A 40 year old female with recurrent fever

A 40 year old female with recurrent fever, Infective endocarditis

1. Dr. Al Hadi Mohammad MD phase –A (Neurology) Department of Internal Medicine Orchid unit, BSMMU A 40-Year-Old Woman with Recurrent Fever

2. Particulars of the patient Name : Shahima Age: 40 years Religion :Islam Occupation :Homemaker Marital status : Married Address : Jhinaidaha Date of Admission :06/10/2022

3. Chief complaints Recurrent Fever for 3 Month Multiple Rash in The Body for 15 days Pain and Swelling of Multiple Joints for 15 days

4. Background History Diagnosed as a case of Rheumatic fever at the age of 8 Has been suffering from palpitations ,dyspnea ,orthopnea for the past 10 years

5. Background History Diagnosed as a case of Chronic Rheumatic Heart Disease with severe Mitral Stenosis on June 2022 in NICVD Underwent PTMC on 19.06.2022

6. Chief complaints Recurrent Fever for 3 Month Multiple Rash in The Body for 15 days Pain and Swelling of Multiple Joints for 15 days

7. History of present illness Recurrent Fever 3 months High Grade Continuous Chills and Rigor and profuse sweating Highest recorded Temperature 105⁰F Subsided by Oral Paracetamol Fever lasts for 10-15 days with 3-5 days Apyretic period

8. Not associated with Night sweats Evening rise of Temperature

9. Skin rash Multiple Erythematous Palpable Painful Variable in size and shape Non itchy Involving both lower limbs , buttock, both upper limbs

10. Joint pain 15 days Acute onset Gradually progressive Symmetrical Involving both wrist joint, knee joint, ankle joint Inflammatory in nature

11. On query- Occasional palpitation and shortness of breath on Moderate exertion Relieved by taking rest No diurnal variation

12. There is no history of- Loss of consciousness Loin pain, passage of high colour urine Significant hair loss, photosensitivity, oral ulcer, change of colour of fingers upon exposure to cold Dental procedure Intravenous drug abuse PTB or contact with smear positive PTB patient

13. Family History No H/O such illness in her family

14. Treatment history Year Medication Duration Compliance 2022 Tab Metoprolol(25mg) Tab Phenoxymethyl Penicillin (250mg) Tab Furesemide+Spironolactone (20/50 mg) 4months Regular Good

15. Gynecological and Obstetric history Married Age of Menarche:13years LMP:28.09.2022 Menstrual period:3-4days Menstrual cycle:28-30days Menstrual flow: Average

16. Vaccination history Covid 19 vaccine 3 dose Immunized as per EPI schedule

17. General examination Patient is conscious, co operative Decubitus :on choice BMI:20kg/m2 Mildly anemic, non icteric, bilateral pedal edema present Multiple purpuric rash of variable size involving both lower limb ,buttock, both upper limbs, palpable, painful No clubbing, cyanosis, Koilonychia, Leukonychia No lymphadenopathy, Thyroid gland is not enlarged No splinter hemorrhage, Oslers nodule, Janeway lesion Pulse-110/min, BP- 90/60mmHg, Temperature 103⁰F

18. G/E:contd Bed side urine for proteinuria is positive Other general examination findings are within normal limit

19. Systemic examination Cardiovascular System Examination- Pulse-110/min, BP- 90/60mm Hg, JVP not raised, All peripheral Pulses are present Precordium - There is no visible impulse Apex beat left 5 th intercoastal space 8cm from mid sternal line First heart sound is loud in all area, there is a mid diastolic murmur best heard in the mitral area Low pitch , localized, rough, rumbling ,grade 3/6, best heard with the bell of the stethoscope in left lateral position with breath holding after expiration.

20. Muskuloskeletal system Gait: Normal Arms: Grade 2 tenderness in both wrist and both elbow joint Legs: Swelling and grade 2 tenderness in both knee and both ankle joints Spine: Normal

21. Other systemic examination : Other systemic examination reveals no abnormality

22. Clinical diagnosis : Provisional Diagnosis : Chronic Rheumatic Heart Disease with Mitral Stenosis with post PTMC state with Infective Endocarditis Differential/Diagnosis : SLE with vasculitis HSP

23. After Admission

24. Investigations: CBC on 06.10.22 Result Hb% 11.1gm/dL ESR 40mm in1st hour WBC 11,500 /mm 3 Platelets 2,20000/mm 3 RBC indices MCV 67 fl MCH 21.8 pg MCHC 32.6g/L RDW 17.2% CBC on 06.10.22 Result Neutrophil 84% 8,500 /mm 3 Lymphocyte 22% 2530/mm 3 Monocyte 3% 460/mm 3 PBF RBC- Microcytic hypochromic WBC- Neutrophilic leucocytosis Platelet- normal Comment :Microcytic hypochromic anemia with Neutrophilic leucocytosis

25. Urine RME (on 6.10.22) Protein ++ Sugar Nil Microscopic examination Pus cell 25-30 /HPF Epithelial cells 1-3/HPF RBC 15-20 / HPF Investigations

26. Investigations on 06.10.22 Name of test Result CRP 143 mg/L ANA Negative Anti Ds-DNA Negative cANCA Negative pANCA Negative

27. Investigations on 06.10.22 Name of test Result S. Creatinine 2.42 mg/dL FBS 4.9 mmol/L S. Electrolyts Na + K + Cl 123mmol/L 3.6 mmol/L 87 mmol/L

28. Blood for CS- Micrococcus luteus

29. Urine for CS- E. coli

30. ECG: Normal

31. Trans Thoracic Echocardiogram- Mild to moderate mitral stenosis with trivial MR No vegetation is seen

32. Trans-esophageal echocardiogram pending

33. Empirically treated with- Inj. Meropenam (500mg) I/V 8 hrly Inj. Linezolid (600mg) I/V 12 hrly

34. Investigations: CBC on 19.10.22 Result Hb% 8.6 gm/dl ESR 45mm in1st hour Platelets 2,75000/mm 3 RBC indices MCV 69.4 fL MCH 21.8 pg MCHC 31.4 g/L RDW 17.9% CBC on 19.10.22 Result WBC 4,500/mm 3 Neutrophil 66% 2970/mm 3 Lymphocyte 27% 1200/mm 3 Monocyte 5% 230/mm 3

35. Urine RME (on 12.10.22) Protein Nil Sugar Nil Microscopic examination Pus cell 1-5/HPF Epithelial cells 1-3/HPF RBC Nil Investigations

36. Investigations on 17.10.22 Name of test Result S. Creatinine 1.6 mg/dL CRP 16.4 mg/L S. Electrolyts Na + K + Cl 137mmol/L 4.0 mmol/L 101 mmol/L

37. Pending Investigations- Trans esophageal echocardiogram Skin biopsy and histopathology

38. Final diagnosis

39. Current Medication Inj. Meropenam (500mg) I/V 8 hrly Inj. Linezolid (600mg) I/V 12 hrly Tab spironolactone (25mg) 1+0+0 Tab Metoprolol (25mg) 1+0+1

40. Follow up Fever has subsided Skin rash resolving

41. Problem List What is the diagnosis? What further investigations can be done? Need for any Anti thrombotic prophylaxis

42. Thank You