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A CASE OF 31/FEMALE WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Dr .G.Vamsi Krishna

PGY2

Department of General Medicine

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CHIEF COMPLAINTS

A 31 year old female patient , Housewife by occupation , education till degree , came with

CHIEF COMPLAINTS :

Oral ulcers since 4 months
Fever on and off since 2 weeks
B/L knee pains since 2 weeks

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HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2 years ago and then she developed pain in her right shoulder . which was dull aching and continuous type of pain , for which she went to a local hospital and was prescribed some medication (unknown - ?NSAID)
Meanwhile , the pain kept alternating between right and left shoulder and sometimes both simultaneously.

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She experienced tightness of shoulder joints on waking up and needs someone to pull her up from the bed. She had mild symptomatic relief initially with those medications but pain kept recurring.

Then 6 months later she developed fever, oral ulcers, redness of eyes and diminished vision, facial puffiness and went to a private hospital.

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On routine investigations, they found that she was losing a lot of proteins in her urine, they decided to do kidney biopsy, after which a diagnosis of Lupus nephritis was made. She was started on Tab.Prednisolone 20 mg OD & MMF 500 mg 2tab BD .
After 6 months, steroids were tapered & stopped and was prescribed Tab.Mycophenolate mofetil 500 mg (2 tab at 8 AM and 1 tab at 8 PM) for 4 months, which she used for 1 month and stopped.

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2 months later she developed oral ulcers, hair loss, proximal interphalangeal joint pain of both hands in January 2022.
Her proximal interphalangeal joint pain in right and left hands is associated with early morning stiffness.
She visited a local hospital where she was prescribed methotrexate 10 mg once weekly & HCQ 200 mg OD which she used for 1 month & stopped it once her joint pains subsided.

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Now presented with c/o oral ulcers since 4 months
On & off fever since 2 weeks
B/l knee joint pain since 2 weeks
No h/o joint swelling , early morning stiffness

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PAST HISTORY
She was a k/c/o Hypothyroidsm ,and on medication ( Tab . Thyronorm 50mcg )
No H/O DM ,HTN ,CVA , CAD , Bronchial asthma , Epilepsy.

SURGICAL HISTORY
Cataract surgery of right eye in January 2022.

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TREATMENT HISTORY
Tab. MMF 500mg PO BD (8AM & 8 PM) - stopped
Tab. FOLITRAX 10mg weekly once - stopped
Tab. LIVOGEN PO BD - stopped
Tab. HCQ 200mg OD - stopped
Tab. SHELCAL PO OD
Tab. THYRONORM 50mcg

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OBSTETRIC HISTORY
31 year old P2 L2 A1 D0
In 2014 Dec, when she was 24 years she got married.
In 2015, her first pregnancy reached full term and NVD was done.
In 2018, her second pregnancy, she underwent an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication.(Tab Thyronorm 50mcg )
In 2019, her third pregnancy, reached full term and NVD was done.

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PERSONAL HISTORY
DIET – Mixed
APPETITE – Normal
SLEEP – Adequate
BLADDER AND BOWEL MOVEMENTS – Regular
No addictions

FAMILY HISTORY
Not significant
No similar complaints in the family

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GENERAL EXAMINATION

Patient is conscious , coherent , co-operative

Moderately built and Moderately nourished .

Pallor +
Icterus –
Cyanosis –
Koilonychia –
Clubbing –
Lymphadenopathy –
Oedema -

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MACULO PAPULAR RASH ON FOREHEAD

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ULCERS ON LOWER LIP

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VITALS
Temperature – 102F
BP – 120/80 mmHg
Pulse rate – 110 bpm
Spo2 – 98% at room air
Respiratory rate – 20cpm

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SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM
Inspection
Chest wall is bilaterally symmetrical
No precordial bulge
No visible pulsations , engorged veins , scars and sinuses

Palpation
JVP – Normal
Apex beat – Felt in left 5 th Intercostal space in the midclavicular line

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Auscultation
S1 S2 Heard
No murmurs or thrills

RESPIRATORY SYSTEM
Trachea – Central
Bilateral air entry +
NVBS Heard
No added sounds

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PER ABDOMEN
Abdomen is Soft , Non Tender
No organomegaly
Bowel sounds Heard
No palpable mass
No free fluid

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CENTRAL NERVOUS SYSTEM
Patient is conscious
Speech is Normal
No signs of Meningeal irritation
Motor and sensory system is normal
Cranial nerves are intact
CNS: E4V5M6

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INVESTIGATIONS

HEMOGRAM:
Hb: 9.3 gm/dl
TLC: 3500 cells/cumm
N/L/E/M: 78/15/2/5
RBC count: 3.62 millions/cumm
PLT count: 2.30 lakhs/cumm
Smear: Microcytic hypochromic anemia with leucocytopenia

CUE:
Albumin: trace
Sugars: nil
Pus cells: 2-3
Epithelial cells: 2-3

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LFT
TB: 0.9
DB: 0.2
AST: 18
ALT: 10
ALP: 123
TP: 6.3
ALB: 3.16
A/G Ratio: 1.01

RFT
Blood urea: 24
S.creatinine: 0.7
Na+: 138
K+: 4.1
Cl-: 105

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DIAGNOSIS

SYSTEMIC LUPUS ERYTHEMATOSUS - CLASS III LUPUS NEPHRITIS
WITH HYPOTHYROIDISM
WITH BILATERAL RETINAL VASCULITIS

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TREATMENT

IVF NS/RL @ 75ml/hr
Inj.Neomol 1 gm IV SOS
Tab.Dolo 650 mg PO/QID
Mucopain Gel for L/A over ulcers
Tab.Prednisolone 20 mg OD
Tab.Naproxen 250 mg BD
Tab.Folic acid 5 mg OD (weekly twice)

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DISCHARGE ADVISE

Patient improved symptomatically was discharged with the following discharge advise.
Tab. Dolo 650 mg PO/TID
Mucopain Gel for L/A over ulcers
Tab.Prednisolone 20 mg OD
Tab.Naproxen 250 mg BD
Tab.Folic acid 5 mg OD (weekly twice)
Plan to add MMF in future visits.

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QUESTIONS

Here in this case it is mentioned as LUPUS NEPHRITIS Class III
How many classes of LUPUS NEPHRITIS are there and what is class III in specific?

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QUESTIONS

Clinical manifestations & diagnostic criteria for SLE and points favouring the diagnosis of SLE in this patient?

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QUESTIONS

Autoantibodies in SLE?
Most sensitive & most specific antibodies?

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QUESTIONS

Approach & management of SLE?

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THANK YOU !

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