35 year old female presenting with fever and ulcers on feet and hands since 5 days

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .

A 35 year old female, farmer by occupation resident of aakaram came to the general medicine OPD with complaints of fever and ulcers on feet and hands since 5 days

HOPI:

The patient was apparently asymptomatic up until 5 days ago when she  developed low grade fever  sudden in onset , continuous in not associated with chills,sweating, dizziness, fatigue and body pains, nausea, vomiting .

Second day after onset of fever she went to her farm for work in the early morning and injured her left toe while spraying fertilizer . From third day she noticed progressive painful lesions appearing on both lower limbs and upper limbs chest and neck . Not associated with loss of sensation, itching, joint pains.

Difficulty in swallowing and burning sensation in the mouth post consumption of food due to small ulcers in the mouth

No complaints of headache, burning micturition, giddiness, chest pain, shortness of breath, palpitations, cough ,insomnia, loose stools, loss of appetite. 

History of usage of semecarpus anacardium for one day. Following whish she went a local practitioner and was prescribed an tablet containing  deflazocort 6mg for five days itraconazole ,tofloxacin, orividazole, clobetalol propionate, and megaheal ointment for five days.

PAST HISTORY and treatment  : History of psoriasis vulgaris from 2 years for which she used tab METHOTREXATE 7.5mg BD for one month and capsule itraconazole.

Not a known case of DM/HTN/ TUBERCULOSIS/ASTHMA/

PERSONAL HISTORY:

Appetite: decreased

Diet:mixed

Sleep: adequate

Bowel and bladder are regular

Patient denies of any addictions

FAMILY HISTORY:

no history of similar complaints within the family

General examination

Pallor: present

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

SKIN:  HYPERPIGMENTED ULCERATIONS + MACULES ALL OVER THE BODY with local rise of temperature 

Vitals:

Temp: febrile

BP 

Heart rate 110 bpm

Resp Rate 16/min

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM:

I: Chest bilaterally symmetrical, all quadrants

moves equally with respiration

P: Trachea central, chest expansion normal

P: Resonant

A: B/l equal air entry, no added sounds 

CVS EXAMINATION:

I: No precordial buldge. Apical impulse

visible, Venous prominence

P: Apical impulse, No palpebral pulsation.

thrill

A: S1 S2, No murmur

ABDOMINAL EXAMINATION:

Abdomen is soft and non tender

No organomegaly

No shifting dullness

No fluid thrill

Bowel sounds heard

ABNORMAL INVESTIGATION FINDING

1) pancytopenia 

2)RAISED ESR 

3) decreased total protein and albumin

Differential: Methotrexate toxicity ?

                     SLE( anti phospholipid antibody syndrom?)

DISCUSSION:

Reference:

 1) https://link.springer.com/article/10.1007/s13555-014-0056-z

most cases of methotrexate-induced ulceration have been reported in patients with psoriasis on low-dose treatment rather than in those on high-dose oncology regimens

It is postulated that that the increased proliferation of keratinocytes within psoriatic plaques makes them particularly vulnerable to the effects of folate-antagonism. 

Lawrence and Dahl described two patterns of methotrexate-induced ulceration: type 1 as superficial ulceration of existing psoriatic plaques and type 2 as ulceration of non-psoriatic skin.

Diagnosis:

Diagnostic biopsy is rarely required, however, histological features of methotrexate-induced ulceration include swollen keratinocytes with diminished nuclear and cytoplasmic staining and occasional vacuolated or dyskeratotic cells indicative of incipient epidermal necrosis

Treatment:

In cases of ulceration, withdrawal of methotrexate supported by skin-directed therapy usually leads to rapid improvement in ulceration with many patients showing signs of healing within a few days; however, in isolated cases ulceration persists for years 

Prevention:

Pharmacogenomic evaluation of methotrexate may allow for future pre-treatment testing for risk of efficacy and toxicity.