45/F came with History of fever since 1.5 months for which she consulted a chest physician, She was started on ATT on the basis of having "Tuberculous pleural effusion" (No sputum or P fluid examination was done as per history). Fever decreased during ATT, but some other doctor stopped ATT. Now she has joint pains (small joints of hand) . And blackish discoloration of both legs, with few punched out ulcers. General appearance is undernourished debilitated. Please Give your valuable opinions. Hb 6.6 Esr 95

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Fits sle. Remember before doing ana a thorough clinical examination is must. How about oral ulcers, hair loss. Joint pain , pleural effusion and gangrene in a middle aged female is To be thought of sle unless proved otherwise. Tb vasculitis us rarer than sle in this cohort and pt hasn't responded to SLE. Mili would request you to take a rheumatologist opinion as pt has life and organ threatening symptoms

Thank you sir for your detailed response

Gangrene?or vasculitis?,R/o diabetes,Do Color Doppler for any venous insufficiency,ANA.

What's the platelet count and TLC? Get antidsdna,ena,c3 and c4, urine RM for sle Gangrene in sle is mainly due to apla and very rarely due to sle vasculitis. Get apla profile and of course let a rheumatologist handle it

Vasculitis, rule out sle and other Anca related Vasculitis.

gangrene rule out T.B. diabetes. vascular insufficiencies

It's a Gangrene.

Gangrene. What abt ANA? Doppler study of both limbs? Any signs suggestive of connective tissue disorder?

Reinvestiate for TB. Rule out Diabetes. Do a Dopler.

Probably a case of tubercular vasculitis albeit rare but still needs to be ruled out.

We have to rule out any sort of vasculitis SLE

Investigate on lines of connective tissue disease. Look for peripheral pulse.

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