• Apriyanto Lifandy

• Desmy Fadillah
• Name : Ms. YA
• Patient ID : 847183
• Date of Birth : 30/06/2000 (18 years old)
• Address : Bone
• Occupation : -
• Religion : Muslim
• Ethnic : Buginese
• Marital Status : Unmarried
• Room : HCU L1AD, bed 6
Chief complaint: swelling on the entire body
Further anamnesis:
• Swelling on the entire body has been experienced since 8 days ago,
that increased gradually. Patient has been hospitalized at Pelamonia
Hospital with the same complaint in April 2018 and was diagnosed
with inflammation of the kidney.
• No fever at the moment, there is history of 1 year intermittent fever
and was treated with Typhoid Fever 2 months ago.
• Headache is felt occasionally since the last 5 months, seizures attack
existed since 3 days ago with frequency of 4 times. The last seizure
was experienced on 2 days ago. After a seizure attack, the patient
remains conscious. Yellowish discoloration of the skin on the whole
body started to appear 4 days ago.
• Patient noticed abrupt onset of shortness of breath that is
accompanied by productive cough with white mucus since a
week ago but no chest pain.
• There is nausea and vomiting that has been experienced 2 times
since yesterday with abdominal pain that is felt as dull and
aching pain. Patient also complained of abdominal bloating.
There is decreased of appetite with ±10 kg weight loss in the
last 5 months.
• Joint pain on both feet since 8 days ago, accompanied by
swelling. There is history of same complaint since 2 months ago.
• Hair loss has been experienced for a month until now, no history
of redness on face and sensitivity to direct sunlight.
• No complaints of diarrhea, constipation, blood in stool or
abdominal distension.
• There is a presence of dark-colored urine with no complaints of
dysuria, nocturia, polyuria.
• History of receiving blood transfusion in April 2018 at
Pelamonia Hospital
• No history of bleeding
• No history of hypertension, DM, and renal disorder.
• Patient is not a smoker
• No history of alcohol consumption
• No history of routine physical exercise
• No known history of allergy
• No history of consuming herbal and other medicines.
• No history of Hypertension
• No history of DM
• No History of Renal disorder
• No history of Allergy
General Description
General condition: severe illness
Nutritional status: underweight
• Height : 150 cm
• Weight : 35 kg
• BMI : 15,5kg/m2
Awareness : Somnolen (GCS 11 E3M5V3)
Vital Signs
• Blood pressure : 90/60 mmHg
• Heart rate : 114 x/min, regular
• Respiratory rate : 20 x/min, thoracoabdominal
• Temperature : 36.7°C (axilla)
• VAS (numerical) : difficult to evaluate
HEAD AND NECK
 Face : cyanosis (-), malar rash(-), discoid lesion(-)
 Hair : easy to remove
 Eye : isocor pupils, normal light reflex, anemic
conjunctiva, no sub-conjunctival bleeding, sub-
icteric (+)
 Ear : otorrhea (-), tophi (-)
 Nose : rhinorrhea (-), epistaxis (-)
 Mouth : oral ulcers (+)
 Oral cavity : gingival hypertrophy (-)
 Tonsil : T1 - T1, hyperemia (-)
 Pharynx : pharyngeal hyperemia (-)
 Neck : JVP R+2 cmH2O, lymphadenopathy (-), bruit (-)
 Cervical : pain (-), tenderness (-), sign of inflammation (-)
 Thyroid gland : enlargement (-)
THORAX
• Inspection : Symmetrical left and right
• Palpation : Normal vocal fremitus, no palpable tumor mass,
no tenderness
• Percussion : Sonor in both lungs
• Auscultation: Vesicular breathing sounds, wheezing (-), rhales (-)
HEART
• Inspection : Ictus cordis is not visible
• Palpation : Thrill is not palpable
• Percussion : Dull, normal heart borders
• Auscultation: Regular SI/SII sounds, no additional sound.
ABDOMEN
• Inspection : Convex, no darm contour, no darm steifung
• Auscultation: Bowel peristaltic (+), normal
• Palpation : Shifting dullness(+), epigastric pain (-), no mass,
liver and spleen are not palpable
• Percussion : Hipertympani
EXTREMITIES
• Pitting edema (+) on both pedis, petechi(+) on upper and lower
extremities
• Gait : Unable to walk

