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COMMON DISEASES OCCUR COMMONLY

COMMON DISEASES OCCUR COMMONLY. AN INTRESTING CASE OF END STAGE RENAL DISEASE WITH EXTRA RENAL MANIFESTATIONS OF ACUTE HEPATITIS “B” VIRUS INFECTION. Dr.Abhijit Kishore Korane. Department of Nephrology, Apollo Hospitals , Chennai. 63 YEARS MALE PATIENT “KB” K/C/O,

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COMMON DISEASES OCCUR COMMONLY

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  1. COMMON DISEASES OCCUR COMMONLY

  2. AN INTRESTING CASE OF END STAGE RENAL DISEASE WITH EXTRA RENAL MANIFESTATIONS OF ACUTE HEPATITIS “B” VIRUS INFECTION. Dr.Abhijit Kishore Korane.Department of Nephrology,Apollo Hospitals , Chennai.

  3. 63 YEARS MALE PATIENT “KB” K/C/O, • DIABETES MELLITUS--- 20years, • HYPERTENSION---16years, • ISCHEMIC HEART DISEASE,(post CABG- 2001) - COPD,(chronic smoker)

  4. He is a case of End stage Renal disease due to Diabetic Nephropathy on regular Haemodialysis Since March-2008.

  5. He presented to us in last week of Febraury with, • Pain in lower abdomen during haemodialysis for 10 days. • Pain in right shoulder and right hip joint for one week. • Erythematous lesions with itching on lower limbs.

  6. On Examination:- Elderly male, Hypertensive, Vitals- Stable. Skin:- Erythematous, raised non-tender, multiple lesions on lower limbs as well on the back and chest wall. Systemic examination was normal.

  7. CLINICAL DIAGNOSIS, Pain in Abdomen:- ? Mesentric ischemia, (DM,HTN, SMOKER, IHD,ESRD) ? Pancreatitis. Erythematous lesions:- ? Drug reaction, ?cause, (was on haemodialysis elsewere)

  8. Blood Biochemistry, • As a routine practice before haemodialysis, blood was collected for IDNAT(HIV, Hepatitis B, Hepatitis C). • Hepatitis B was positive,(?acute seroconversion) • SGPT and Alkaline phosphatase was high, • Sr.PTH was high(mineral bone disease), • Sr.Amylase and Sr.Lipase was normal( ruled out pancreatitis) • Ejection fraction was normal.

  9. Ig M Anti HbC was positive, ( he had acute Hepatitis B virus infection) HBV viral load was:- 14,501,379. (High) ANA was positive,(? False positive) ANCA, dsDNA were negative.

  10. During the course in the hospital, • He continued to have pain in abdomen during Haemodialysis,(? Mesentric ischemia) which used to subside after reducing blood pump speed. • Skin lesions persisted. • Pain in right shoulder and hip persisted.

  11. CT Abdomen with angiography, failed to reveal any obstruction to blood flow. • Ultrasound of right shoulder and right thigh showed, Localized hematoma. ? Anticoagulation during haemodialysis, ? Cause.

  12. He was subjected to skin biopsy,

  13. Dr Sheba Jacob Department of Pathology

  14. SKIN BIOPSY

  15. DIAGNOSIS ?

  16. Diagnosis was strongly favoring Extra renal manifestations of Hepatitis B virus infection.

  17. Diagnosis, • ESRD with DN, • Acute Hepatitis B virus infection, with vasculitis. (?Polyarteritis nodosa) • Mesentric ischemia. • Haematoma of right pectoralis major and thigh. (?Anticoagulation, ?Vasculitis induced)

  18. Therapy, • Haemodialysis (Heparin free,low pump speed), • ?Steroids,(initiated on oral steroids) • ?Cytotoxic drugs, • Lamivudine.

  19. DISCHARGED

  20. FOUR days later, • Pain during haemodialysis reduced considerably, • Skin lesions reduced considerably, although lesion at nape of neck and chest wall got ulcerated. • Developed severe proximal muscle weakness of both upper and lower limbs.

  21. HEALING SKIN LESIONS AFTER TREATMENT

  22. On Examination, • Power of proximal muscles was II/V, • Power of distal muscles was IV/V.

  23. We suspected, • Steroid toxicity, • Spectrum of Hepatitis B virus infection, - ?GBS(demylenating polyradiculoneuropathy) - ?PAN, - ?Myositis.

  24. BLOOD BIOCHEMISTRY:- CPK:- 1980, (high) Sr.Aldolase:- 22.8,(high) NCV studies:- Bilateral symmetric sensory motor polyradiculoneuropathy. ? Diabetic polyneuropathy, ? Vasculitic.

  25. DAY 2 of admission:- • Continued to have severe weakness of both upper and lower limbs. • Subjected to muscle biopsy.

  26. MUSCLE BIOPSY

  27. IMMUNOSUPPRESION?

  28. Ing. Methylprednisolone 1gm pulse, six doses • Ing. Cyclophosphamide.

  29. COURSE:- Following higher doses of steroids and cytotoxic drug his power improved considerably. We continued him on oral steroids. He is on regular haemodialysis, has no pain during haemodialysis, skin lesions had healed, and muscle power has improved considerably.

  30. EXTRA HEPATIC MANIFESTATION OF HEPATITIS B.

  31. Approximately 400 million people are chronic HBV carriers worldwide. • The spectrum of chronic HBV infection ranges from asymptomatic hepatitis B surface antigen carrier state to chronic hepatitis with progression to cirrhosis and end-stage liver disease. • Several extrahepatic syndromes are associated with chronic HBV infection.

  32. HBV serum sickness-like syndrome, • A serum sickness-like syndrome may occur in 10 to 25% of patients in the early prodrome of acute HBV hepatitis. • Fever, maculopapular or urticarial rash. • Transient arthralgias and/or arthritis involving distal and large joints of the extremities are common.

  33. HBV associated polyarteritis nodosa (HBV-PAN)

  34. In various series the presence of HBsAg in the serum has beennoted in 0 to 54% of cases of PAN.

  35. The initial presentation is similar to the serum sickness-like syndrome and includes fever, arthralgias, urticaria, and palpable purpura. • Unlike the prodromal serum sickness syndrome which resolves spontaneously, in HBV-PAN a frank vasculitis develops over several weeks and may involve virtually any organ.

  36. Abdominal pain secondary to mesenteric ischemia. • Mononeuritis multiplex secondary to involvement of the vasa nervorum of peripheral nerves. • Myocardial ischemia from coronary artery involvement. • Renal involvement may present as renin-dependent hypertension, microscopic hematuria, non-nephrotic or nephrotic proteinuria, or even renal failure.

  37. Pathology:- HBV-PAN consists of focal inflammation of the small and medium sized arteries. The inflammation is panmural, characterized by fibrinoid necrosis, leukocyte infiltration, fibrin deposition, and occasional aneurysm formation

  38. DIAGNOSIS:-

  39. HBV-PAN is associated with abnormal liver function tests and aneurysm formation. • Diagnosis of PAN can be made by skeletal muscle, peripheral nerve biopsy. • Angiography to look for saccular or fusiform aneurysms and/or abnormal narrowing of blood vessels is also useful and may be particularly of value in HBV-PAN. • Renal angiography has the highest diagnostic yield.

  40. Polyarteritis Nodosa with Fibrinoid Necrosis

  41. Dermal Vasculitis

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