30F with pruritic skin lesions
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30 year old female came to casuality with c/o painful lesions along the body since 1 year
HOPI- Patient was apparently asymptomatic 1year back then she observed pain initially over skin of left leg following which she noticed a small nodular lesion initially small with reddish discoloration but progressively grown and felt localized rise in temperature which over days healed with hyperpigmented rashes. Intially she used ayurvedic medicine for few months even then the lesions didnot subside completely. 6 months back she doveloped similar non itchy lesions over both hands extending proximally and healed with hyperpigmented rash.
Pain-Nodules-burning sensation-heals with hyperpigmentation.
PAST HISTORY-Since 8 months she doveloped similar lesions on face and from 1 and half to 2 months she doveloped similar lesions on ears etc currently not healed.
N/K/C/O DM, HTN, TB, ASTHAMA
PERSONAL HISTORY-
Mixed diet
appetite -normal
bowel and bladder - Normal
no addiction
No known allergies
FAMILY HISTORY - not significant
PHYSICAL EXAMINATION-
no pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema, dehydration
VITALS-
temperature - afebrile
pulse rate - 82 bpm
RR - 18 cpm
BP - 130/80 mm hg
SPO2 - 98 on RA
GRBS - 117.mg %
SYSTEMIC EXAMINATION-
CVS-S1 ,S2 heard ,no murmurs
RS -BAE +, NVBS
P/A - soft ,non tender
CNS -
speech - normal
power
U.L - 5/5
L.L - 5/5
TONE - normal
REFLEXES
KNEE - +
BICEP - +
TRICEP-+
ANKLE - +
BRACHIORADIALIS - +
PLANTAR - withdrawal
PROVISIONAL DIAGNOSIS-
? ERYTHEMA NODOSUM LEPROSUM
? CUTANEOUS VASCULITIS
Dermatologist opinion was taken in view of ENL advised for G6PD, Split skin smear and skin biopsy
INVESTIGATIONS-
Final Diagnosis :
ERYTHEMA NODOSUM LEPROSUM
Patient was started in Dapsone and discharged following which after few days she developed anorexia and severe weakness so that she stopped the drug
And the skin lesions increased in severity and distribution.
Following is the conversation between local treating team and our hospital team :
Will it be okay to stop the medicine for a while for that ENL case sir?
Just spoke to her parents.... She isn't eating since 3 days due to anorexia. Only on watermelon. Severe weakness that unable to type in phone also. Temperature spikes happening daily asusual.
May be if we stop them and if she improves temporarily, she can plan a visit to Kims asap
She needs to be admitted here and yes meanwhile best to stop whatever is incriminated
Good evening sir. An update regarding the ENL case
After that day we have stopped all the drugs. Her status was so bad that she couldn't travel anymore
And new lesions appeared all over..
Patient as well as the family were scared and weren't Willing to come back so I have started our Rx since that day
Oh sorry to see this. Please motivate her to come back
Feeling bad to see this. Is this relapse of disease sir..??
It's because the drugs were stopped I guess.
2nd follow up :
Patint came to opd in much better state with all her symptoms in resolving phase.
Significant reduction in skin lesions with ayurvedic treatment and life style modification.
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