CLERKSHIP CASE PRESENTATION ON PEMPHIGUS VULGARIS BY SALMATASNEEM 170310820020 Pharm-D 5th year MESCO COLLEGE OF PHARMACY

SUBJECTIVE

Name of patient: CH.Sheshirekha Age:85yrs Sex: Female DOA:24/3/15 Dept:DVL

Complaints : H/o of fliud filled lesions all over the body.

History of present illness: Patient was apparently asymptomatic 20 days back then she developed swelling over the face with erythema which gradually spread to lower limbs oral mucosa. Some of blisters ruptures with minimal trauma and developed erosions.

Patient history: patient had taken treatment from outside after which instead lesions subside and then she stopped for 4days later which developed lesions all over the body 4days back.

Drug History: she had taken homeopathic medications for 4 days.

Past History: No h/o of similar complaints in the past.

c/o :hypertension since 20yrs, on regular medication.

c/o : chronic utricaria on symptomatic treatment.

Personal History: Mixed diet

sleep, appetite :normal

OBJECTIVE pt c/c/c Afebrile pedal edema (positive) PR :72/min

BP:130/90mmhg

Hb:13.5gm/dl

WBC Count: 3,200

N: 67 % L:28% M:03%

E:02 %

Platelets: markedly platelets

BP:Normo cytic; Normochromic

ESR:15mm

RBS: 168

S.Urea:24 mg/dl

S.Creatinine:0.8 mg/dl

Serum Electrolytes:Na:131 meq/lt

K:4.4meq/lt

Serum Total Bilibirubin :0.9 g/dl

CUTANEOUS EXAMINATION: Multiple fluid filled blisters present over both lower limbs and trunk intermixed with multiple round to oral plaques with central hyperpigmentation and surrounding erythema. Large blisters present over the right hand,left forearm. Palms and soles :blisters present.

Oral mucosa :hyperpigmented healed lesions. Nilsolsky Sign:negative.

SKIN BIOPSY :

Nature of Specimen SKIN BIOPSY.

RESULT: Microscopic Examination of the sections revealed SKIN showing Accantholysis causing separation of epidermal layers causing BULLAE FORMATION.

THE SUPRANASAL BLISTER contains Accantholytic Cellls, Neutrophils And EOSINOPHILS.THE DERMAL PAPPILAE are lined by SINGLE LAYER of BASAL KERATINOCYTES SO called VILLI. THERE are DENSE collection of LYMPHOCYTES ,MONONUCLEUS and EOSINOPHILS FORMING GROUPS IN the SUPERFICIAL LAYERS OF DERMIS. ANDEXA APPEARS NORMAL . SUGGESTIVE OF PEMPHIGUS VULGARIS .

ASSESMENT

Based on the Above Investigations it is confirmed to be as PEMPHIGUS VULGARIS.

PLAN

Drug brand name

Generic name

Indication Dose Route of administration

Frequency

Inj monocef

Ceftriaxone Antibiotic 1gm IV BD

Inj Decadron

Dexamethasone

Corticoteriod

2cc IV BD

Inj Rantac Ranitidine Antacid 50mg IV BD

T.calcium Calcium supplement

Oral OD

T.PCM paracetamol

Analgesic 500mg OD

T.BC B.complex Vitamin supplement

Oral OD

Liquid paraffin

White soft paraffin

Cream Topical OD

Drug brand name

Generic name

Indication Dose Route of administration

Frequency

Betadine mouth gargle

Providone iodine

Oral antiseptic

100ml Topical BD

TESS ointment

Triamcinolone

Topical steriod

0.1 Topical BD

1/GV paint

Gentian violet

Antifungal Topical BD

T.predinisolone

deltasone Corticosteriod

10mg Oral OD

Cap.tetracyline

sumaycin Antibiotic 500mg Oral BD

Patient Counselling

Regarding Disease state PEMPHIGUS VULGARIS: Pemphigus vulgaris is a rare autoimmune

disease that causes painful blistering on the skin and the mucous membranes. In an autoimmune disease, a person’s own immune system mistakenly attacks his or her own healthy body.

