SpA axial and peripheral with nonspecific colitis.pptx

A 50 year old diabetic man with Multiple joint pain and peripheral neuropathy

1. A 50 - Year -O ld Diabetic Man with Multiple Joint Pain And Peripheral Neuropathy Dr . Md Jubayer Abedin Mallik MD Phase A ( Pulmon ology) BSMMU Internal Medicine-orchid unit

2. Particulars of patient Md Mustafizur Rahman 50 Years Diabetic Teacher Hailing From : Sirajganj Date Of Admission: 03/10/22

3. Chief complaints Recurrent joint pain for 6 years with last episode for 3 months Burning sensation in both lower limbs for 3 months Weight loss for 1 year

4. Presenting illness Multiple Joint pain 6 years ,markedly increased for 3 months Insidious onset Gradually progressive Asymmetrical Involving SI joint, DIP, PIP, MCP, wrist joint, knee joint, ankle joint Difficult to perform daily activity More marked at morning & rest Morning stiffness more than 1 hour Improve partially with activity or NSAID He feels difficulty in bending forward

5. Not associated with Rash Nail change Urethral discharge Painful red eye Dysuria Raynaud’s phenomenon

6. Burning sensation Lower limbs Involving below the knee Persist through day and night Progressively increasing Associated with sleep disturbance No significant aggravating or relieving factors

7. Weight loss 29kg in last 1 year Unintentional Inspite of good appetite At this time he was diagnosed as a case of DM

8. On Query He feels dizzy on standing from sitting position Generalized weakness for last 2 months

9. DM for 1 year Initially poorly controlled In last one month good controlled with oral medication No h/o hypoglycemic or hyperglycemic event

10. He had diarrhoea 2 months back 6-8 times Small to moderate ammount Semisolid Not mixed with blood/ mucous Colicky abdominal pain periumbilical 10-20 minutes each time Increased after taking food Relieved spontaneously or taking anti- spasmotic

11. Diagnosed as Ulcerative Colitis

12. Complete Blood COUNT: 27/05/22 03/07/22 31/07/22 09/08/22 Hb-14.3g/dl ESR-64 WBC-9.83x10^9/cum N-69% Platelet-417x10^9/ cumm MCV- 86.6 fl MCH- 28.6 pg Hb-10.2g/dl ESR- 101mm WBC- 18,900/ cumm N-79% Platelet-4,50,000 MCV-82.3 fl MCH- 27.3 pg Hb-8 gm/dl Hb-9.6 g/dl ESR- 32 Wbc-3.1x10^9/ cumm N-69% Platelet: 3,82000/ cumm Mcv-87 fl MCH-30 pg

13. CRP 24mg/l (03/07/22) 52mg/l ( 16/08/22) s. creatinine 0.9 mg/dl S. Albumin 3.3 09/08/22 s. Bilirubin 0.7mg/dl SGPT 11u/l HBA1C 12.5% ( 27/11/21) 10.72 %( 27/05/22) 7.6% ( 03/07/22) S. Electrolyte Na:137 K:3.2 ( 27/08/22) Na:135 K :2.9 (07/08/22) Na: 137 K: 2.2 (05/06/22) Iron profile S.Iron: 17.6umol/l, S.Ferritin: 1638.5, , TIBC: 19.4umol/l, Tsat- 90% 10/08/22 Stool R/E Pus cell: plenty 10/08/22 Stool c/s no growth

14. Faecal Calprotectin 336 ug/g 10/08/22 Clostridium difficile by RT PCR negative HBsAg Anti HCV HIV Negative Negative negative 10/08/22 S.TSH 1.07 ui /l 10/08/22 Xray L/S spine Both view spondylosis with discitis with B/L sacroiliitis 03/06/22 Colonoscopy The mucosa of the colon including rectum appears congested, oedematous , bleed to touch with continuous ulcers involving the left colon Histopathology Chronic Non Specific ulcer Colonoscopy normal colorectum and terminal ileum 21/08/22 Endoscopy normal upper GI endoscopy 21/08/22 MR Abdomen wall thickening with luminal narrowing in terminal ileum involving IC junction 25/08/22

15. Colonoscopy Comment: Feature suggestive of Ulcerative Colitis

16. Past history H/O Fournier’s gangrene operation on 21.11.21 H/O cholecystectomy on 21/05/22

17. Drug History Tab. Azathioprine 50mg 1+0+1 One and half month Tab. Prednisolon 20mg 2+0+0……14 days 1+0+0…. 7 days 21 days Tab. Mesalazine 400mg 2+2+2 On going Cap. Pregabalin 50mg 1+0+1 On going

