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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