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    Case Report: Systemic Lupus Erythematosus

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    desmyy
    Mrs. T, a 23-year-old female student, presented with pain in the metacarpal joints of both hands for 3 months. She also reported a reddish rash on her face and body triggered by sun exposure, hair loss, fatigue, appetite loss, and occasional fever. Physical examination found malar rash, easy hair removal, oral ulcers, and tenderness in the arms. Laboratory tests showed anemia, increased ESR and LED, low complement levels, and protein in the urine. She was assessed with systemic lupus erythematosus and anemia of chronic disease. The treatment plan included steroids, methotrexate, meloxicam, and monitoring of symptoms

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    Case Report: Systemic Lupus Erythematosus

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    desmyy
    75 views32 pages
    Mrs. T, a 23-year-old female student, presented with pain in the metacarpal joints of both hands for 3 months. She also reported a reddish rash on her face and body triggered by sun exposure, hair loss, fatigue, appetite loss, and occasional fever. Physical examination found malar rash, easy hair removal, oral ulcers, and tenderness in the arms. Laboratory tests showed anemia, increased ESR and LED, low complement levels, and protein in the urine. She was assessed with systemic lupus erythematosus and anemia of chronic disease. The treatment plan included steroids, methotrexate, meloxicam, and monitoring of symptoms

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    Laporan kasus rheumatologi

    Original Title

    Rheuma 1

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    Mrs. T, a 23-year-old female student, presented with pain in the metacarpal joints of both hands for 3 months. She also reported a reddish rash on her face and body triggered by sun exposure, hair loss, fatigue, appetite loss, and occasional fever. Physical examination found malar rash, easy hair removal, oral ulcers, and tenderness in the arms. Laboratory tests showed anemia, increased ESR and LED, low complement levels, and protein in the urine. She was assessed with systemic lupus erythematosus and anemia of chronic disease. The treatment plan included steroids, methotrexate, meloxicam, and monitoring of symptoms

    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    75 views32 pages

    Case Report: Systemic Lupus Erythematosus

    Uploaded by

    desmyy
    Mrs. T, a 23-year-old female student, presented with pain in the metacarpal joints of both hands for 3 months. She also reported a reddish rash on her face and body triggered by sun exposure, hair loss, fatigue, appetite loss, and occasional fever. Physical examination found malar rash, easy hair removal, oral ulcers, and tenderness in the arms. Laboratory tests showed anemia, increased ESR and LED, low complement levels, and protein in the urine. She was assessed with systemic lupus erythematosus and anemia of chronic disease. The treatment plan included steroids, methotrexate, meloxicam, and monitoring of symptoms

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    CASE REPORT

    SYSTEMIC LUPUS
    ERYTHEMATOSUS
    presented by :
    Andi Amalia Yasmin – C11114042
    Priady Wira Prasetia – C11114092

    DIVISION OF RHEUMATOLOGY
    DEPARTEMENT OF INTERNAL MEDICINE
    MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
    2018
    PATIENT IDENTITY
     Name : Mrs. T
     Age : 23 years old
     Gender : Female
     Address : Bontosallang
     Occupation : Student
     Religion : Moslem
     Marital Status : Single
     Hospital : RSWS (Rheumatology Outpatient Clinic)
     MR : 826611
    HISTORY TAKING
     Chief Complaint :
    Pain in metacarpal joint of both hands.
     Further Anamnesis :
    Pain in metacarpal joint of both hands since 3
    months ago. There is no morning stiffness or swelling.
    Also, there is reddish appeared on her face but not
    itchy. Reddish also in another lesion other part of
    body trigger with sun exposure. Patient also
    complained of hair loss. Fatigue and loss of appetite
    and sometimes feel fever.
    HISTORY TAKING
     No history of seizure
     No History of short of breath
     No History of chest pain
     No History of leg swelling
     Ho history of bleeding
     History of reccurent mouth ulcer
     There is weight loss (10 kg in 3 months)
     No history of taking medication
     No family history with the same symptoms
    Past medical History
     No history of Hipertension

