Systemic lupus erythematosus associated with erythema multiforme: A rare case report of Rowell's syndrome.

Key Clinical Message: Although it is very uncommon, SLE may initially present with recurrent episodes of EM-like rash. Despite the various possibilities underlying their association, prompt identification, and treatment of SLE in patients presenting with EM is important to prevent death or serious organ damage. Abstract: Rowell's syndrome (RS) is an uncommon presentation of systemic lupus erythematosus (SLE) with erythema multiforme (EM)-like lesions associated with specific serological changes, including positive rheumatoid factor (RF), speckled antinuclear antibody (ANA), positive rheumatoid factor, or anti-La antibodies in the serum. Our case, a 41-year-old male, presented with features of EM. Upon investigation, we identified underlying systemic lupus erythematosus, marking a rare instance of SLE presenting for the first time as EM. Classical or true EM is precipitated by trigger factors such as infective agents like the herpes simplex virus, Mycoplasma pneumoniae, drugs like anticonvulsants, antibiotics, and non-steroid anti-inflammatory drugs, any underlying malignancy, or connective tissue disorders, and is not associated with any specific serological abnormalities. EM cases associated with LE lesions where an EM trigger factor is missing are considered an RS diagnostic criterion. In this case report, the importance of considering SLE in patients presenting initially with recurrent episodes of EM-like rash is emphasized. RS should be considered, especially when there is no evidence of triggering factors. Early diagnosis and prompt treatment of SLE are crucial to preventing death and irreversible organ damage.

Purpura fulminans in probable scrub typhus group of rickettsioses from hilly region in Nepal - A case report.

Introduction: Purpura fulminans is an acute and fatal condition presenting with acute progressive hemorrhagic infarction of the skin and disseminated intravascular coagulation. Scrub typhus, is an emerging disease of Nepal, despite being a rickettsioses has been rarely associated with Purpura fulminans. The non-specific clinical presentation and limited diagnostic facility make it difficult for clinicians to diagnose the disease. Knowing the prevalence of the disease, suspecting the disease early and treatment with appropriate antibiotics can limit the course of the disease. Case presentation: A 46-year-old female with no comorbidity presented with febrile illness and generalized weakness in the emergency department. During the course in hospital, she developed purpura followed by painful hemorrhagic bullae in bilateral lower limb with bluish discoloration in bilateral feet. IgM antibodies against the Orientia Tsutsugamushi antigen came out to be positive making diagnosis of purpura fulminans secondary to scrub typhus. She recovered with anti rickettsial therapy. Discussion: Purpura fulminans is an emergency condition. Scrub typhus, one of the rare cause, is diagnosed with Rickettsial DNA by PCR or by Indirect Immunofluorescence Assay (IFA) or Indirect Immunoperoxidase Assay (IPA). Medical management includes Doxycycline, fluid therapy, antipyretics and surgical management includes escharotomies and fasciotomies if required. Conclusion: We feel that clinicians should be aware of rickettsia as a differential of acute febrile illness, especially when the patient presents from endemic areas. In addition to it, they should be aware of rare presentations such as purpura fulminans which can help with early suspicion of the disease and appropriate antibiotic therapy.

Upper Gastrointestinal Bleeding among Patients Admitted in Department of Emergency in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Upper gastrointestinal bleeding is a common medical emergency with significant morbidity and mortality. Its causes can be classified under variceal bleeding or non-variceal bleeding. Peptic ulcer and variceal bleeding are common causes. Thus, this study aims to find the prevalence of upper gastrointestinal bleeding among patients attending the Department of Emergency in a tertiary care centre. Methods: This was a descriptive cross-sectional study conducted on patients admitted to the Department of Emergency a tertiary care centre from September 2020 to August 2021 among 3375 patients. The ethical approval was obtained from the Institutional Review Committee of the hospital (Reference number: 328). Patients presenting with the clinical features of upper gastrointestinal bleeding in the form of hematemesis or melena were enrolled after written informed consent. Data entry was done in Statistical Packages for the Social Sciences version 20.0. for descriptive analysis. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data. Results: Out of 3375 admissions in the Department of Emergency, 85 (2.52%) (1.99-3.05 at 95% Confidence Interval) patients presented with upper gastrointestinal bleeding. Conclusions: The prevalence of upper gastrointestinal bleeding is lower in comparison to other studies done in similar settings. Keywords: bleeding; emergency medicine; upper gastrointestinal tract; varices.

Central pontine myelinolysis in a chronic alcoholic patient with mild hyponatremia: A case report.

Introduction: Central pontine myelinolysis is a type of osmotic demyelination syndrome, which involves damage to parts of brain most commonly pons. The most common causes include rapid correction of hyponatremia but other precipitating factors including alcoholism, diabetes, and chronic liver disease should also be considered. Case presentation: We present a case of 44-year-old male with a history of chronic alcohol consumption, who presented in emergency room with complaints of slurring of speech and weakness of both upper and lower limbs. His MRI brain reveals 'trident-shaped' appearance with findings of High T2W/FLAIR signal noted in the pons with relative sparing of the periphery and hypo intense on T1W images. He was managed conservatively. Clinical discussion: Proper diagnosis with MRI is needed for early detection so that proper intervention can be made on time. Conclusion: CPM can occur in the patient even if they are normonatremic or hyponatremic but can precipitate in Chronic Alcoholic patients.