• Arm : Normal

• Leg : Pedis dextra et sinistra : tenderness

(+), dolor (+), calor (+), rubor (-),
edema(+)

• Spine : Normal
 Complete Blood Count (CBC)

Leucocyte 3.200 / uL 4000-11.000/µL

Erythrocyte 2.63 x 106 / uL 4.5-5.5 x 106 / µL

Hemoglobin 8,9 g/dL 13.0 – 16.0 g/dL

Hematocrit 28 % 40-50 %

Thrombocyte 44.000 / µL 150.000-450.000 / µL

MCV 105 fL 80-100 fL

MCH 34 pg 27-34 pg

MCHC 32 g/dl 31-36 g/dL

Neutrophil 82.2 % 50-70 %

Lymphocyte 12.8 % 20-40 %

Monocyte 5.0 % 2-8 %

Eosinophil 0.0 % 2-3 %

Basophil 0.0 % 0-1 %

ESR 121/127 <10
Creatinine 0.75 0.6-1.3 mg / dL
Ureum 86 10-50 mg/dL
GOT 596 <38 U/L
GPT 84 <41 U/L
Bilirubin 5,41/5,32 <1,1/<0,3 g/dL
Blood Glucose 91 140 mg/dL
Total protein 4.7 6,6-8,7 g/dL
Albumin 1.4 3,5-5,0 g/dL
Sodium 140 136-145 mmol/L
Potassium 4,1 3,5-5,1 mmol/L
Cloride 106 97-111 mmol/L
PT/APTT/INR 10.5/27,6/0.97 10-14/22-30 seconds
Urinalysis
Protein +3 negative

Blood +3 negative

Bilirubin +3 negative
• Bilateral bronchopneumonia
• Hepatomegaly;
• Bilateral hydronephrosis;
• Ascites
Result: cerebral atrophy
 Assessment Planning Diagnostic Planning Therapy

1. Severe Systemic Lupus Peripheral Blood Smear, • KIE

Reticulocyte, Coombs test • Observation of vital
Erythematosus
Esbach test, C3 and C4, signs/hour
ACR Criteria:
ANA test • Methylprednisolone 500
- Oral ulcers(+)
mg/24 hours/drips for 3
- Non-erosive arhtritis (+) characterised by
days
tenderness and swelling
• Omeprazole 40 mg/12
- Serositis: ascites  proven by shifting
hours/iv
dullness (+) and abdominal USG
- Renal disorder: urinalysis  Proteinuria
(3+)
- Hematological disorders: anemia (Hb: 8,9
g/dL), leucopenia (3200/µL), lymphopenia
(12,8%), thrombocytopenia (44.000/µL)
- Seizures
ACR score: 6/11
 Planning
Assessment Planning Therapy
Diagnostic

2. Hypoalbuminemia - High-protein diet

Based on: Human albumin 25%
- Inadecuate intake 100cc/24hours/iv
- Edema on pedis D/S, face edema, ascites,
shifting dullness(+)
- Serum Alb: 1,4 g/dL, total protein: 4,7 g/dL

3. Suspect of Auto-immune Hepatitis (AIH) Methylprednisolone 500

Based on: mg/24 hours/drips for 3
- Sub-icteric days
- Elevated serum transaminase levels
SYSTEMIC LUPUS ERYTHEMATOSUS
 Systemic Lupus Erythematosus
(SLE) is a heterogeneous autoimmune
disease characterized by the
production of antibodies to
components of the cell nucleus in
association with a diverse array of
clinical manifestations and multi-
organ involvement.
90% of patients are women of child-bearing years.
65% of patients with SLE have disease onset between the ages
of 16 and 55 years, 20% present before age of 16, and 15%
after the age of 55.
SLE appears to be more common in urban than rural areas.
Prevalence in US  20 to 150 per 100.000 women; African-
American and Afro-Caribbean women are affected more
frequently than Caucasians.
Prevalence in Indonesia  based on the most recent survey
performed in 2017: 0.5% of total population.
 Genetic, gender, hormon,
and environmental factor

