methyl prednisolone injection 2x62,5mg, then switch to oral and tapering off, MMF 2x500 mg, folic acid

1x1 gr, omeperazole 1x20 mg, CaCO3 3x500mg, paracetamol 3 x500mg (prn), washed eriythrocyte transfusion and albumin infuse.

INADEQUATE THERAPY OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) ?

EVRIYANTI T, ANTONI, OKTAVIANDANI W, ALIANA R, ABIDIN AZ, ALMAR A, SILAHUDDIN M, YUNIZA*, KURNIATI N*, SALIM EM* * Allergy and Immunology Division, Internal Medicine Departement of Hoesin M Hospital / Medical Faculty of Sriwijaya University, Palembang
PRELIMINARY
SLE is an autoimmune disease, characterized by the production of antibodies against components of the cell nucleus, associated with extensive clinical manifestations. Autoimmune hemolytic anemia (AIHA) is anemia caused by an autoantibody directed against red cells antigen that makes the erythrocytes being destroyed. Lupoid hepatitis is a chronic liver disease with unclear etiology, characterized by inflammation and hepatocellular necrosis. Generally, there will be autoantibody in systemic circulation.

CASE REPORT
Mrs.N/ 31 years old/ address: Lubuk Linggau, Sumatera Selatan. Chief complaint: Increasing joint pain since 2 days ago. Additional complaint: Eyes appeared yellow since 1 week ago. History of present illness: Since 6 months ago, the patient complained joints pain, hair loss, mouth sores, fever & red spots on the facehospitalizedsaid having SLE. Then, she went home & got th/ methylprednisolone, CaCO3 & omeprazole. She didnt control routinely. Since 1 month ago, she complained all of the signs and symptoms like 6 months ago, which worse since 2 days agoshe couldnt move her hands & feet. Therere also yellowish eyes color, dark tea color urinating & nausea. Physical examination: CM, BP:100/70 mmHg, P:106 x/min, RR: 22x/min, T: 38.3C. Pale conjunctiva palpebra (+), jaundice sclerae (+), hair loss (+), malar rash (+), oral ulceration (+), hepatomegaly (+), joint pain (+), edema of the dorsum pedis (+).

ADDITIONAL EXAMINATION
*

DIAGNOSIS
SLE flare up + AIHA + Lupoid hepatitis

Laboratory: Hb 8.8 g/dl, platelet 11,000/mm3, ureum 60 mg/dl, albumin 1.7 g/dl, Na 126 mmol/l, Ca 1.45 mmol/l, total bilirubin 26.49 mg/l, direct bilirubin 5.04 mg/dl, indirect bilirubin 21.45 mg/dl, alkaline phosphatase 294 U/I, AST 196 U/I, ALT 66 U/I. Urinalysis: erythrocyte 23/LPB, blood (+), bilirubin 4.8. HBsAg (-), AntiHCV (-), IgM antiHAV nonreactive, Coombs test (+), SMA (-), C3 20 (N:84-160 mg/dl), C4 5 (N:10-40 mg/dl), Anti dsDNA 786 (N<100 Iu/ml), ANA IF >1/1000 (N<1/100).

THERAPY
IVFD NS gtt XX/minute Methylprednisolone inj. 2x62,5mg, switch to oral and tapering off Mycophenolate mofetil 2x500 mg Folic acid 1x1 gr Omeprazole 1x20 mg CaCO3 3x500mg Paracetamol 3x500mg (prn) Washed erythrocyte transfusion Albumin infuse

Funduscopy: Moderate vasculitis Abdominal USG: Hepatomegaly caused by hepatitis ECG: Sinus tachycardy Thorax X-ray: Cardiomegaly. Echocardiografi: Minimal pericardial effusion. MEX-SLEDAI score: 28

DISCUSSION & CONCLUSION

Diagnosis of SLE flare up + AIHA+ lupoid hepatitis based on anamnesis: joints pain, hair loss, mouth sores, fever & red spots on the face, yellowish eyes color, dark tea color urinating & nausea. The patient had been diagnosed with SLE since 6 months ago, but she didnt control routinely. From physical examination, we found fever, pale conjunctiva palpebra (+), jaundice sclerae (+), hair loss (+), malar rash (+), oral ulceration (+), hepatomegaly (+), joint pain (+). From additional examination, therere anemia, trombositopenia , hiperbilirubinemia (especially indirect bilirubin), bilirubinuria, Coombs test (+), decrease of complements, increase of Anti dsDNA & ANA, abdominal USG: hepatitis, funduscopy: vasculitis, minimal pericardial effusion & MEX-SLEDAI score 28. The treatment of this patient was already correct, by giving steroid, Mycophenolate mofetil, washed erythrocyte tranfusion, folic acid, etc.
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