Saturday, November 12, 2016

A 40 year old woman with ulcerative lesions over skin and mouth by Sumedha Dhar, 3rd Semester, MBBS


This is a HIPAA de-identified open-online-patient-record posted here autumn 2016 after collecting informed patient consent (form downloadable here ) by Sumedha Dhar, 3rd Semester, MBBS, WBUHS, West Bengal 

A 40 year old woman presented with numerous erosions on her face,neck and eyes. She also presented erosions inside her mouth and complained of increased salivation with difficulty in swallowing associated with a burning sensation on trying to swallow food.
Her medical history showed similar case a about 8 months back when she was admitted to the female ward on reference from the Dermatology department after pemphigus vulgaris was suspected and she was treated after which her conditions improved and she was discharged to home care. ( Editor's/Facilitator's note to history taker: Sumedha please let us know how the diagnosis in her case was confirmed).

On investigation Type2 Diabetes mellitus was also detected.
She was absolutely well for 3-4 months,when again one day she noticed some small eruptions on her back which looked like those of chicken pox. Gradually these eruptions kept spreading on her upper part of chest,neck,then her face and buccal cavity and finally her eyes. These eruptions burst with pus like discharge that had burnt smell.

This time the condition worsened as there was inflammation over her eyes and she couldn't open them which was not present in the previous episode of pemphigus.She initially had complained of pain associated with itching, but at present has no such complains.

She was treated with Dexamethasone,10℅light liquid paraffin,clobetasol and gentamicin.

Sumedha What was/is being done for her diabetes?


As we wait for Sumedha to find out how the diagnosis was confirmed in our patient we can take a look at how the usual pemphigus vulgaris patient's skin looks under the microscope? Here's an illustrative image borrowed from:

Conversational Clinical decision support: 

Rakesh Biswas Nidhi you may know Arijit who would have been your colleague in Manipal around 2004 and is currently my Dermatology colleague here in IQ city Medical College, Durgapur. 
Nidhi Agarwal Thanks for introducing Rakesh sir , I didn't know Arijitearlier but some time back we got introduced to each other in a common dermatology forum through FB 😊

Sir this one of the very few Dermatological emergency cases which need to be closely monitored and yes DCP threapy or if patient or hospital can afford then Rituximab can be started..