Immunological
dysregulation

Cleareance
dysfunction
Defective antigen
Dendritic cell presentation

B-Cell T-Cell

Antinuclear Antibody

- Abnormal complement
- Increased apoptosis
dysfunction Tissue
- Defective cytokine
- Defective phagocyte Damage production
activation
 Criteria Definition
Fixed erythema, at or raised, over the malar eminences, tending to spare the
Malar rash
nasolabial folds
Erythematous raised patches with adherent keratotic scaling and follicular
Discoid rash
plugging; atrophic scarring occurs in older lesions
Skin rash as a result of unusual reaction to sunlight, by patient history or
Photosensitivity
physician observation
Oral ulcers Oral or nasopharyngeal ulceration, usually painless, observed by a physician
Non-erosive arthritis involving two or more peripheral joints, characterized by
Arthritis
tenderness, swelling or effusion
a. Pleuritis: convincing history of pleuritic pain or rub heard by a physician or
Serositis evidence of pleural effusion or
b. Pericarditis: documented by ECG or rub or evidence of pericardial e usion
a.Persistent proteinuria >0.5 g per day or >3+ if quantitation is not
Renal disorder performed or
b.Cellular casts: may be red cell, haemoglobin, granular tubular, or mixed
Neurological a. Seizures
disorder b. Psychosis
a. Haemolytic anaemia with reticulocytosis, or
Haematologic b. Leucopenia: <4000/mm3, or
disorder c. Lymphopenia: <1500/mm3, or
d. THrombocytopenia: <100 000/mm3 in the absence of consuming drugs
a. Anti-DNA: antibody to native DNA in abnormal titer, or
b. Anti-Sm: presence of antibody to Sm-nuclear antigen, or
c. Positive finding of antiphospholipid antibodies based on: (1) an abnormal
Immunologic serum concentration of IgG or IgM anti cardiolipin antibodies, (2) a positive test
disorder result for lupus anticoagulant using a standard method, or (3) a false positive
serologic test for syphilis known to be positive for at least 6 months and
confirmed by Treponema pallidum immobilization or fluorescent treponema
antibody absorption test
An abnormal titer of antinuclear antibody by immunofluorescence or an
Antinuclear
equivalent assay at any point in time and in the absence of drugs known to be
antibody
associated with ‘drug-induced lupus’ syndrome
 Mild Moderate Severe
• Skin • Mild – moderate nephritus • Severe Nephritis (Class IV, III+V,
Manifestation • Thrombocytopenia IV+V or III-V with impaired renal
• Arthritis (thrombocyte 20-50x103/mm3) function
• Major serositis • Refractory Thrombocytopenia
(<20 x 103 /mm3)
• Refractory Hemolytic Anemia
Therapy
Induction Therapy • Associated with lung
Choloroquine or
MP iv (0,5-1gr/day for 3 days (haemorrhagic)
MTX
followed by: • Abdominal vasculitis
and/Or TR
AZA (2mg/kg/day) or MMF (2-
CS (low dose)
3gr/day) Induction Therapy
NSAID
+ MP iv (0,5-1gr/day for 3 days)
CS (0,5-0,6 mg/kg/day for 4-6 CYC iv (0,5-0,75 gr/m2/month x 7
weeks then lowered slowly dose)
RP

Maintenance Therapy RS TR
AZA (1-2mg/kg/day) or MMF (1-2
gr/day) Maintenance Therapy Needed Rituximab
+ CYC iv (0,5-0,75 gr/m2/3 Calcineurin Inhibitor
KS (lowered until 0,125 mg/kg/2 days months for one year) IVIg
dose)
 General practitioner
PRIMARY HEALTHCARE CENTRE SUSPECTED SLE

Reconcile

MILD SLE RHEUMATOLOGIST / INTERNIST

• Diagnose
• Activity review and disease stage
SLE with complication / • Medication planning
increase activity • Monitoring disease’s activity regularly

Moderate and Severe SLE

Refractere SLE/life threatening
1. Hemoglobin, leucocyte, cells count, erythrocyte sedimentation
rate (ESR)
2. Blood chemistry (ureum, creatinine, liver function, lipid profile)
3. ANA serology
4. Anti-dsDNA
5. Complement (C3, C4)
• Over the past decade in US, the five-year survival rate of
patients with SLE has improved to more than 95% because of
more effective recognition and treatment of infectious and
renal complication.
• Poor prognosis mostly associated with high serum creatinine
levels (>1.4 mg/dL), hypertension, NS (protein >2,6 g/24 hr),
anemia (Hb <12,4 g/dL), hypoalbuminemia,
hypocomplementemia, aPL, and male sex.
• Complication: Hemolytic anemia, thrombosis, cerebral lupus,
nephritic lupus, secondary infection.