     No History of Renal disorder

     No history of pulmonary TB

     No history drug allergy


    Personal history
     Patient was not a smoker

     No history of alcohol consumption

     Patient was a College Student in Farmacy

     No history of routine physical exercise


    Famiy History
     No history of Hypertension

     No History of Renal disorder

     No history of pulmonary TB

     No history of allergy
    PHYSICAL EXAMINATION
    GENERAL DESCRIPTION
     General condition : moderate illness
     Nutrition : Normoweight (BMI =18,7 kg/m2)
     Awareness : Conscious (GCS 15 E4M6V5)
     Vital sign
    - Blood pressure : 110/70 mmHg
    - Heart rate : 98x/min, regular
    - Respiratory rate : 20x/min, thoracoabdominal
    - Temperature : 36,5oC
    - VAS : 3/10 (numerical)
    PHYSICAL EXAMINATION
    HEAD AND NECK
     Face : cyanosis (-), jaundice (-), malar rash(+)
     Hair : easy to remove (+)
     Eye : anemic (+/+), icterus (-),conjunctivitis (-),
     Ear : otorrhea (-), tophi (-)
     Nose : rhinorrhea (-), epistaxis (-)
     Mouth : ulceration (-), oral ulcers (+)
     Tonsil : T1 – T1, hyperemia (-)
     Pharynx : hyperemia (-)
     Neck : JVP R+2 cmH2O, lymphadenopathy (-), bruit (-)
     Cervical : pain (-), tenderness (-), sign of inflammation (-)
     Thyroid gland : enlargement (-)
    PHYSICAL EXAMINATION
    THORAX
     I : Symmetrical left and right
     P : Normal vocal fremitus, no tumor mass, no tenderness,
     P : Sonor in both lung fields
     A : Vesicular breath sound, no rhales, no wheezing

    HEART
     I : Ictus cordis not visible
     P : Thrill not palpable
     P : Normal heart borders
     A : Normal SI/II heart sound, no additional sound
    PHYSICAL EXAMINATION
    ABDOMEN
     I : Flat, follow the motion of breath, distension (-)
     A : Peristaltic (+) with normal impression
     P : No mass, No epigastric pain, Liver and spleen are not
    palpable
     P : Tympani (+), no ascites

    EXTREMITY
    No deformity, No oedema, no tenderness
    RHEUMATOLOGY STATUS
     GAIT : Normal

     ARM :
     Dextra and sinistra : Normal, tenderness (+), deformity (-),
    color (-), dolor (+), rubor (-), squeez test (+)

     LEG : Normal, vasculitis (+), deformity (-)

     SPINE : Normal
    LABORATORY FINDING
    Components Findings Reference

    WBC 6.000/mm3 4000-10.000/mm3

    LED 22mm/hours M (0-15mm/h) ; F (0-20mm/h)

    Hemoglobin 8,5 gr/dL 12.0 – 16.0 g/dL

    PLT 120.000/mm

    Renal Function

    Ureum 16 mg/dL 10-50mg/dL

    Creatinin 0,9 mg/dL M (<1,3) ; F (<1,1)


    ASSESMENT
    Systemic Lupus Erythematosus
    (ACR 5/11)
    Anemia On Chronic Disease dd Fe
    Deficiency
    PLANNING DX
     ANA profile (Anti dsDNA, Anti Ro, anti SM, ACA)

     Coomb test, reticulocyte, Fe, TIBC, Feritine,


    Peripheral Blood Analysis

     ESR, CRP

     Complement test (C3 & C4)

     Thorax X-Ray, ECG

     Urinalysis and urine Esbach


    PLANNING TX
     Education about Disease, treatment, monitoring and
    prognosis

     Methylprednisolone 4mg/8hours/oral

     Methotrexate 10 mg/ weeks

     Meloxicam 7,5mg/24hours/oral
    Plan monitoring
     LED/CRP

     SLEDEI Score

     Complement C3 & C4

     Routine Blood Count

     Renal function
    DISCUSSION
    SYSTEMIC LUPUS ERYTHEMATOSUS
    DEFINITION

    Systemic lupus erythematosus


    (SLE) is an autoimmune
    disease in which organ and
    cells undergo damage initially
    mediated by tissue-binding
    autoantibodies and immune
    complexes.
    EPIDEMIOLOGY
     90% of patient are women of child-bearing years

     Onset usually between ages of 15 and 45 years

     In the United States  20 to 150 per 100.000 women;


    highest prevalence is in African-American and Afro-
    Caribbean women, and lowest prevalence is in the
    white men

     In 2013 at RS Hasan Sadikin Bandung  10,5% of


    patient visiting the rheumatology clinic
    PATHOGENESIS
    DIAGNOSIS
    Suspicion of SLE need to be considered if there is 2 (two) or more criteria as
    listed : 1. Young woman with 2 or more organs included
    DIAGNOSIS
    MANAGEMENT
    Mild Moderate Severe
    • Skin • Mild – moderate Nefritis • Severe Nefritis (Class IV, III+V,
    Manifestation • Thrombocytopenia (trombosit IV+V or III-V with impaired
    • Arthritis 20-50x103/mm3) renal 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
    AZA (2mg/kg/day) or MMF TR
    CS (low dose)
    (2-3gr/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)
    MANAGEMENT
    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
    MONITORING
    1. Hemoglobin, leucocyte, cells count, erythrocyte
    sedimentation rate (ESR)

    2. Blood chemistry (ureum, creatinin, liver function,


    lipid profile)

    3. ANA serology

    4. Anti-dsDNA

    5. Complement (C3,C4)
    PROGNOSIS
    • 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 (prot
    >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.
    THANK YOU

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