Ընդհանուր տվյալներ
46-year-old female Caucasian married
Կյանքի և հիվանդության անամնեզ
o Diagnosed with systemic sclerosis 4 years ago after experiencing skin changes and Raynaud's phenomenon. o No significant history of other autoimmune diseases. o Currently on low-dose corticosteroids and methotrexate for disease management. o No history of smoking, minimal alcohol consumption.
Հիվանդի գանգատները
• Tightening and hardening of the skin, especially on the hands and face. • Limited mobility of the fingers, difficulty with gripping objects due to skin tightness. • Raynaud’s phenomenon (fingers turning white or blue in response to cold or stress). • Mild joint pain in the hands and wrists. • No complaints of shortness of breath or swallowing difficulties. • Fatigue and sleep disturbances.
Առաջնային ձևաբանական տարրեր
Երկրորդային ձևաբանական տարրեր
Ցանի տեղակայումը
Եղունգների և մազերի ախտահարումը
Լաբորատոր, հյուսվածաբանական, գործիքային, դերմատոսկոպիական և այլ հետազոտությունների տվյալներ
1. Laboratory Results: o Complete Blood Count (CBC): Mild anemia, which is common in patients with systemic sclerosis. o Creatinine: Normal, ruling out significant renal involvement at this point. o Liver Function Tests (LFTs): Normal, no signs of liver involvement. o Antinuclear Antibody (ANA): Positive with a centromere pattern, which is typical of limited systemic sclerosis (a subtype of scleroderma). o Anti-Scl-70 antibodies: Negative, which helps differentiate between limited and diffuse scleroderma. o Erythrocyte Sedimentation Rate (ESR): Mildly elevated, which is nonspecific but could indicate an inflammatory process. 2. Skin Biopsy: o Histology shows fibrosis of the dermis, with collagen deposition leading to thickening of the skin. o Vascular changes are seen, including the thickening of the walls of blood vessels and mild capillary drop-out. o No signs of active inflammation or ulceration. 3. Pulmonary Function Tests: o Normal spirometry and lung volumes at present, indicating no significant pulmonary fibrosis. This is consistent with limited scleroderma, which typically has a slower progression of lung involvement compared to the diffuse form. 4. Echocardiogram and Kidney Function Tests: o Normal findings at this stage, no signs of heart or kidney involvement (e.g., no pulmonary hypertension or scleroderma-related renal crises).
Դիֆերենցիալ ախտորոշում
Dermatomyositis morphea SLE RA
Նախնական ախտորոշումը
Systemic sclerosis
Վիտամինոթերապիա
DMARDS Raynaud's Phenomenon: o Calcium channel blockers (e.g., nifedipine) for managing Raynaud’s symptoms. o Prostacyclin analogs in more severe cases. o Avoidance of cold exposure and stress management.
Տեղային բուժումը
2. Topical Treatments: o Moisturizing lotions or emollients to manage skin dryness and prevent cracks. o Topical steroids (low-potency) may be used for localized inflammation or rashes, but their role in systemic scleroderma is limited.