RESUMO
Tetralogy of Fallot (TOF) is the most common congenital heart disease (CHD) with an incidence of four in every 1000 live births in Pakistan. Classically, these children present with central cyanosis in early life; however, milder defects may remain asymptomatic for months or even years. We report a malnourished and anemic teenage male, who was admitted with shortness of breath, hemoptysis, fever, palpitations, and weight loss. On examination, vitals were stable, except for oxygen saturation, which was 84% on pulse-oximeter. Bilateral basal coarse crepitations were present on respiratory examination with a markedly reduced air entry in the right upper zone. A 2-3/6 systolic ejection murmur was appreciated on cardiac examination. The chest X-ray was consistent with a collapsed right upper lobe with fibrosis. Echocardiography was consistent with findings of TOF. Based on sputum for acid-fast bacilli (AFB smear) and GeneXpert (Cepheid Inc., Sunnyvale, California, US) Mycobacterium tuberculosis/resistance to rifampin (MTB/RIF), the patient was diagnosed with multi-drug resistant pulmonary tuberculosis (MDR-PTB). However, when the patient didn't improve with anti-tuberculous therapy, a computed tomography (CT) scan chest was done, which raised a suspicion of aspergilloma. The culture and cytology of bronchoalveolar lavage (BAL) were done, which confirmed pulmonary aspergilloma. Undiagnosed congenital heart diseases are rare in adults. Pulmonary TB is rarely reported in right-to-left shunts; however, clinicians should maintain a suspicion of this correlation.
RESUMO
Lupus erythematosus (LE) is termed as an autoimmune chronic condition which involves a spectrum of symptoms. It is a part of the connective tissue diseases. Its cutaneous form is termed as cutaneous lupus erythematosus (CLE). Prevalence of CLE is about 70 cases per 100,000 persons. The least common variety of CLE is lupus profundus (LP)-only 5% of cases. Lupus profundus, although rare, must be kept in the differential diagnoses of ulcerated lesions. It may present as a localized entity or in association with systemic lupus erythematosus (SLE) or it may lead to SLE later in life. Early diagnosis based on histopathology and aggressive treatment is essential to prevent significant physical morbidity and progression to systemic involvement. We report a case of biopsy-proven lupus profundus in a 40-year-old female who presented with high-grade fever and multiple ulcerated lesions. The lesions were appreciated on the left thigh, right gluteus, and left arm. They had an erythematous base and edematous necrotizing centers with purulent discharge. She had a history of oral ulcers, joint pain, photosensitivity, dyspnea, peptic ulcer disease, and signs of depression. Her autoimmune assays were unremarkable. We treated her with antibiotics, oral hydroxychloroquine, and oral corticosteroid. Potassium permanganate wash and methylprednisolone aceponate were applied locally on the lesions. Ulcerated LP is a rare cause of ulcerated/indurated, painful subcutaneous plaques. It may present as a localized entity or in association with SLE or it may lead to SLE later in life.
