IgA vasculitis (A Case Presentation).pptx

IgA vasculitis

1. CASE PRESENTATION DR BILAWAL RESIDENT DERMATOLOGY

2. HISTORY 36 Years old female known case of DM since 10 years (uncontrolled), resident of Karachi, presented to skin OPD CHK with complains of Skin rash on both legs for 2 months Ulcerated lesions on feet for 1 week

3. HOPC According to my patient she was in her normal state of health besides Diabetes mellitus (for which she was non compliant to medications) developed skin rash 2 months ago initially on chest followed by abdomen and lower limbs. The lesions were non itchy red colored spots. Later she developed similar lesions over the dorsum of feet which were itchy and became ulcerated with pussy discharge and burning pain. At the time of presentation however the rash over trunk had been faded.

4. CONT… She remembers net like pattern of discoloration over the legs which persisted for one week. She also complained of two episodes of joint pain including knee and ankles. She denies any history of fever, photosensitivity or oral ulcers. There was no history of abdominal pain, melena, hematuria or frothy urine.

5. SYSTEMIC REVIEW = E xertional SOB when going upstairs PAST MEDICAL = History of D&C 1 year back. DRUG HISTORY = Tab metformin 500mg BD and Tab Glicalizide 30mg OD.

6. EXAMINATION Middle aged lady of average height and weight oriented with surroundings with normal vitals. There was no pallor, jaundice , cyanosis, clubbing or edema. JVP not raised, lymph nodes were not palpable and thyroid was not enlarged. PERIPHERAL PULSES WERE PALPABLE

7. SKIN EXAMINATION There are multiple well-defined erythematous ulcerated plaques of variable sizes and shapes present bilateral symmetrically on the dorsal aspect of feet . The borders of these ulcerated plaques are slopping with violaceous margins, having slough on the base, no temperature gradient and no active discharge . Palpable Purpura are present on the extensor aspect of bilateral legs. On diascopy test these are non blanching.

8. DIFFERENTIALS? Small to medium vessel vasculitis ANCA associated vasculitis IgA vasculitis Cutaneous PAN ?? Vasculitis secondary to CTD Lupus vasculitis Rheumatoid vasculitis

9. INVESTIGATIONS HB 11 TLC 13.9 PLT 456 CRP 44 RBS 439 HBA1C 16.2% VIRAL MARKERS WERE NON REACTIVE UREA & CREATININE , LFTs WITHIN NORMAL RANGE

10. Cont.. ANA +++ with homogenous pattern. Anti dsDNA negative ENA profile negative C3 & C4 normal c-ANCA and p-ANCA negative Urine DR = Glucose 3+ Protein 2+ LIPID PROFILE = Raised T riglycerides ULTRASOUND DOPPLER = No arterial insufficiency and no evidence of DVT

11. Chest X-ray normal X-ray paranasal sinuses normal Echo was normal with ejection fraction of 60%

12. HISTOPATHOLOGY Sections examined from skin biopsy show an intact epidermis with overlying orthohyperkeratosis . Underlying dermis shows dense perivascular mixed inflammatory cell infiltrate including neutrophils which is infiltrating into the walls of small sized vessels . Foci of karryorhectic debris and fibrinoid necrosis of the vessel walls are also seen. IMF was done on fresh tissue and showed positivity of IgA in vessel walls, while rest of the panel was negative.

13. FINAL DIAGNOSIS IgA vasculitis

14. MANAGEMENT Tab deltacortil 5mg 4+2 Imuran 50mg bd Inj Tanzo 4.5gm iv tds Inj Insulin 70/30 32units@morning 20units@night along with regular insulin on sliding scale. Inj tramal with metacolon iv tds Wound hygiene and topical care. Pulsed Inj methylprednisolone 1gm iv od for 3 days