CASE REPORT

Systemic Lupus Erythematosus

USWAH SUDIRMAN (C111 12 153)

NUR REZKY EKO PUTRI (C111 09 354 )

Advisor
dr. Frans

Department Of Internal Medicine

Rheumatology Division
Faculty of Medicine in Universitas Hasanuddin Makassar 2017
 PATIENT IDENTITY

Name : Mrs. JM
Age : 46 years
Date of admission : March, 11, 2017
Address : Takalar
Occupation : Farmer
Religion : Moslem
Marital Status : Married
Race : Makassar
Medical Record : 793020
Room : HCU
 HISTORY TAKING
Chief Complaint: Decreased of consciousness

Experienced since last 10 days before come in hospital, happened

suddenly.
Become heavy the last 4 days, patient cant eat or drink
Patients with a history of fever for 1 week, before decreased of
consciousness.
Before decreased of consciousness patient looks sleepy, agitated and
slowly decreased of consciousness.
There is a history of seizures several times over in the home, and twice
while in Wahidin Hospital.
There is no nausea and vomitting, there is no cough
There is a history of weight loss 10 kg over the last 1 month
There is a history of hair loss since the last 3 months.
 HISTORY OF DISEASES

There is no history of hipertention

There is no history of diabetes mellitus, heart disease or stroke.
There are history of hospitalized with abdominal pain 3 months ago,
and with nosebleed 1 month ago
There is no history of photosensitivity, athralgia or allergy.
No family history with the same symptoms or disease
Normal defecatian and urination via cateter since 11 days.
 PHYSICAL EXAMINATION

GENERAL DESCRIPTION :
- Impression : Moderate illness
- Nutritional Status : Well-nourished
- GCS : E4V3M5

VITAL SIGN
Blood Pressure : 140/100 mmHg
Heart Rate : 120x/minute
Respiratory Rate : 22x/minute
Temperature : 38,5oC
VAS : 0/10
 PHYSICAL EXAMINATION

HEAD
Pale conjungtiva (-), icteric (-), oedema palpebra (-)
Malar rash (+). Oral ulcer (-). Alopecia (+)
JVP R+1 cmH2O

THORAKS
I : Symmetrical left and right
P : no Tumor mass , no tenderness
P : Sonor in both lung fields
A : The sound of breathing: Vesicular
Additional sound: Rhonki at mediobasal hemitorax dextra
et sinistra. Wheezing -/-
 PHYSICAL EXAMINATION
HEART
I : Ictus cordis not visible.
P : Ictus cordis palpable at ICS V linea axillaris anterior
sinistra.
P : Right heart border in ICS IV linea parasternalis
dextra;

ABDOMEN
Left heart border in ICS V linea axillaris anterior

I sinistra
: Convex, follow the motion of breath
A
A :: Heart sound
Peristaltic (+)I /normal
II pure, regular, no murmur

P : Liver : unpalpable. Lien : unpalpable

P : Tympani (+) , shifting dullness (-)c

Extremitas : No Edem (-), Vaskulitis (+)

 PHYSICAL EXAMINATION

NEUROLOGICAL STATUS
GCS E4M3V5
Excitatory Meningeal : Stiff neck (-), Kernig Sign (-)/(-)
FKL : can not be evaluated
Nn.Cranial : pupil round, isokor 2,5 mm ODS
Nn. Other Cranial : can not be evaluated
Motoric : Rf Rp

Sensoric : can not be evaluated

Otonom : urination via catheter
 RHEUMATOLOGY EXAMINATION

1. GAIT: unable to walk

2. ARM :
Acute Cutaneus Rash (-), deformity(-), ROM can not be
evaluated
3. LEG :
No sign of inflammation, deformity(-), ROM can not be
evaluated
4. SPINE : can not be evaluated
Alopecia
Malar Rash
Vaskulitis
 LABORATORY REPORT
Routine Blood, March, 10, 2017 Hematologic March, 10, 2017
WBC 13.700 mm3 Coagulatio
HB 11.6 gr/dl n 13,8
PLT 99.000 mm3 PT
NEU 77,1 % APTT 22
LYM 15,4 % INR 1,23
Blood Chemistry March, 10, 2017 Electrolit
Kidney Na/K/Cl 156/4.3/121 mmol/l
Function Bil. Total 2.87
Ureum 183 mg/dl Bil. Direct 1.70
Creatinin 2.15 mg/dl
Imunoserologic Test, March, 10,
Liver
2017
Function 134 u/l
Prokalsiton 0.73 ng/ml
SGOT 64 u/l
in
SGPT
Troponin I 0.19
GDS 127 mg/dl
 LABORATORY REPORT

Blood Chemistry (AGD), March, Urinalysa March, Leukosit +-

10, 2017 Vit.C -
10, 2017
Warna Kuning Sedimen 3 lpb
pH 7,499
kecokelat Leukosit 9 lpb
Pco2 22,1 mmHg Sedimen -
an
SO2 99,8 % PH 6,0 Eritrosit -
PO2 241,4 mmHg BJ 1,017 Sedimen Torak 8 lpk
HCO3 17,4 mmol/l Protein ++/100 Sedimen Kristal Bakteri
Glukos - Sedimen Epitel (+)
CtO2 16,4 vol% e Lain
CtCO2 18.0 mmol/l Bilirubi - Sedimen Lain-
BE -6,0 mmol/l ne Lain
Urobili Normal
nogen
Keton -
Nitrit -
Blood +/25
 LABORATORY REPORT

