A ten-year-old previously healthy girl, who began two months before admission to the hospital with lesions on her scalp, posteriorly on her nose, then on her face and then on her mouth.
The patient was evaluated by a dermatologist, a dentist and an otorhinolaryngologist; treatment was performed due to suspicion of impetus.
No improvement was observed; in the following two weeks, the patient presented erythematous lesions on the fingers and was diagnosed with viriasis.
Even without improvement, these lesions are also observed in the fingers of both feet, associating abdominal pain and occasional vomiting.
Always affiliate, the mother refers to observing "hair loss", without other associated clinical signs.
Personal history without interest.
Family history: father diagnosed with irritable colon, without recurrences or symptoms similar to that of the girl; a maternal sister prima diagnosed one year ago with Schonlein-Henoch purpura.
When admitted to the hospital he is febrile (38oC), with good general appearance.
Physical examination revealed right malar erythema respecting the nasolabial fold, erythema and mild swelling in the left lacrimal area.
Purpuric lesions occur in the pulp tissue of the hands, feet and heels.
Aphthous stoma and enanthema are present in the oropharynx.
She doesn't have lymphadenopathies.
The osteoarticular and neurological examinations and the cardiopulmonary auscultation were normal.
1.
Leukocytes requested: in the blood count, Hb 10.6 g/dl, leukocytes 3500/μl with normal formula, platelets 126 000/μl (one month before only highlighting 4400/μl).
Blood smear showed no morphological changes.
Sedimentation rate was 44 mm/hour.
Acute phase reactants: C-reactive protein 0.18 mg/dl, procalcitonin 0.06 ng/ml.
Coagulation study, rheumatic tests and proteinogram were normal.
Immunoglobulins with IgG 1830 mg/dl and IgA 271 mg/dl. Complements C3 23.7 mg/dl and C4 4.2 mg/dl. Autoimmunity: antinuclear antibodies 1/1280 positive (SM).
Urine secretion 150-250 red blood cells/field
Bacterial serologies for Mycoplasma, parasitaria toxoplasma and viral to Epstein- couple, adenovirus B19, adenovirus, and coxsakie negative.
Positive cytomegalovirus IgM should be highlighted.
Hemoculture and pharyngeal, oral, conjunctival swabs were negative.
Chest radiography and abdominal ultrasound showed no pathological findings.
With the above mentioned clinic and dermatological structure, the patient was suspected of having systemic lupus erythematosus (SLE), and antiphospholipid antibodies (GAD), positive anti-lungus antibodies (APA), and positive anticardiolipin antibodies (Ig).
When more than four criteria of the American Association of Rheumatology were met, the diagnosis of SLE was confirmed and a renal and rheumatologic evaluation was requested.
Treatment was prescribed with general measures, antimalarials (hydroxychloroquine) and oral corticosteroids (prednisone), maintaining corresponding reviews in multidisciplinary follow-up.
