Case 3 - Systemic Lupus Erythematosus
Dr. Gary Mumaugh – UNW St. Paul
CASE HISTORY
A.B. is a married, 47-year-old white female homemaker with two children and a 15-year medical history of systemic lupus erythematosus. She has no known allergies. The patient takes an occasional naproxen for joint pain and antacid for heartburn but no other prescription or OTC medications. She neither smokes nor drinks alcohol. Except for lupus, the patient’s medical history is unremarkable.
Patient Case Question 1. What is the relevance of this information to her disease?
She is 5 feet, 5 inches in height and weighs 102 pounds, a decrease in weight of 23 pounds since her last physical examination nearly 1 year ago. The patient’s BP is 110/70, HR 70, RR 15/unlabored, and oral temperature 99.8 F.
She has four brothers and three sisters. An older sister has rheumatoid arthritis, an aunt has pernicious anemia, and her deceased mother suffered from Graves disease.
Patient Case Question 2. What is the significance of the patient’s family history?
Medical History
Fifteen years ago, A.B. complained to her primary care physician of multiple rashes that developed on her arms and legs whenever she went out into the sun. She also complained of several small patches of hair loss on her head that she attributed to stress and an airplane trip that she took three months previously. Flying terrifies her. Furthermore, she mentioned at that time that she lacked energy, became tired very easily, and always needed to take at least one nap each day. She was also suffering from mild arthritic pain in her fingers and elbows but attributed the joint discomfort to “growing old.”
She had been aware of these problems for approximately four months. A physical examination was conducted during which the physician noted multiple rash-like lesions on sun-exposed areas of the body, primarily on the arms and legs. A tissue biopsy of one of the lesions was taken and microscopic examination of the tissue revealed vasculitis (white blood cells within the walls of blood vessels). An ANA test was positive. The lungs were clear to auscultation, heart sounds were normal with a prominent S1 and S2, and there was no evidence of enlarged lymph nodes. Blood tests revealed an Hctof 23% and an RBC count of 3.5 million/mm3. She was also slightly jaundiced with some yellowing within the sclera. Microscopic examination of a peripheral blood smear revealed that red blood cells were normal in shape, size, and color, ruling out iron, folate, and vitamin B12 deficiencies. The total WBC count was 5,500/mm3. Urinalysis was normal. She was placed on prednisone for two months, during which time all signs and symptoms of disease resolved.
Patient Case Question 3. What might have caused the lack of energy in this patient, and what type of tests might be ordered to support this conclusion?
Patient Case Question 4. What is the significance about the patient’s Hct, RBC count, WBC count and platelet?
Patient Case Question 5. What is the most likely cause of jaundice in this patient?
Five years ago, A.B. presented again to her primary care physician, this time complaining of a productive cough and stiffness and pain in her hands and feet that seemed to come and go and to affect different joints (migratory polyarthritis). She is afraid that she is developing rheumatoid arthritis like her older sister.
Her BP at this time was 140/90, HR 105, and she had a temperature of 100oF. Auscultation of the lungs revealed abnormal lung sounds, suggesting that she had bronchitis. A chest x-ray revealed mild pulmonary edema but no white blood cell infiltrates in the terminal airways. The physician was concerned about susceptibility for developing pneumonia. Axillary and inguinal lymph nodes were slightly enlarged.
Blood tests revealed an Hctof 43%, a Plateletcount of 330,000/mm3, and a total WBC count of 1,200/mm3. A urinalysis was essentially normal. The patient was given a 10-day course of antibiotic therapy to prevent pneumonia and placed on prednisone again. All signs and symptoms resolved within three months. Now she returns to her PCP complaining of fatigue, anorexia, weight loss, and significant swelling within the abdomen, face, and ankles. The PCP notes that a ”butterfly-shaped” rash is present across the bridge of her nose and cheeks. Blood tests reveal an Hctof 24%. The WBC count is 2,400/mm3. A dipstick examination of the urine revealed an abnormal protein concentration and microscopy showed the presence of significant numbers of red and white blood cells. A 24-hour urine protein collection revealed excretion of 2.5 g protein/24 hr.
Patient Case Question 6. What is the association between the abnormal blood test results, abnormal lung sounds, and productive cough?
Patient Case Question 7. Patients with SLE should receive an influenza vaccination every year and a pneumococcal vaccination every 5 years. Why?
Patient Case Question 8. Explain the butterfly rash and it’s significance to SLE.