Medicine e-log: Long case elog

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A CASE OF RECURRENT MULTIPLE SKIN ERUPTIONS

A 23 year old lady,Psychologist by Occupation, resident of Nalgonda Came to the OPD with

Chief complaints of - Multiple small Painful red colored skin eruptions over the upper and lower limbs and back of the trunk since 8 months

History of presenting illness

Patient was apparently asymptomatic 8 months ago and then she developed multiple small red Palpable eruptions on both lower limbs which were not associated with Burning or itching sensation . After 1 week She developed Occasional Burning over the lesions. She consulted a local dermatologist where she was prescribed antihistamines and was asked to avoid oily foods and vit. C and the lesions didn't subside. So she was referred to another Hospital where she was diagnosed with HENOCH SCHONLEIN PURPURA

Investigations done were - CUE, ASO TITRE, ESR, RFT, Serum Bilirubin which were normal.

Diascopy showed Non blanchable palpable erythematous Purpura

Medications -

Antihistaminics[Tab. TECZINE 5 mg]
Calosoft lotion
Halovate lotion

After 1 week new purpuric lesion started to develop Over the thighs

Investigations : Serum Creatinine and Uric acid were normal

Medications

OMNACORTIL 20mg
PANTOP 40 Mg

After 2 Weeks she had history of travel for 3 days during which she developed

painful Soles

On the next day She presented with increased number of purpuric lesions over both the legs and hands and back of the trunk associated with pain, itching and Burning Sensation

H/o Joint pains initially in the left wrist later Progressed to left elbow

She had Pedal edema and Pain in the lower limb

Investigations -

Haemogram showed normochromic normocytic Blood Picture with Neutrophilic leucocytosis

Medications - Tab. ZERODOL and Tab. SHELCAL

After a week She presented with Weight gain of 5kgs in a week and Facial Puffiness. On Examination, Striae were Seen on legs and thighs and few purpura located Over thighs, legs and dorsum of Hand

Advised to Consider using immunosuppressants and taper steroids.

Steroid dose was reduced from 20 mg to 15 mg

Tab. METHOTREXATE 2.5 mg test dose was given

Tab.FOLIC ACID 5mg on a day other than Methotrexate

After 10 days She complained abdominal pain which improved by next morning and Methotrexate dose was increased to 7.5 mg and FUDIC CREAM Was prescribed

On follow up after a week She was found to tolerate the dose of Methotrexate well with reduction in number of new lesions and the above drugs were continued with addition of MOISTUREX Soft cream

4 days later improvement was Seen with mild pain on both the soles (reduced in intensity)

Methotrexate dose was increased to 10 mg
folic acid on the day other than Methotrexate
Tab. ZERODOL P(SOS)
Tab. MVT

on follow up after a week Improvement was seen with a Cummulative dose of 30 mg and She Complained of mild itching and Burning Sensation over pubic region

On Examination Single Hyperpigmented plaque noted over Pubic area which aggravated on Using Sanitary Napkins and was prescribed LULIFIN cream

4 days later improvement was Seen with Cumulative dose of Methotrexate 50 mg and following drugs were Prescribed

LIVOGEN on day other than Methotrexate
Methotrexate12.5 mg
Tab. SUPRADYNE
ABZORB Dusting Powder

2 Weeks later improvement was seen

Cumulative dose of Methotrexate75 mg and the above medications were continued and 1 week later She Complained of Nausea, loss of appetite and Insomnia and she was Prescribed Tab. Amitriptyline 5 mg

2 weeks later She Showed Painful skin lesions on both palms and Soles with Cumulative dose of Methotrexate 125 mg

Medications

METHOTREXATE 12.5 mg
VENUSIA Soft lotion on itchy lesions
NMFE lotion over stretch marks and all over the body
Tab. LIVOGEN on day other than Methotrexate
Tab. SUPRADYNE

2 Weeks later She presented with new lesions over Palms associated with itching (Cumulative dose of Methotrexate 150 mg) and Tab. TECZINE 10 mg and Tab. PANTOP-D were prescribed

20 days later She presented with new lesions Over Palms and soles and between the Web Spaces Since 1 week and painful Soles while walking especially early in the morning

On examination Multiple erythematous pinpoint Sized Papules noted all over the palms,Web Spaces and both Soles ( Cumulative dose of Methotrexate 170 mg )

Medications

Methotrexate dose reduced to 5 mg Once weekly for 2 Weeks and then 2.5 mg Weekly once for1 week
NOMATE Cream on alternate days over the lesions
Liquid PARAFFIN

10 days later She complained of appearance of new lesions and was advised to Stop all medications and report to OPD for Skin biopsy and was prescribed Tab.DEFZA 12 mg and Tab. TECZINE 5 mg (for pain)

- 2 weeks later, Biopsy was done and Histopathological report showed Neutrophilic Leucocytoclastic Vasculitis and was advised to check G6PD levels and was prescribed Tab. DAPSONE 50mg

20 days later She presented with Itchy purpura Over both feet