Thursday, January 17, 2013

Diagnostic Dilemma . . .

We had a very interesting case yesterday night . . . 

I shall call her DDe. DDe, 26 years had delivered her first baby 7 days back by normal vaginal delivery at home following which she was fine for the next 3 days.

On the 4th day after delivery, the family noticed rashes all over her body including her face. There was no fever. 

They took her to a local hospital where she was being managed for the last 2 days. As she was not improving, the relatives brought her here. In addition to the above skin manifestation, her fingers had become stiff and was blackening. 

Below are the significant snaps . . . 

Actually, the nose was all gangrenous and was smelling bad . . . it had rather become like a bag of pus. In addition, the tips of the fingers also had become gangrenous. There were ecchymotic patches all over the trunk and body. 

There was discoloration of the toes too. However, it had improved in the morning. 

Blood investigations: 
Total counts: 44,000/cu mm 
Platelets: 115,000/cu mm, 
Differential Count: P85, L11,Myelocyte2, Metamyelocyte2
Serum creatinine: 1.79 mg%, ESR: 70 mm/1st hour. 

My first diagnosis was septicemia in a setting of a connective tissue disorder. 

We tried to refer the patient all through the night . . . And we succeeded to convince the relatives by morning. 

On admission, she had tachypnoea. And it had worsened overnight. However, she was maintaining her saturation, although there was coarse crepitations all over the chest. We could not get a Chest X-Ray. 

However, we got a different diagnosis after the peripheral smear examination - which showed a hypochromic microcytic picture, poikilocytosis with ?? sickle cells. There was marked leucocytosis with neutrophilia, shift to left and toxic changes. 

The patient is now on her way to the Medical College, BHU, Varanasi. After the peripheral smear, I wonder if it is a sickle cell crisis following septicemia. Since the peripheral smear result arrived after the patient left, we could not get any more history. 

Please do give your opinion on this patient. 


  1. Pregnancy outcome appears to be worse in SLE patients whose disease flares up during pregnancy. Malar rash (rash on cheeks); sensitivity = 57%; specificity = 96%

  2. SLE with lupus nephritis and may be vasculitis/APLA syndrome.

  3. I agree with Ron,The breathlessness might be due to a pericardial effusion with early failure/ PE secondary to vasculitis /APLA.