Systemic Lupus Erythematosus: A Case Report Mohamed Nifras, Sharooq Hameed, Shanmukakumaran Manotharan, Tharika De Alwis, Muzaina Iqbal

Systemic lupus erythematosus (SLE) is a complex, multi-organ autoimmune disease with diverse clinical manifestations due to immune dysregulation such as; autoantibody production, immune complex deposition in tissues and excessive complement activation. The pathogenesis of SLE still remains unknown; however, the roles of epigenetics has also been identified lately. The worldwide incidence of SLE varies by race, of which, 90% of SLE patients are women, particularly during the child-bearing age.  

Background

Sarah Armstrong, 32, presented with swollen and painful right calf, nocturnal leg cramps, sleeping difficulty, tiredness, lethargy, decreased appetite,drastic weight loss, ‘frothy’ urine and unexplained skin rashes recently She is a mother of a five year old boy and had a miscarriage two years ago.

Physical Examination – Slight swelling of right knee, height – 5,4”, weight – 8st 3lbs, temperature – 37.2ºC, heart rate – 82 bpm, BP – 112/70 mmHg

• An autoimmune disorder, particularly a rheumatic condition was suspected.

• First line investigations: Haematology – Full blood count (FBC) revealed low red blood cells (RBC), haematocrit (Hct) and white blood cells (WBC), indicating haemolytic anaemia and leukopenia.

Blood picture revealed abnormally sized RBCs and increased number of immature RBCs, explaining her lethargy and tiredness.

Biochemistry – Urea and electrolytes evaluate renal and liver functions. High blood urea nitrogen (BUN) value indicated possible impaired kidney function. CRP value was normal, which is a characteristic in SLE patients. Urinalysis monitors the properties of urine indicating renal or systemic abnormalities. Results revealed traces of protein, referring to an impaired kidney function. Liver function test (LFT) determines hepatocellular abnormalities; SLE patients have 25-50% chances of developing hepatic abnormalities. LFT showed very low total proteins, supporting renal impairment.

• Second line investigations: Biochemistry – Serum creatinine determines the state of kidney functions. Results showed high levels, implying impaired kidney function. Microalbuminuria was present, further supporting renal impairment. Lipid panel indicates a measure of cardiovascular disease (CVD) risks; 20 - 30% of SLE patients have high risks of CVDs. Normal results were observed, implying no cardiac involvement as of now.

Radiology – Ultrasound (U/S) of the abdomen aids identification of visual organ abnormalities. U/S revealed bilateral glomerulonephritis.

Immunology – Antinuclear antibody (ANA) test evaluates the concentration of autoimmune antibodies; 97% of SLE patients are positive for ANA. ANA test showed positive, confirming SLE as the diagnosis.

Table 3. Urine analysis

Table 5. Lipid panel

Sarah was diagnosed with SLE induced Glomerulonephritis  Treatment - anti-inflammatory drugs, steroid creams and prednisolone Further diagnosis – Antids-DNA and Antiphospholipid antibodies tests

Case Presentation

First line tests

Second line tests

References

Conclusion

Malar Rash

Discoid rash

Neurologic disorder

Oral

ulcersImmune disorder Serositis Blood

disorderRenal

disorderPhoto-

sensitivityMusculo-skeletal

ANA positive

Figure 2. Blood picture showing anisocytosis with microspherocytes, reticuolcytosis at 5%

Table 2. Urea and electrolytes

Table 4. Liver function test

• Serum creatinine – 440 µmol/L (70-150 µmol/L)

• Microalbuminuria – 120 mg/L (30-300 mg/L)

Table 1. Full blood count

Haematology

Biochemistry

Component Result Reference rangeSpecific gravity

1.018 1.010-1.025

pH 5.0 4.6-8.0Glucose Negative NegativeProtein Trace NegativeCasts Occasional

hyaline casts

Negative or occasional

hyaline casts

RBC Occasional Negative or occasional

Component Result Reference rangeAST 36 U/L 5-35U/L

ALT 28 U/L 5-35 U/L

ALP 62 U/L 30-150 U/L

Total protein 40 g/L 60-80 g/L

Albumin 42 g/L 35-50 g/L

Billirubin Assayed in the lab

3-17 μmol/L

Test Results (mg/dL)

Reference range (mg/dL)

Cholesterol <200 <200

HDL cholesterol

>59 >50

LDL cholesterol

<130 <130

Triglyceride 30 <150

Component Result Reference range

Blood urea nitrogen 25.5 mg/dL 6-20 mg/dLCreatinine To be assayed in Lab 70–150μmol/LSodium 138 mEq/L 135–145 mEq/Lchloride 104 mEq/L 95-105 mEq/LPotassium 4.2 mEq/L 3.5-5.0 mEq/LPhosphate 3.9 mg/dL 3-4.5 mg/dLUric acid 3.1 mg/dL 2.6-7.2 mg/dLC-reactive protein 10 mg/L <10 mg/LCalcium 8.9 mg/dL 8.5-10.3mg/dLFasting glucose 72 mg/dL 70-110 mg/dLCO2 27mmol/L 24-29 mmol/L

Component Result Reference range

Haemoglobin to be assayed in A410

115–160g/L

Red Blood Cells 3.9x 1012/L 4.2-5.4 x 1012/LWhite Blood Cells 4.1x 10 9/L 4.5-10 x 1012/L Neutrophils 62% 40–75% Basophils 1% 0–1% Eosinophils 2% 1–6% Monocytes 7% 2–10% Lymphocytes 28% 20–45%Haematocrit 0.35 L/L 0.37–0.47L/LPlatelet count 150 ×109/L 150-400×109/LMCV 86 fL 76–96 fLMCH 28 pg 27-32 pgMCHC 33 g/dL 30- 36 g/dL

Biochemistry

Immunology Radiology• ANA Test - Positive • U/S of abdomen – Bilateral

glomerulonephritis

Discussion

Figure 3. Photomicrograph indicating the presence of ANA using indirect immunofluorescene.

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4. Longmore, M., Wilkinson, I.B., Baldwin, A. and Wallin, E. (2014) Oxford handbook of clinical medicine, 9th edn. New York: Oxford University Press.

5. Lupus Research (2016) Symptoms of Lupus. Available at: http://www.lupusresearch.org/lupus/symptoms.html (Accessed: 3 March 2016)

6. WebMD (2016) Slideshow: A Visual Guide to Lupus. Available at: http://www.webmd.com/lupus/ss/slideshow-lupus-overview (Accessed: 2 March 2016).

American College of Rheumatology criteria for SLE diagnosis

Figure 1. Symptoms presented by the patient 3, 5, 6