18. Deflazacort 6mg Ireegularely taking in last 6 years Last taking 2 months back NSAID Irregularely taking Tab. Empagliflozin/ linezolid (10/5) 1+0+0 On going

19. General Examination Ill looking Co-operative. Whitish ,greasy, scaly lesion in scalp and eyebrow Onychomycosis in finger and toe BP- 90/7 mmHg (on lying flat) 60/40 mmHg ( on standing) Pulse- 100 / min ( Feeble) Temperature-97°F RR-1 5 /min Lymph nodes: not palpable JVP: not raised No thyromegaly

20. Systemic Examination Musculo-Skeletal Examination : Look: no joint swelling Feel: B/ L DIP, PIP, MCP, joint tenderness MRC grade 2 B/L wrist, elbow, knee, ankle joint tenderness MRC grade 1 Move: pain in passive movement of B/L wrist, ankle joint SI joint examination: Tenderness over the SI joint Compression and Distraction test positive Modified Schober test: positive

21. Systemic Examination Nervous System: Higher psychic function : normal Fundoscopy: Normal B/L cataract present Lower Limb Examinatio: Inspection : Symmetrical wasting on proximally striae present, no fasciculation Bulk : Reduced symmetrically both proximally and distally Tone : Normal Power : MRC grade 4/5 proximally 4/5 distally Reflex : Knee jerk: absent bilaterally Ankle jerk: present Planter: flexor

22. Co-ordination : normal Romberg's : Absent Gait : normal Sensory examination : vibration sense lost upto medial malleolus on both side other modalities normal

23. Other systemic examination Revealed normal

24. Provisional Diagnosis DM with Peripheral Neuropathy 2° Adrenal Insufficiency due to axis suppression (due steroid withdrawal) Peripheral Arterial Disease Seborrheic Dermatitis Ankylosing Spondylitis ( axial and peripheral involvement) with Non-Specific Colitis

25. Differential Diagnosis For Polyarthritis Enteropathy Associated Arthritis Psoriatic Arthritis

26. Investigations

27. After Admission

28. CBC Hb-11g/dl ESR-25 WBC-10.5x10^9/cumm N- 64% Platelet- 3,50,000/cumm MCV-96.1fl MCH-30.1pg CRP 37.8mg SGPT 11 U/L S. Creatinine 0.56ug/dl S. Electrolyte Na: 138 Na: 142 K:3.1 (03/10/22) K:3.6 (10/10/22) Cl: 103 Cl: 106 S.Mg 1.7mg/dl S. Albumin 26 g/l Corrected Calcium 8.3mg/dl Urine R/M/E Sugar +++ Sugar +++ Pus cell- plenty/hpf( 03/10/22) Pus cell: 2-4/hpf (10/10/22) Lipid Profile Total Cholestrol : 121 mg/dl Triglyceride :276mg/dl HDL : 19 mg/dl LDL :47mg/dl

29. s Urine C/S No growth MT test Negative (0mm) HBA1C 5.3 S. Vitamin B12 1035 pg /ml (290-980) RA Negative Anti CCP Negative (<1.5u/l) HLA B27 Positive Basal Cortisol 41.8 mmol/l (101.2-690 mmol/l) S. ACTH 44.7 pg/ml (8.3-57.8pg/ml) USG of W/A 1.Coarse hepatic parenchyma 2.Left renal cortical cyst Chest Xray P/A View Nomal Xray SI joint Modified Ferguson View B/L Sacroilitis ( Grade 4)

30. Referral Note From Rheumatology: Probably a case of Ankylosing Spondylitis with Non-Specific Colitis From Gastro-enterology: probably a case of Non- Specifoc Colotis From Skin and VD: This skin lesion is Seborrheic Dermatitis with Onychomycosis

31. Problem List Is It Ankylosing Spondylitis or Enteropathic Arthritis? Choice of DMARD? Cause of weight loss of 29 kg in 1 year?

32. Current Medication Tab. Aspirin 75mg 0+1+0 Tab. Sulfasalazine 500mg 0+0+1…7 days 1+0+1….7 days 1+1+1…7 days 2+0+2…continue Tab. Etorix 120mg 0+0+1 Tab. Cholecalciferol 1000IU 0+1+0

33. Tab. Prednisolone 20mg……7 day 17.5mg…. 7 days 15mg……7 days 12.5mg….7days 10mg………7 days 7.5mg…….7 days 5mg………7 days

34. Thank You