Biopsy should be done and one sample should be sent for DIF
Rakesh Biswas
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Boudhayan Dm Arijit Ray Your thoughts on this patient of yours in view of student learning. Sangita Chaudhuri Boudi if u could kindly share ur experience and some of ur papers on managing this patient
Ananya Chakraborty Must congratulate you guys for this initiative and support to your students
Ananya Chakraborty Am adding few of our motivated students Boudhayan
Rakesh Biswas Dr Ananya, Hope to collaborate with you on a project in "Patient centered pharmacology."
Arijit Ray This is a suspected case of Pemphigus Vulgaris.. histopathology (skin biopsy) couldn't be done, as we couldn't get a Fresh Blister...few lesions are vegetative (thick areas); which is also suggestive of Pemphigus vegetans (variant of pem. Vulgaris)
Nidhi Agarwal Arijit when you do biopsy , take two sample second from the edge and do send it for DIF
Arijit Ray Mam..DIF is not available
Rakesh Biswas
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Arijit Ray Pemphigus Vulgaris is a autoimmune blistering disorder....mucosal (oral, genital) involvement is must along with cutaneous involvement
Arijit Ray Clinical presentation - Flaccid blisters followed by Erosions...NIKOLSKY sign : positive (on pressure there is skin/Epidermal detachment)...
Boudhayan Dm Well I have to review the patient tomorrow..........In view of the feeding difficulties and also because she is on steroids Started her on Insulin....Need to review tomorrow and titrate her dose.....Also need to review her Chest X ray as there was a suspicion of associated lower respiratory tract infection..........In view of all the factors Insulin is the safest and best drug to use in this case at least for the time being............Ananya Chakraborty Maam could u kindly help us with association of Oral Hypoglycemic agents and Pemphigus worsening
Boudhayan Dm Angira Dasgupta For the UG students could kindly discuss the importance of cough in the background of Pemphigus on steroids ....Could u kindly discuss the bedside approach to a patient with COUGH and the necessary clinical methods of the Respratory system examination with links to appropriate videos......Also could u kindly throw light on the the management Strategies...........Ananya Chakraborty Maam could u kindly discuss the pharmacology behind cough medications and the approach to Rx - application/ clinical pharmacology .... Prasanna Datta Request our ENT specialist to kindly throw light on her findings and the possible modalities of Rx from the ENT perspective
Boudhayan Dm Ananya Chakraborty Maam for the UGS (mostly 3rd term )could u kindly teach the UG students abt STEROIDS and the various immuno modulatory agents
Prasanna Datta In this case the mouth opening of the patient is poor(trismus grade 3), the oropharynx cant be examined properly. On auscultation the patient is having creps in chest. So most likely the cough is due to chest infection. Also the patient should be given an anti reflux medication coz gerd also aggravates cough.also a ct pns should be done to rule out the post nasal drip(to rule out sinusitis) as a cause of cough.thats all from ent side.
Boudhayan Dm Dr Prasanna Datta Could you kindly teach the UGs abt Trismus ...... it's grades of severity...... it's assessment and if possible could you kindly attach video links so that they can see and learn ...... A warm welcome to You
Prasanna Datta Its a screen shot
Rakesh Biswas
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Boudhayan Dm For UG students : Pemphigus article
Pemphigus is an uncommon autoimmune blistering disease, mediated by antibodies directed against…
Boudhayan Dm A link for UG students to know more abt Insulin
Information architecture, Web Design, Web Standards.
Boudhayan Dm Ananya Chakraborty Maam sharing an article for the UGs on Insulin..........Kindly give them an insight into the possible qs they might face in the theory and practical exam from the topic of Insulin so that they are ready for their exam also during this patient centred learning
Boudhayan Dm COUGH management
Cough is one of the most common symptoms for which patients seek medical attention from primary care…
Boudhayan Dm Now we have been talking abt possibility of hypertension in this patient. Here is a link to how to check BP
Videos in Clinical Medicine from The New England Journal of Medicine — Blood-Pressure Measurement
Boudhayan Dm Here is a guide to Dermatology exam basics........ Arijit Ray Sangita Chaudhuri Could u kindly share the examination methods videos with our UG students
Boudhayan Dm Arijit Ray Ananya Chakraborty Sangita Chaudhuri Could u all kindly highlight the precautions or contraindications or restraint you exercise while using Antibiotics for secondary infections in these patients...... UG students can start reading the antibiotics general chapter in KD Tripathi in relation to this patient
Rakesh Biswas Thanks Boudhayan for all those links for the students. I hope they are not too overwhelmed with information overload. 
Boudhayan Dm Load for the entire week as I will be busy with World Diabetes Day programme over the next one week
Rakesh Biswas AdwayaAadiptaSumedhaBimlesh add all your batch-mates here so that the load can be balanced. 
Rakesh Biswas
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Rakesh Biswas Boudhayan your evening round inputs on this patient for the benefit of the treating team Arijit et al and our students particularly with respect to her respiratory tract issues and insulin issues?
Sumedha Dhar She is recovering of her lesions and could open her eyes
Boudhayan Dm Arijit Ray The patient is being switched to Oral Prednisolone 50 mg daily once...........Well it would be nice if we could discuss the steroid equivalent dosing............I will try to post a chart comparing Dexamethasone vs Prednisolone
Boudhayan Dm This will help us determine the Insulin dose tomorrow. Patient has been on Dexamethasone so far .....SO 1.5 mg Dexa equivalent to 10 mg of Prednisolone. Dexa is long acting and Prednisolone Intermediate acting. Now 50 mg of Prednisolone will be equival...See More
Boudhayan Dm Will request my seniors Milind Patil Karthik Balachandran Rajan Palui Kaushik Biswasto throw light on these equivalent changes of Steroids and to explain the role of each steroid on Glycemic control in terms of the rise and fall during various times of the day
Boudhayan Dm For the 3rd semester students I would also invite DrAnanya Chakraborty to kindly throw light on the Pharmacology of Steroids
Arijit Ray Pt. was having 2 ampules of Dexamethasone
Boudhayan Dm Arijit Ray So 16 mg of Dexamethasone......... Will it possible to explain to the students why we make this switch from Injectable to oral and vice versa and how do we exactly decide upon the dose
Arijit Ray As the severity has decreased, so I decided to shift from Injectable to Oral...
Rakesh Biswas
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Boudhayan Dm Angira Dasgupta maam would invite your comments and analysis on the approach towards a patient with Pemphigus on Azathioprine and Steroids presents with cough what should be the approach towards evaluation and treatment
Boudhayan Dm Ananya Chakraborty Maam can we go into the depths regarding how the two different steroids Dexamethasone and Prednisolone affect glycemic control. Karthik Balachandran Sir could we have ur inputs regarding the temporal relationship of steroid administration and glycemic deterioration
Boudhayan Dm Dr. Sunny Sengupta Amit Kumar Deb Shreshth ShankerWelcome all to the discussion. The patient's primary concern is loss of vision completely. Cornea is in a bad shape and she has been advised Keratoplasty from a higher centre..........Her Pemphigus / Diabetes / HTN is no longer her concern( The difference between what patient perceives as important and what doctors from various depts seeing her perceive as important) HOW SHOULD WE GO About it.......... In terms of Diabetes Control introduction of Metformin ( as active infection is not suspected presently) has led to nice glycemic control with reduction in Insulin doses with CBG s mostly between 100-200 yesterday. Karthik Balachandran Soumik Goswami Your views regarding the optimum time of introduction of Metformin in such scenarios. Would request Dr. Arijit Ray to discuss the present status of the patient and the planned course of action in the patient.
Boudhayan Dm Arijit RayRakesh BiswasPrasanna Datta As patient and her relatives were reluctant abt Insulin usage at home....So she had to be dicharged on OHA's ....expecting her sugars to remain on the higher side .....Patient will follow up in Dr. Rakesh Biswas Sir's OPD soon with SMBG readings....The dose can be changed accordingly

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