Doctors Corner

This section is only meant for medical professionals. It shares without names or identities some of Dr Khubchandani’s recent important and interesting medical cases, pictures, situations- all in a day’s work.

This section will be periodically changed and its contents may not be used without permission.

Turning Points and Learning Points

Case 1

An eighteen month old girl was brought for a sudden excessive weight gain since 6 months. She weighed 17 kg on presentation. The parents showed the photograph of the girl on her first birthday which depicted a normal looking for age child. There were classic features of hypercortisolism but there were no signs of sexual precocity.  Her 8 am cortisol levels were normal an her ACTH was suppressed. There was no history of oral corticosteroid use.

Turning Point

The child had a skin rash for which she had been prescribed a clobetasol containing ointment. Seeing relief the mother was refilling her prescriptions from the compounder of the general practitioner without seeing the physician. Over six months she had used about 35 tubes of the ointment.

Learning points

  • Topical steroid creams can be absorbed from the skin to cause systemic effects.
  • Topical steroid creams are classified based on their ability to cause systemic effects and clobetasol is a super potent molecule. It should not be used in young children and in the older ones its use should be restricted to less than two weeks.
  • Just as we measure oral medicines in number of tablets or teaspoons skin preparations are measured in FTU (finger tip units)
  • Self- medication and easy over the counter availability of several drugs are a dreadful combination.
  • Historical pictures stored by parents (of health and disease) provide vital clues for a physician.

Case 2

A four year old male child is brought for a swollen ankle since about 3 weeks. The paediatrician has proposed a diagnosis of oligoarticular juvenile arthritis and has suggested an intraarticular injection. The parents seek a second opinion. The ANA is negative and eye examination is normal

Turning Points

The child’s CBC and ESR were normal. This is a male child and ANA and eye check are negative. Also the swelling emerged suddenly one evening, leading the child to limp. The needle of suspicion pointed away from oligoarticular JIA. Also isolated ankle joint swelling is not the classic presentation of oligoarticular JIA. Being a male child with acute onset of a swelling in a weight bearing joint a coagulopathy was suspected. Indeed the PTTK was prolonged and PT was normal and factor studies confirmed hemophilia.Replacement therapy was offered and the child referred to a hematologist

Learning Points

Pediatric rheumatology is all about a careful history and physical examination. Keeping one’s eyes and ears open to subtle clues helps to recognize specific patterns which help to fit the jigsaw.

Note for Doctors

Doctors wishing to contact Dr Khubchandani to discuss and/or refer their cases please email at khubchandani_office @yahoo.co.in. Mention your telephone numbers. Dr Khubchandani will call you or email you.