A CASE REPORT ON SYSTEMIC LUPUS ERYTHEMATOSUS

IgG:Negative, C3-81mg/dl, C4-50mg/dl, lupus anticoagulant: Negative and AntidsDNA:68. The CT Brain report shows large left MCA territory infract with mass effect and multiple other infarcts in left capsuloganglionic region left thalamus mid brain and pons which indicating CVA. The ECHO reports show LV dysfunction indicating myocarditis secondary to SLE. The HRCT of lungs revealed patchy ground glass opacity in the posterior segment of right upper lobe, few subtle ground glass opacities scattered in the basal segments of left lower lobe and few fibro atelectatic bands in the posterior basal segment of right lower lobe.Following days the patient had complaints of hypoxia, aspiration pneumonia, on and off fever and hypotension.The culture test was performed and report revealed Staphylococcus haemolyticus in blood ,klebsiella species in Tissue and Bronchoalveolar lavage. psychosis


INTRODUCTION
Systemic lupus erythematosus (SLE) is characterized by auto antibodies against self-antigens, resulting in inflammation mediated multiorgan damage.Infections, cardiovascular diseases and renal failure which accounts for the majority of mortality in these patients 1 .The Lupus foundation of America estimates prevalence to be atleast 1.5 million cases 2 .In 2008 National arthritis working group study reported the prevalence of 161000 cases of SLE identified and 322000 cases of definite or probable SLE 3 .The frequency of SLE varies by race and ethnicity, with higher rates reported in Blacks and Hispanics.The complications seen in the EDs should be treated in the normal way, the most often seen being pulmonary embolism, respiratory embolism, respiratory arrest, hemoptysis,acute myocardial infarction, and stroke 4,5 .Numerous other complications including cerebritis, renal dysfunction, pulmonary hemorrhage, and pericardial tamponade can be treated by proper consultations 6 .Congestive heart failure in patients with SLE is often multifactorial in origin 7 .Individuals with lupus have a considerably high risk of stroke, atherosclerosis or early "coronary heart disease" (CHD) and many other "cardiovascular-related disorders" as relative tothose without lupus 8 .Numerous clinical signs include proteinuria, renal involvement, muco-cutaneous involvement/ ulcers, malar rash, seizures, urinary cellular casts, fever, hemolytic anemia, thrombocytopenia, and lymphadenopathy 9 .People with SLE often experience a wide range of symptoms as well as have multiple combinations of the organs involvement, while no definitive test can establish the systemic lupus diagnosis 10 To assist health care professionals to improve the SLE diagnosis accuracy, 11 such criteria were identified by the American Rheumatism Association 11 .These include discoid skin rash (redness in patches with hypopigmentation and hyperpigmentation tends to cause scarring), arthritis (more than two tender and swollen joints of the extremities), malar (observed on face mainly over the cheeks) "butterfly" rash, irritation of brain (manifested by psychosis or seizures referred to as "lupus cerebritis"), pericarditis or pleuritis, mucous membrane ulcers, antinuclear antibody, blood-count abnormalities, photosensitivity (rash observed in skin in reaction to exposure to ultraviolet light or sunlight), and abnormalities in kidney 7 .
Pharmacological therapy varies depending on the severity of the disease condition and the organ systems involved.Patients with mild symptoms may only require the use of NSAIDS or antimalarials, while more severe disease may require corticosteroids or immunosuppressant 12 .Unfortunately there is a higher mortality risk due to a higher risk of complications, and adverse effects due to high doses can make interpretations of clinical presentations or clinical responses complicated 12 .It is therefore important that the management of SLE patients require a healthcare team of multiple disciplines and professions, with close monitoring and control to prevent the worsening of the disease or the development of complications.This case study presents a case of an SLE patient who has developed complications during her course of treatment.The study aims to emphasize the need for proper guidelines for management of SLE and its complications that could change the disease course.

