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Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

A 32 year old male patient presented with

  • Swelling of Bilateral lower limbs since 1 month.
  • Hypopigmented skin lesions on nose, arms, chest since 3 months.
  • Distension of abdomen since 15 days
  • Yellowish discoloration of sclera since 4 days
  • Pain abdomen since 4 days
  • Breathlessness since 2 days

PAST HISTORY
No similar complaints in the past

PERSONAL HISTORY
Non smoker
Alcoholic 270 ml/day since 8 years, last drink 1 week ago

Sleep- disturbed
Appetite-decreased

GPE
32 year old patient who is moderately built and nourished, well oriented
pallor +
Icterus ++
B/L pedal edema +

Hypopigmented skin on nose, chest, arms.

No lymphadenopathy, clubbing , cyanosis, flapping tremors

VITALS :
PR:86bpm , regular
BP:130 /90 mm of Hg
RR: 16 cycles/ min
SpO2:99%at RA

Hb :10.7 g/dl
TLC:11070 cells/cumm
ESR :85mm (raised)
PCV : 29.8%
RBC: 3.25mil/cumm
Platelet:1.89 lakh /cumm
Reticulocyte : 1.4%
PBS: normocytic normocromic anemia
with neutrophilic leukocytosis.
rouleax formation, target cells present .
RDW: 17.7 %
Na : 128mEq/L

Urine Routine : normal

Anti-HIV , HBSAG ,
HCV : antibodies were nonreactive

LFT :
Total bilirubin:5.35mg/dL
Direct bilirubin:3.61mg/dL
Serum albumin :1.6g/dL
AST:170
ALT:25
PT,APTT,INR : Normal
Ammonia :55micromoles/L(16 to 60)

Serum Fe : 37.96µg/dL TIBC : 109µg/dL Serum ferritin:970.3ng/ml

Chest X-Ray :B/L CP angle blunting

USG abdomen:
Cirrhosis of liver ,
Moderate ascites,
Bilateral pleural effusions, Left > Right.

Upper GI Endoscopy
Palatal ulcer with early esophageal varices.
Sub mucosal nodule with features of portal hypertensive gastropathy

Skin biopsy was done which was suggestive of Discoid Lupus Erythematosis (DLE)

Chronic liver disease with portal hypertension with signs of liver cell failure with Discoid Lupus Erythematosis

Inj Furosemide 40 mg Stat IV. Later 20 MG 1-1-0

Tab Ursodeoxycholic acid 300 mg 1-0-1

Inj Thiamine in 100  ml NS 0-1-0

Inj Ceftriaxone 1gm IV 1-0-1

Tab Propranolol  40 mg 1-0-0

Tab Spironolactone

 25 mg 1-0-0

Topical Steroids and Sun screener was advised by the dermatologist Patient was asked to come for follow up for further evaluation. But was lost for follow up.

The three most widely recognised forms of Alcoholic Liver Disease are alcoholic fatty liver (steatosis), acute alcoholic hepatitis, and alcoholic cirrhosis. At least 80% of heavy drinkers develop steatosis, 10%–35% develop alcoholic hepatitis, and approximately 10% will develop cirrhosis [1]

There is a clear dose-dependent relation between alcohol intake and the incidence of alcoholic cirrhosis. A daily intake of more than 60 g of alcohol in men and 20 g of alcohol in women significantly increases the risk of cirrhosis. In addition, daily drinking, as compared with binge drinking, appears to be more harmful.[2]

Symptoms may not be visible in early stages

  1. Pain and swelling in abdomen
  2. Decreased appetite and weight loss
  3. Nausea and vomiting
  4. Fatigue

Severe and specific symptoms can include encephalopathy and hepatic fever. [3]

Clinical presentation is similar to other forms of end-stage liver disease but may be accompanied by concurrent alcoholic hepatitis. Spider angiomata, along with palmar erythema, enlargement of parotid and lacrimal glands, testicular atrophy, ascites, venous collaterals, jaundice and encephalopathy.[3]

Alcoholic fatty liver disease: Steatosis is invariable if consumption exceeds 80 g of alcohol per day. It is reversible with abstinence but may progress to cirrhosis if excess alcohol intake persists.[4]
In this case during the analysis of LFT, AST is more than ALT, which is charecteristic feature of Alcoholic liver disease[5]

Discoid lupus erythematosus (DLE) is a chronic and common form of cutaneous lupus — a form of skin inflammation of unknown cause. It occurs particularly on sun-exposed skin, such as the face, ears, and scalp, but occasionally is much more extensive, involving large areas of skin. Permanant scarring can occur if treatment is delayed. [6]

Local steroids, with sun screeners are tried. For severe cases anti inflammatory drugs like Hydroxy chloroquine and immunosupressent are tried.[6,7]

  1. Grant BF, Dufour MC, Harford TC (1988) Epidemiology of alcoholic liver disease. Semin Liv Dis 8:12–25
  2. Grant BF, Dufour MC, Harford TC. Epidemiology of alcoholic liver disease. Semin Liver Dis 1988; 8(1):12–2
  3. Maddrey WC. Alcoholic hepatitis: clinicopathologic features and therapy. Semin Liver Dis 1988; 8(1):91–102.
  4. Teli MR, Day CP, Burt AD, et al.(1995) Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver. Lancet 346:987–990.
  5. Marsano, L.S.; Mendez, C.; Hill, D.; et al. Diagnosis and treatment of alcoholic liver disease and its complications. Alcohol Research & Health 27(3):247–256, 2003.
  6. Jessop S, Whitelaw DA, Grainge MJ, Jayasekera P. Drugs for discoid lupus erythematosus. Cochrane Database of Systematic Reviews. 2017(5).
  7. Moura Filho JP, Peixoto RL, Martins LG, Melo SD, Carvalho LL, Pereira AK, Freire EA. Lupus erythematosus: considerations about clinical, cutaneous and therapeutic aspects. Anais brasileiros de dermatologia. 2014 Feb;89(1):118-25.
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