening 5pm, cooks food, have dinner and go to bed by 9pm. 

PAST HISTORY:

NO h/o hypertension, diabetes,asthma, epilepsy, tuberculosis

No known allergy 

TREATMENT HISTORY : History of psoriasis vulgaris from 2 years for which she used tab methotrexate 7.5mg BD for one month and capsule itraconazole.

PERSONAL HISTORY:

Appetite: decreased

Diet:mixed

Sleep: adequate

Bowel and bladder are regular

Patient denies of any addictions

FAMILY HISTORY:

no history of similar complaints within the family

General examination

Pallor: absent

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

SKIN :hyperpigmented macules and ulceration All over the body 

Local rise in temperature present 

Vitals:

Temp: afebrile on time of examination 

BP 110/70

Heart rate 110 bpm

Resp Rate 16/min

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM 

I: Chest bilaterally symmetrical, all quadrants

moves equally with respiration

P: Trachea central, chest expansion normal

P: Resonant

A: B/l equal air entry, no added sounds 

CVS EXAMINATION:

I: No precordial buldge. Apical impulse

visible, Venous prominence

P: Apical impulse, No palpebral pulsation.

thrill

A: S1 S2, No murmur

ABDOMINAL EXAMINATION:

Abdomen is soft and non tender

No organomegaly

No shifting dullness

No fluid thrill

Bowel sounds heard

ABNORMAL INVESTIGATION FINDING

1) TOTAL PROTEIN AND ALBUMIN  slightly decreased 

2)RAISED ESR (however crp Seems to be normal)

Fever chart

BLOOD UREA LEVEL 

LIVER FUNCTION TEST 

CBP-pancytopenia

SERUM CREATININE 

ESR

COMPLETE URINE EXAMINATION 

Ecg-normal sinus rhythm 

2d echo

DIFFERENTIAL -

Pancytopenia with Methotrexate toxicity

? systemic lupus erythematus (anti phospholipid antibody)

TREATMENT

Tab.augmentin 625 po/bd

Tab dolo 650 mg

Tab.folic acid

Follow up

1/1/2023

S:

No fever spikes 

O :

Pt is 

conscious,coherent,cooperative

BP - 110/70mm Hg

PR - 80 bpm

Temp - 97.3F

Grbs: 91 mg/dl

Skin : hyperpigmented ulcerations + macules all over body 

Local rise of temperature: + 

Non pitting type of pedal edema +

CVS - S1,S2  heard , JVP not rised, no added sounds ,apical impulse present 

RS - BAE + , NVBS

PA - soft ,NT, BS +

CNS - NFND

A : 

Pancytopenia secondary to methotrexate toxicity 

P:

Tab. Tab Augmentin 625 mg / Tid (D3)

Tab. Dolo 650 mg po/bd

Fudic cream L/A bd for 1 week

Tab folinic acid 15 mg / bd

2/1/23

S: itching present

O: consious coherent cooperative

Bp 120/80mm hg

PR:82/min

Cvs -s1 s2 heard

Abdomen soft

Cns no focal deficit

GRBS-120MG/DL

Input 900ml output 300ml

A: Pancytopenia secondary to methotrexate toxicity

P:

Tab. Tab Augmentin 625 mg / Tid (D3)

Tab. Dolo 650 mg po/bd

Fudic cream L/A bd for 1 week

Tab folinic acid 15 mg / bd

Discussion 

https://www.cureus.com/articles/54681-methotrexate-toxicity-a-simple-solution-to-a-complex-problem

Learning point

In case of methotrexate toxicity,stop taking drug and give iv infusion with leucovorin and glucarpidase with folic acid supplementation 

There are mainly two reasons for methotrexate toxicity -1.overdosing

2 . generally methotrexate given with folic acid supplementation , patient may confuse and take methotrexate in place of folioc acid PO BD dose

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038108/#:~:text=%5B1%5D%20Cutaneous%20ulceration%20has%20been,reported%20in%20patients%20with%20psoriasis.

https://www.researchgate.net/publication/309750451_Mucocutaneous_Ulcerations_and_Pancytopenia_due_to_Methotrexate_Overdose