CASE PRESENTATION:
A 29 year old female patient was admitted to the emergency department with complaints of generalized tiredness, fever with joint pain, swelling, and few episodes of seizure on and off and blackish discoloration of right prig toe.The patient had numbness on left upper and lower limb.On local examination she had butterfly rashes over the cheeks and gangrenous blackish discoloration over the right big toe and her vital signs were noted for tachycardia 143 beats per minute, temperature 100.5°F and BP 100/60 mm Hg.Initial laboratory tests demonstrated hypothyroidism and severe inflammatory condition: hemoglobin of 11.2 g/dL (12.0 -16.0 g/dL), platelets 380 × 109/mL, white blood cells (WBC) count of 25.3 × 103/μL, CRP of 78.8010 mg/L (< 10mg/L) ,TSH of 10.61 mU/L (0.4 -4mU/L).Other investigations include beta 2 glycoprotein IgG:Negative, C3-81mg/dl, C4-50mg/dl, lupus anticoagulant: Negative and AntidsDNA:68.The CT Brain report shows large left MCA territory infract with mass effect and multiple other infarcts in left capsuloganglionic region left thalamus mid brain and pons which indicating CVA.The ECHO reports show LV dysfunction indicating myocarditis secondary to SLE.The HRCT of lungs revealed patchy ground glass opacity in the posterior segment of right upper lobe, few subtle ground glass opacities scattered in the basal segments of left lower lobe and few fibro atelectatic bands in the posterior basal segment of right lower lobe.Following days the patient had complaints of hypoxia, aspiration pneumonia, on and off fever and hypotension.The culture test was performed and report revealed Staphylococcus haemolyticus in blood ,klebsiella species in Tissue and Bronchoalveolar lavage.
Based on all these findings she was diagnosed with SLE.She was treated with injection Hydrocortisone 50mg and later changed to oral prednisolone 25mg, Hydroxychloroquine200mg, Digoxin0.5mg,Aspirin 75,Eltroxin25mcg, antiepileptic such as Inj.Levetiracetam 500mg, Inj.Fosphenytoin 150mg and antibiotics such as Inj.Meropenem 2g and Inj.Colistin 3mu.The patient showed symptomatic improvement through the course of treatment.

DISCUSSION:
SLE carries the highly variable prognosis for individual patients.SLE's evolutionary history varies from fairly benign to fast growing and often lethal illness.The disease characteristics often vary between the individuals.
SLE is an autoimmune disorder characterized by multisystem inflammation, clinical manifestation, relapsing and remitting course.90% of the SLE cases occur in women, particularly at child bearing age.The nature of the disease is milder and the chances of survival are higher in persons with isolated skin and musculoskeletal involvement than for those with the renal diseases 13 and CNS diorders 14 .Congestive heart failure in patients with SLE is often multifactorial in origin 15 .Individuals having lupus possess a significantly high risk for stroke, atherosclerosis or premature "coronary heart disease" (CHD) and many other "cardiovascular-related conditions" as compared to those deprived of lupus 16 .

Mr. Ajeena Anto et al. ISSN NO: 2231-6876
The diagnosis of the SLE is on combination of clinical results and laboratory data.In 2008, The American College Of Rheumatology (ACR) and The European League Against Rheumatism (EULAR) published new standards for the classification of SLE 17 .Prognosis factors from the EULAR recommendation 18 .
 Clinical findings: Skin lesions, arthritis, serositis, neurologic manifestations such as seizures, psychosis and renal involvement  Diagnostic study results: Anemia, thrombocytopenia, leukopenia, increased serum creatinine levels  Immunologic test results: Serum C3 and C4 concentration (which may be low), as well as the presence of anti-double-stranded DNA (anti-dsDNA), and antiphospholipid (aPL), and anti-ribonucleoprotein (anti-RNP).Management of systemic lupus erythematosus (SLE) often depends on disease severity and disease manifestations, 19 although hydroxychloroquine has a key role for long-term treatment in all SLE patients.Cutaneous symptoms, musculoskeletal symptoms, and serositistypically represent a milder disease, that may wax and wane with the progression of the disease.These are often regulated with nonsteroidal anti-inflammatory drugs (NSAIDS) or low-potency immunosuppression drugs beyond hydroxychloroquine and/or short courses of corticosteroids.More prolonged steroid use is generally intended for cases which involvesvital organs 20 .In addition to thenon-pharmacologic and pharmacological therapies, the primary concern for the individuals with SLE requires medical and educational resources.Drug therapy for SLE are designed to suppress the inflammation and immune responses 7 .

CONCLUSION
The current case report implies that SLE should be considered during refractory heart failure to substantial conventional therapy, exclusively in young females.Furthermore, early corticosteroids treatment, either with or without immunosuppressive agents, might result in improved and better outcomes.SLE treatments need to be planned on individual basis with primary consideration in order to use the best suited therapy to target the affected organ systems.Lack of certain biological markers, heterogeneity of the disease as well as absence of single outcome measurement for improvement often makes it a critical process.It is therefore important to involve professionals from various disciplines, to form a multidisciplinary team, depending on the organ systems affected.Fast and reliable flow of information is crucial among clinicians working together to provide a positive prognosis for the patients.There needs to be constant monitoring and evaluation of therapeutic regimens of the patient along with their response, due to the complicated and severe nature of the disease.

ACKNOWLEDGEMENT
We take this opportunity to express our sincere gratitude to all the department faculty members for their help and support to publish this case report.