Pemphigus vulgaris is the most common type of a group of autoimmune disorders collectively called pemphigus. Each type of pemphigus is characterized by the location where the blisters form. Pemphigus vulgaris affects the mucous membranes, which are found in the mouth, throat, nose, eyes, genitals, and lungs. This disease usually starts with blisters in the mouth and then on the skin. The blisters sometimes affect the membranes of the genitals.

Patient counselling regarding medication

Monocef: Ceftriaxone is a third-generation cephalosporin antibiotic. Like other third-generation cephalosporins, it has broad spectrum activity against Gram positive and Gram negative bacteria. In most cases, it is considered to be equivalent to cefotaxime in terms of safety and efficacy.

Adverse effects: Eosinophilia,thrombocytosis,diarrhea,rash.

Decadron: Dexamethasone is a type of steroid medication. It has anti-inflammatory and immunosuppressant effects. It is 25 times more potent than cortisol in its glucocorticoid effect, while having minimal mineralocorticoid effect.

Adverse effects: acne, adrenal suppression,arrhythmia,depression.

Ranitidine: Is a histamine H2-receptor antagonist that inhibits stomach acid production. It is commonly used in treatment of peptic ulcer disease and gastroesophageal reflux disease. Ranitidine is also used alongside fexofenadine and other antihistamines for the treatment of skin conditions such as hives.

Adverse effects: Abdominalpain,agitation, alopecia,confusion.

Patient counselling regarding life style modification:

The primary aim of treatment is to decrease blister formation, prevent infections and promote healing of blisters and erosions.

Taking good care of your wounds can help prevent infection and scarring.

Generously sprinkling talcum powder on your sheets may help keep oozing skin from sticking.

Avoid situations in which your skin could be touched or bumped, such as contact sports.

To ease discomfort, treat sores and blisters with soothing or drying lotions or wet dressings. But, check with your doctor before using lotions or wet dressings for the first time.

Avoid spicy or acidic foods, as well as those containing garlic, onions or leeks.

These foods can irritate or even trigger blisters.

Minimize sun exposure. Ultraviolet light may trigger new blisters.

Talk with your dentist about maintaining good oral health. If you have blisters in your mouth, it may be difficult to brush your teeth properly. Ask your dentist what you can do to protect your oral health.

Ask your doctor if you need calcium and vitamin D supplements. Corticosteroids can affect your calcium and vitamin D needs, so ask your doctor if you need a calcium supplement or any other additional nutrients.

DRUG INFORMATION QUERY

What is Nikolsy sign?

Nikolsky sign is a skin finding in which the top layers of the skin slip away from the lower layers when slightly rubbed.

Nikolsky's sign is a clinical dermatological sign, named after Pyotr Nikolsky (1858–1940), a Russian physician who trained and worked in Ukraine, which was part of the Russian Empire at that time. The sign is present when slight rubbing of the skin results in exfoliation of the outermost layer.

Nikolsky's sign is almost always present in toxic epidermal necrolysis and is associated with pemphigus vulgaris. It is useful in differentiating between pemphigus vulgaris or mucous membrane pemphigoid (where it is present) and bullous pemphigoid (where it is absent). The Nikolsky sign is dislodgement of intact superficial epidermis by a shearing force, indicating a plane of cleavage in the skin. Also present in Scalded Skin Syndrome caused by the exfoliative toxin of S. aureus.

Drug interactions

Dexamethasone+prednisolone:

Dexamethasone will decrease the level or effect of prednisolone by affecting hepatic/ intestinal enzyme CYP3A4 metabolism. Significant interaction possible,monitor closely.

Tetracyline +Ceftiaxone:

Tetracyline decreases effects of ceftriaxone by pharmacodynamics antagonism . Significant interaction possible,monitor closely.bacteriostatic agents may inhibit the effects of bactericidal agents.

THANKYOU