Routine Blood, March, 11, 2017 Routine Hematologic,

March, 11, 2017
RBC 5.170.000 mm3 LED First Time : 36
mm
WBC 13.400 mm3
Second Time : 65
HB 14.3 gr/dl mm
HCT 44.7 %
MCV 86 um3 Other Hematologic,
MCH 27.6 pg March, 11, 2017
MCHC 31.9 gr/dl Coombs Positive 2
PLT 106.000 mm3 Test
NEU 75.7 %
Blood Chemistry
LYM 16.3 %
(Liver Function), March, 11,
MONOSIT 6.1 % 2017
Albumin 3.2 gr/dl
 LABORATORY REPORT

Routine Blood, March, 14, Anemia

2017 Eritrosit Normostik Normokrom,
WBC 22,600 mm3 anisopoikilositosis,
Ovalosit (+), fragmented cell
HB 10,1 gr/dl
(+), polikromasia (+),
PLT 53.000 mm3 Bena inklusi (-), normoblast (-)
HCT 34 % Leukosit Jumlah meningkat, PMN >
Limfosit, vakuolisasi (+),
MCV 90 fL Granulasitoksik (+), sel muda
MCH 27 pg (-)
Trombosit Jumlah menurun, morfologi
MCHC 30 gr/dl
normal
NEU 84,7 % Kesan / Saran Anemia Normositik Normokrom
Susp. Ec Perdahanan disertai
LYM 9,9 %
Leukositosis dengan tanda
tanda infeksi
Trombositopenia
 LABORATORY REPORT

Routine Blood, March, 18, 2017 Blood Chemistry March, Other Chemistry
18, 2017 Cristal 4,5 mg/dl
WBC 8,600 mm3 Acid
Kidney
HB 8,9 gr/dl Function Electro
Ureum 73 mg/dl lit 161/3,4/128
PLT 29.000 mm3 Creatini 0,58 mg/dl Na/K/C mmol/l
HCT 29 % n l
Liver Other
MCV 88 fL Function 56 u/l Esbach Negative (-)
MCH 28 pg SGOT 42 u/l
SGPT 5,3 gr/dl Sel LE Negative (-)
MCHC 31 gr/dl Protein 2,3 gr/dl
NEU 75,10 % Total 3,0 gr/dl
Albumin
LYM 19,5 % Globulin
GDS 167 mg/dl
 LABORATORY REPORT

CT-Scan :
Right intracerebral hemorrhage

Foto thoraks :
- Aorta dilatation
- Heart and lungs within normal limits
 DIAGNOSIS & PROMBLEM LIST
No PROBLEM PLAN PLAN THERAPY
DIAGNOSTIC
1. SLE ANA profile --Methylprednisolone
Based on 2015 ACR/SLICC Revised 500 mg/24hours/drips
criteria for diagnostic SLE (5points) IV (during 3 days)
a. Malar Rush (+) -Monitor SLE Disease
b. Vaskulitis (+) activity index
c. Alopecia (+)
d. Psychosis/seizures/confussion
(+)
e. Hematologic disorder (+)

Based on MEXSLEDAI
1) Neurological disorders score 8
2) Thrombocytopenia score 3
3) Alopecia score 2
 DIAGNOSIS & PROMBLEM LIST

No PROBLEM PLAN PLAN THERAPY

DIAGNOSTIC
2. Consciousness Ec. Suspect Ur/cr per 3 days IVFD NaCl 20 tpm
Encephalopaty Metabolic DD/ Citicolin 500 mg /12 j/iv
Hemoragic Stroke Sohobion 1 amp / 24 j/
Based on : im
Dexamethason
History of Seizure (+) 5mg/6j/iv
CT- Scan : Intracerebral Hemoragic Diazepam 1 amp / iv
Dextra Phenitoin 2 amp/drip iv
in 100 cc NaCl 0,9%
( dalam 30 m3nit)
 DIAGNOSIS & PROMBLEM LIST

No PROBLEM PLAN DIAGNOSTIC PLAN THERAPY

3. Acute on Kidney Injury DD/ -Abdomen USG - Treat underline disease

Nefritic Lupus
Based on :
- Diagnosed as SLE
- Ureum : 183 (73 mg/dl)
- Cr : 2,15 (0,58 mg/dl)
- Proteinuria : ++/100
- Esbach (-)

4. Hipertension Grade I - Valsartan

Based on : 80mg/24hr/orally via
- BP : 140/100 mmHG NGT
 DIAGNOSIS & PROMBLEM LIST

No PROBLEM PLAN DIAGNOSTIC PLAN THERAPY

5. Hypernatremia Control Electrolite Post - IVFD NaCL 0,9 % 20

Based on : Correction tpm
Sodium : 156

6. Bisitopenia Blood Peripheral Smear Treat underline disease

Based on :

Trombosit 99.000 mm3

Hb 11.6 gr/dl
 DISCUSSION
Systemic Lupus
Erythematosus
 DEFINITION

Systemic lupus erythematosus (SLE) is an autoimmune disease in

which organs and cells undergo damage initially mediated by
tissue-binding autoantibodies and immune complexes.

