د سامح

1. Case Presentation
By
Sameh El-Sayed El-Mataany
Egyptian Nephrology Fellowship trainee
NMGH

2. History
 A 32-year old female, married, from
Zefta presented to ER with:
◦ Shortness of breath
◦ Bilateral leg swelling
◦ Oliguria

3. History
Present history
The condition started one month ago
by gradual onset and progressive
course of dyspnea on exertion, lower
limbs edema and oliguria.
She was diagnosed to have SLE 1
month prior to presentation.

4. History
Past history
No history of hypertension, diabetes, CKD,
surgery.
History of rheumatic heart disease since
childhood.
Frequent suicidal attempts and antipsychotic
therapy for depression for 9 years
History of 2 abortions.

5. History
Family history
Not significant

7. Examination:
O/E:
 The patient appeared ill, fully conscious
and irrirable.
 Pallor.
 Bilateral congested neck veins.
 BP: 120/70 mmHg, pulse 100 b/m,
afebrile.
 Chest: NAD
 Heart: pansystolic murmur over the apex
radiating to axilla.
 Abdomen: lax, no palpable organs.
 Bilateral pitting L.L. edema below knee.

9. Investigations:
10.3 gm/dL (NN)
15100
52
Full Blood Count:
Hb.:
TLC:
Platelet count:
0.52 mg/dL
2.6 gm/dL
Total Bilirubin:
Albumin:
1.25INR:
96CRP:

10. Investigations:
++
5 /HPF
Absent
30 – 35 cells/HPF
Urine analysis:
Protein:
Pus cells:
Casts:
RBCs:
1.1 mg/dl
79 mg/dl
2.5
Renal profile:
Serum creatinine:
Blood urea:
K
7.5
37 mmHg
29.5 mmoL/L
ABG:
PH:
PCo2:
HCo3:

11. Investigations:
PositiveANA:
PositiveAnti ds-DNA:

12. Investigations:
After admission Further workup
was done:
 Urine A/C: 530 mg/gm
 C3 & C4: Normal
 Anti-cardiolipin IgM & IgG: Positive
 LA: Positive

13. Investigations – cont.:
Pelvi-abdominal US:
 Bilateral normal kidneys as regard size,
echogenicity and CMD with no stones or
back pressure.

14. Investigations – cont.:
Echocardiography:
 EF: 30 %
 Diastolic dysfunction
 Severe MR & AR
 Global hypokinesia

15. History

16. Management:
 Fluid chart
 Ampicillin-sulbactam 1.5 gm/12 hours
i.v.
 Hydroquine 200 mg b.i.d
 Furosemide 40 mg oral once daily
 Digoxin 0.25 mg tab. E.O.D
 Captopril 25 mg tab. b.i.d
 Aspirin 75 mg tab. Daily

17. Neurological consultations was done
in view of psychosis and unilateral
weakness and orderd Brain MRI
which revealed:
Multiple small recent infarcts mostly
due to underlying vasculitis

18. Management of
Neuropsychiatric SLE:

19. After neurological consultationWe
decided to start:
 Pulse steroid therapy with
Methylprednisolone 500 mg for
five days under cover of
Imipenem.
 Plasma exchange for 5 sessions
(via right IJ vein CVC).
 Warfarin 3mg/day.

20. We decided to proceed to renal
biopsy

21. Biopsy result:

23. Diagnosis
Lupus Nephritis class II

24. KDIGO Clinical Practice Guideline
for GN 2012

25. Progress notes:
 The patient condition stabilized with
improvement of neurological symptoms
and signs.
 CRP: 6
 After completion of pulse steroid dose
Prednisone 60 mg/d plus Azathioprine 100
mg/d were initiated.

26. The patient was discharged
with weekly follow up in OPC

27.  After 1 week during the follow up visit
the patint presented with fever and
chills.
 During clinical exam an ejection
systolic murmur (new murmur) was
auscultated at the second intercostal
space in the right upper sternal border
radiating to carotid arteries..

28. Investigations:
 CBC: TLC: 15700
 ESR: 1 st hour: 70
 CRP: 96

29. CXR:

30. Cardiological consultation and
Echocardiography were done

32.  Samples for blood culture were
withdrawn
 Empiric Antimicrobial therapy was
initiated with: Vancomycin 500
mg/8hours i.v.i. plus ceftriaxone
2gm/d i.v.
 Warfarin was stopped.

33. 2015 ESC Guidelines for the
management of IE

34. 2015 ESC Guidelines for the
management of IE

35. Blood culture and sensitivity
result:

36. The patient was switched to
Linezolid 600 mg PO q12hr for
6 weeks.

37. Progress notes:
 The patient condition stabilized and fever
subsided.
 CRP: 12
 Follow up Echo. After 10 days: Decrease
in size of vegitations to 0.3 cm2.

38. Take home messsage:
 Aseptic measures are mandatory during
venous catheter manipulation and during
any invasive procedures in order to
reduce the rate of health care-associated
IE.
 Echocardiography and blood cultures are
the cornerstone of diagnosis of IE. TTE
must be performed first, but both TTE
and TEE should ultimately be performed
in the majority of cases of suspected or
definite IE.