RHEUMATOLOGY DIVISION
CASE REPORT
Amir Farid bin Aminuddin
C 111 12 806
Nurul Nabilah Azra binti
C 111 12 863
Advisor : dr. Meriam Malinda
CASE STUDY
A woman, 21 years old was admitted with chief
complaint of joint pain for the past 3 months, and has
exacerbated in the past month. The pain has caused
the patient to avoid any physical activities. The
patient states that all her joints are in pain especially
her knees and fingers. Patient has consulted a doctor
previously due to her pain and was prescribed pain
medication (patient does not know the type given) but
there was no change in her condition.
Patient has had a history of fever that has been
inconsistent in the past month. Hair loss (+) Cough (-)
Nausea (-) Vomiting (-) Abdominal Pain (-). Micturition
and Defecation are normal. Weight loss in the past month
though the patient does not know how much. Loss of
appetite in the past month.
Physical examination :
Vital Signs:
BP : 100/70 mmHg
RR : 20x/min
HR : 88x/min
Temp : 37.0 C
Anemic (+), Icteric (-), Malar Rash (+), Oral Ulcer (+)
Discoid Rash (-);
Breath sound : Vesicular, rh-/-, wh-/-, S1/S2 : reguler,
Hepar/Lien : No enlargement
Extremeties : Normal
Rheumatology status :
Gait : Antalgic
Arms :
Shoulder joint D et S :
Tenderness (-), Effusion (-), Erythema (-), Oedema (-)
Elbow joint D et S :
Tenderness (-), Effusion (-), Erythema (-), Oedema (-)
Wrist joint D et S :
Tenderness(-), Effusion (-), Erythema (-), Oedema (-)
Leg :
Genu D et S:
Tenderness (+), Oedema (-), Crepitation (-), Effusion (-)
Spine : normal
Laboratory Report
TEST
VALUE
WBC
4200
HB
10.1
MCV
82
MCH
28.9
PLT
150.000
GDS
88
UREUM
24
CREATININE
0.7
NATRIUM
133
KALIUM
3.5
CHLORINE
98
ANA TEST
POSITIVE
PROBLEM LIST
Based on American College of Rheumatology (ACR)
1997 Revision
O : Oral ulcer
A : Arthritis
M : Malar rash
H : Haematologic disorders
(Anaemia, Leukopenia, Thrombocytopenia)
Constitutional
Fever
Weight loss
Hair loss
1. Diagnosis & differential diagnosis
Diagnosis
SLE (Systemic lupus erythematosus)
Differential diagnosis
Sjogren syndrome
Rheumatoid arthritis
SLE
A chronic autoimmune disease
Causes an attack on the cells, tissues and organs of the body, damage the organs
and/or render the organs dysfunctional
Most affected organs : brain, heart, lungs, liver, kidneys, blood vessels, joints,
tissues, skin and the overall nervous system
Etiology : genetics / exposure to the environmental pollutants
Both men and women can be affected
Predominantly found in women between the child-bearing ages of 15-44
More common in women or African American, Asian, and Latino decent
SLE
Sjogrens syndrome
Rheumatoid arthritis
Definition
Chronic inflammatory
disease- autoantibody
response that involve skin,
joints, kidney, blood cells
and nervous systems
Chronic inflammatory
disorder- lymphocytic
infiltrates in exocrine
organs- involve eye,
mouth, parotid glands,
lungs, kidney, skin, NS
Chronic symmetrical
polyarthritis of the
small joints of the
hands and feet as well
as the larger
appendicular joints
Etiology
Autoimmune
Factor that induce T-cell
intolerance
Sex hormone
Ultraviolet rays
Drugs
Infection
Autoimmune disease
Factor :
Virus
Genetic
Environment
Autoimmune
Infection
Virus
bacteria
SLE
Sjogrens syndrome
Rheumatoid arthritis
Epidemiology
Female > male
9:1
20-40 years old
Female > male
9:1
40-60 years old
Female > Male
3:1
40-50 years old
Main clinical
presentation
Systemic :
fever
Weight loss
Fatique
Articular
symmetric polyarticular
arthritis involving the
small joints of the hands
and feet
Morning stiffness > 1
hours
Laboratory
Skin
Arthritis
Pleuritis
Pericarditis
Disturbance
renal,
hematology,
immunology and
neurology
Specific antibody:
ANA
Anti ds-DNA
Anti-SM
o
o
o
o
o
Xerophtalmia
Xerostomia
Parotitis
Extragrandular
manifestation
skin
Lung
BV-vasculitis
Arthritis
Kidneys
Specific antibody :
Anti-Ro
Anti-La
Rheumatoid Factor
2. Evaluation anamnesis & diagnostic
The following are the ACR diagnostic criteria in SLE :
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood disorders
Renal involvement
Antinuclear antibodies
Immunologic phenomena (eg, dsDNA; anti-Smith [Sm] antibodies)
Neurologic disorder
Malar rash
Discoid rash
3. Workup Diagnosis
Lab diagnostic
The following are useful standard laboratory studies
when SLE is suspected:
CBC with differential
Serum creatinine
Urinalysis with microscopy
Auto antibodi test : ANA
Radiology Imaging
Evaluation of anamnesis, physical and
additional examination
D Discoid lession
Inspection if there is discoid lession at the body (abdomen, extremities)
P Photosensitivity
Ask the patient if she ever notice, when going out during the day
(scorching sun), and when she remove her shirt there will be a rash at the
exposed skin.
