Chapter 100: Systemic Lupus Erythematosus: Sometimes, It’s Lupus Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Discuss the clinical presentation of SLE, including its complications.

• Design appropriate therapy for the treatment of SLE and the complications of antiphospholipid syndrome (APS) and iron deficiency anemia.

• Construct a monitoring plan for SLE, including disease activity, drug efficacy, and drug toxicity.

• Recommend appropriate therapy for the treatment of SLE during pregnancy.

PATIENT PRESENTATION

Chief Complaint

“My knees are killing me, I’m tired all the time, and I’ve got horrible pain in my stomach.”

HPI

Ann Baker is a 32-year-old woman who has been having knee pain on and off for about 2 years. She has been to the doctor a few times since then with the same complaint. Workups showed no radiologic changes to the knees, and the doctor settled on a diagnosis of early arthritis. She was not evaluated by a rheumatologist. Despite scheduled APAP and ibuprofen throughout the day, the pain has not decreased much. The pain seems to be cyclical; it is very bad for a period of weeks, and then it wanes over time. It is also worse in the summer. She thinks the rashes she gets now and then on her face and arms have something to do with the pain, since the rash happens around the same time of a bad flare-up. No matter how much sleep she gets, it does not seem to be enough; a couple of sleep medications later, she is no better than before she tried them. She has also noticed a darkening of her stool over the past couple of months.

PMH

• Knee pain × 2 years

• HTN × 1 year

• Depression × 3 years

• Fatigue × 1 year

FH

Father alive in his mid-60s; has HTN and dyslipidemia. Mother alive in her mid-60s; has asthma and seasonal allergies.

SH

Employed as a travel agent; married 5 years; occasional EtOH use and no current or past tobacco use. On inquiry, Ms Baker states she and her husband are trying to conceive.

Meds

• Hydrochlorothiazide 12.5 mg PO once daily

• Amlodipine 5 mg PO once daily

• Fluoxetine 20 mg PO once daily

• Ibuprofen 800 mg PO four times daily

• Acetaminophen 500 mg PO three times daily

• Past meds: Zolpidem 10 mg PO at bedtime and ramelteon 8 mg PO at bedtime (stopped using both after inefficacy)

All

NKDA

ROS

(+) Fatigue, rash; (–) fever, chills, peripheral edema, or alopecia

Physical Examination