Systemic lupus erythematosus, an autoimmune disease with multiple clinical ways of presentation
15 Vistas
Licencia
Este es un artículo de acceso abierto, distribuido bajo los términos de Creative Commons Attribution (CC .BY. NC-4). Esta permitido copiar y redistribuir el material en cualquier medio o formato. Remezclar, transformar y construir a partir del material . Usted debe dar crédito de manera adecuada, brindar un enlace a la licencia, e indicar si se han realizado cambios. Puede hacerlo en cualquier forma razonable, pero no de forma tal que sugiera que usted o su uso tienen el apoyo de la licenciante. Usted no puede hacer uso del material con propósitos comerciales.
Systemic lupus erythematosus, an autoimmune disease with multiple clinical ways of presentation
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect any organ in the body. Therefore, the clinical manifestations that patients present are highly variable, they can have mild conditions such as localized skin or joint manifestations, up to more serious conditions, such as kidney, hematological or central nervous system conditions 1. The SLE is characterized by abnormal production of autoantibodies, the most characteristic are antinuclear antibodies (ANA), and their specificities, and antiphospholipid antibodies. 1,2.
In SLE, the most frequently affected systems are the skeletal muscle and the mucocutaneous, with a variable frequency between 80 and 90% of cases. It is followed in frequency by the manifestation of serositis between 50 to 70%, 30 to 60% of patients present pleuropulmonary manifestations at least once during the course of their disease, and this condition is associated with higher mortality. Pleuropulmonary disease in SLE can be directly associated with SLE or be secondary. Renal involvement is present in 40 to 60% of cases, it is one of the most serious manifestations of SLE, with high morbidity and mortality, and may present with a rapid progression to end-stage kidney disease, which determines the need for major diagnosis and treatment. 3
In this review, we present a clinical case of SLE with particular clinical manifestations, with the aim of providing the reader with key findings in this pathology to improve the precision of the diagnosis early and thus initiate treatment in a timely manner.
Lupus erythematosus is an inflammatory autoimmune disease of the connective tissue.4 Skin and mucosal lesions appear in 80% of patients.5 It is important to mention that the patient had previously been treated for a clinical picture of iron deficiency anemia, for which she received iron VO 100mg every 12 hours, causing metrorrhagia. However, when requesting blood chemistry, the results suggested in this patient, anemia of chronic disease, therefore it was important to rule out an associated inflammatory disorder like SLE.Subsequently, due to the presence of asymmetric lymphadenopathies in the cervical region, the echographic sonographic shows multiple mix nodules of variable sizes distributed in both sides in the neck. Polyadenopathy syndrome is a frequent manifestation in systemic lupus erythematosus (SLE). Adenopathy’s are generally small in size and are found in the cervical, inguinal, and axillary region. They are present in up to 25% of patients and usually appear in the early stages of the disease or in relapses. 6. So, in order to rule out other infectious processes or a hematologic proliferative disease, tests for these possibilities were negative. The American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) have established new criteria for the classification of Systemic Lupus Erythematosus (SLE), in which antinuclear antibodies (ANA) are required for classification and are divided into 7 clinical domains (constitutional, hematological, neuropsychiatric, mucocutaneous, serous, musculoskeletal and renal) and three immunological (antiphospholipid, complement and specific antibodies), with their respective scores and at least 10 points are required to classify the patient with SLE. In the case of these patient, these criteria are met, reaching a score of 48 points. 10
The patient had renal activity, evidenced by biopsy. To treat it, among the least toxic regimens recommended by the ACR EULAR / ERA-EDTA guidelines, mycophenolate mofetil (MMF) is an excellent choice. According to several randomized controlled trials (RCTs) a dose of 2 gr daily of MM, is not inferior to the National Institute of Health (NIH) regimen. It has been observed that the use of glucocorticoids, antimalarials and immunosuppressants can accelerate catabolism, alter the absorption of 25 (OH) D and condition resistance at the nuclear vitamin D receptor. For all the aforementioned in the studies, the patient was administered 3 pulses of methylprednisolone 1 gram every 24 hours for 3 consecutive days, continuing with reductive doses of prednisone of 1 mg per kilogram of oral weight, induction therapy was started to remission with mycophenolate progressively until reaching 3 grams, hydroxychloroquine, calcium and vitamin D were also added, achieving remission of symptoms. At 3 months, antiphospholipid antibodies were performed again, which were positive, and in laboratory studies there was a decrease in proteinuria from 24 hours to 0.5 grams in 24 hours, that is, the patient is having a total response and a favorable evolution. The optimal duration of maintenance therapy in lupus nephritis is unclear. The EULAR / ERA-EDTA guidelines recommend that maintenance immunosuppression be continued for at least 2-3 years in patients who respond to induction therapy (GC or immunosuppressant). 10