In most patients, autoantibodies are present for a few years before the
first clinical symptom appears.

Symptoms vary from person to person, and may come and go, depend
on what part of the body is affected, can be mild, moderate, or severe.

Diagnosis can be difficult because lupus mimics many other

diseases; it requires clinical and serologic criteria.

Kasper D et al, 2015. (Harrisons Principle of Internal Medicine, 19 th ed.)

 EPIDEMIOLOGY

Ninety percent (90%) of patients are women of child-bearing years;

people of all genders, ages, and ethnic groups are susceptible.

Prevalence of SLE in the United States is 20 to 150 per 100,000

women depending on race and gender; highest prevalence is in
African-American and Afro-Caribbean women, and lowest prevalence
is in white men.

Kasper D et al, 2015. (Harrisons Principle of Internal Medicine, 19 th ed.)

 PATOPHYSIOLOGY
1. SLE occurs due to disruption of the regulation of autoimmune causes
excessive increase in autoantibodies.
2. This imunoregulasi disruption caused by a combination of genetic
factors, hormonal, imunology and environmental.
Genetic Factor Environment
1. Genetic factors have a very important 1. Diet, affecting the production of
role. Approximately 10% -20% of inflammatory mediators.
patients with SLE have close relatives 2. Toxins / drugs, to modify the cellular
suffering from SLE. response and immunogenicity of self
2. SLE incidence is higher in antigen.
monozygotic twins (25%) compared 3. Physical / chemical such as ultraviolet
with dizygotic twins (3%). (UV), can cause inflammation,
3. Genetic elements that most strongly triggering apoptosis of cells and cause
associated with SLE are genes of the tissue damage.
Major histocompatibility complex 4. UV radiation can trigger and
(MHC), especially the HLA (Human exacerbate photosensitivity rash in
Leukocyte Antigen) DR2 SLE, UV rays can also change the
structure of the DNA that causes the
2015 ACR/SLICC REVISED CRITERIA FOR DIAGNOSIS
OF SLE
Acute/Subacute cutaneus lupus rash Up to 2 points
Malar rash 2.P
Subacute cutaneous lupus erythematosus (SCLE) rash 1.P
Palpable purpura or urticarial vasculitis 1.P
Photosensitivity 1.P

Discoid lupus erythematosus (DLE) rash or hypertrophic lupus rash 1.P

Non-scarring frank alopecia 1.P
Oral/nasal ulcers 1.P
Joint disease 1.P
Pleurisy and/or pericarditis 1.P
Psychosis and/or seizure and/or acute confusion 1.P
2015 ACR/SLICC REVISED CRITERIA FOR DIAGNOSIS
OF SLE

Kidney involvement Up to 2 points

Proteinuria 3 + or 500 mg/day or urinary casts 1.P

Biopsy-proven nephritis compatible with SLE 2.P
Hematologic Up to 3 points
WBC count < 4000/mm3 or lymphocyte count < 1.P
1500/mm3 on 2 occasions or WBC count < 4000/mm3
along with lymphocyte count < 1500/mm3
Thrombocytopenia < 100.000/mm3 1.P
Hemolytic anemia 1.p
Serologic tests Up to 3 point
2015 ACR/SLICC REVISED CRITERIA FOR DIAGNOSIS OF
SLE

The patients with 5 points out of 16 points, have

definite diagnosis of SLE.
1.Malar rash (+)
2.Vaskulitis (+)
3.Alopecia (+)
4.Psychosis/seizures/confussion (+)
5.Hematologic disorder (+) Plt: 99.000
MEX SLEDAI SCORE
 BASED ON MEX LEDAI SCORE
The patient with 13 score out of 32 score, so this
patient in category severe SLE
1) Neurological disorders score 8
2) Thrombocytopenia score 3
3) Alopecia score 2
Mild or Moderate Flare Severe Flare

Change in SLEDAI > 3 points Change in SLEDAI > 12

Prednisone>0.5 mg/kg/day hospitalization

Prednisone >0.5 mg/kg/day

Increase in Prednisone, but not to >0.5 mg/kg/day
Or methylprednisolone pulse doses 0,5-1gr/intravenous

New Cytoxan, Azathioprine, Methotrexate,

Added NSAID or Plaquenil
Hospitalization (SLE)

 PROGNOSIS

Although current treatment of lupus has improved survival

dramatically, prolonged and complete remission (defined as 5 years
without clinical and laboratory evidence of active disease and on no
treatment) has remained elusive for most patients.

Moreover, a significant number of patients (1020% in tertiary referral

centres) do not respond adequately to immunosuppressive therapies.

The European League Against Rheumatism (EULAR), 2012.

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