I Immunologic
Ask for ds-DNA and anti-Sm)
N Neurologic disorders
Ask the patient if she had frequent headache with no definitive reason,
seizure, and also have history of taking psychiatry medication
R Renal disorders
Ask for urinalysis, do the sediment test urine to analyse content of urine
Ask for protein esbach test, to evaluate the present of protein in urine
Consistent proteinuria 0.5g/24hr
A ANA test
Ask for ANA profile
S Serositis
Pleuritis
Palpation : pleural effusion : vocal fremitus decrease
Auscultation : present of friction rub
CXR : to check for pleural effusion
Pericarditis
Auscultation : Heart sound
Electrocardiography
Echocardiography
4. Diagnostic Criteria
The diagnosis are make through ACR 1997
(American College of Rheumatology) criteria.
To make diagnosis of lupus, it is generally accepted
that 4 of11 criteria should be present or 3 of 11
criteria present with ANA test positive.
Criteria of the American Rheumatism Association for the Classification of SLE
1. Malar rash.
2. Discoid rash.
3. Photosensitivity.
4. Oral ulcers.
5. Arthritis.
6. Serositis.
Pleuritis.
Pericarditis.
7. Renal disorder.
Proteinuria > 0.5 g/24 h or 3+, persistently.
Cellular casts.
8. Neurological disorder.
Seizures.
Psychosis (having excluded other causes, e.g. drugs).
9. Haemolytic disorder.
Haemolytic anaemia.
Leucopenia or <4.0 x 109/l on two or more occasions.
Lymphopenia or <1.5 x 109/l on two or more occasions.
Thrombocytopenia <100 x 109/l.
10. Immunological disorders.
Positive LE cell.
Raised anti-native DNA antibody binding.
Anti-Sm antibody.
False-positive serological test for syphilis, present for at least six months.
11. Antinuclear antibody in raised titre.
oral ulcers
discoid rash
malar rash
CLASSIFICATION OF SLE
Classification of SLE is divided into 3 groups
based on the severity of symptoms.
Classification of SLE for this patient : Mild
mild
Skin manifestation, arthritis , organ system
function within normal limits
moderate
found lupus nephritis mild to moderate,
thrombocytopenia <50,000 and serositis major
severe
Life-threathening, thrombocytopenia
<20,000 , severe nephritis, vasculitis
abdomen, severe anemia hemolytic, massive
pleural and pericardial involvement,
significant renal damage, CNS involvement )
5. PATHOMECHANISM OF SLE
Interactions between
susceptibility genes &
environment factors
Autoantibody will bind
with its antigen and
results in the formation
of immune complexes
The immune complexes
travel throughout the
body and cannot be
phagocytes by
mononuclear
Abnormal immune
responses
Autoantibody will attack
nucleus, cytoplasm,
surface of the cell, IgG
& coagulation factor
It will induce the
activation of
complement system
which then activate the
inflammatory responses
Hyperreactivity &
hypersensitivity of T &
B lymphocytes
Autoreactive T cell
formed and induce B
cell to produce
autoantibody
Clinical manifestations
on target organs
MANIFESTATION OF SLE
Musculoskeletal Athralgia, myalgia
Cutaneous - Photosensitivity, discoid rash, malar rash
Renal Proteinuria, Nephrotic syndrome, ESRD
CNS Cognitive disorder, headache, seizure
Vascular occlusions Thrombosis
Pulmonary Lupus pneumonitis, ARDS
Cardiac CAD, pulmonary hypertension
Hematologic - Anemia, leukopenia, lymphopenia,
thrombocytopenia
Gastrointestinal Nausea, mild pain, diarrhea
Ocular Conjuctivitis, episcleritis, sicca syndrome
6. TREATMENTS
Non pharmacology :
Education/counselling
Rehabilitation programmes
Avoid ultraviolet radiation
uses of sunblock ( spf >15 )
Diet regulations
low saturated fat intake
- fish oil consumption
Pharmacology :
Corticosteroid Prednisolon 7,5 mg/24hr/oral
NSAIDS : Meloxicam 7,5 mg/24hr/oral
Chloroquin 250mg/24hr/oral
Algorithm in management of systemic lupus erythematosus (IPD pg 3367)
THANK YOU