Dila Nandari (100100375)

CASE REPORT

Systemic Lupus Erythematosus

Supervisor: dr. Gema Nazri Yanni,
Mked(Ped),Sp.A

Systemic Lupus
Erythematosus

Definitio
n:

chronic intermittent autoimmune

inflammatory characterized by
autoantibodies directed against selfantigens, immune complex formation,
and immune dysregulation, resulting in
damage to essentially any organ

. . . Systemic Lupus Erythematosus

Epidemiolo
Ethnics /
Prevalence of SLE gy
VARIES

Races
Geographics
Sex

= 4 : 1
>> childbearing
age

hypertensi
on

genetic

hormones
Drug
allergy
Sunreactive
Skin type

Etiolo
gy?

environme
nt

medication

smoking
transfusio
n

Family
history

. . . Systemic Lupus Erythematosus

Pathogen
esis
Environmental

Genetic
Factors

Factors

B-cell activation T-cell

defects

. . . Systemic Lupus Erythematosus

Pathogen
esis

. . . Systemic Lupus Erythematosus

AutoAntibodies

SelfAntigens

Ag Ab
Complex

. . . Systemic Lupus Erythematosus

Clinical
Manifestations
Constitution
al
Cardiovascula
r

Mucocutaneo
us

Pulmonar
y

Target
Organs

Neurologic
etc

Musculoskele
tal
Renal

Hematologi
c

. . . Systemic Lupus Erythematosus

S erositis
Diagnosis

O ral ulcers
A rthritis
P hotosensitivity
B lood disorders
R enal involvement
A nti-nuclear
antibodies
I mmunologic
phenomena
N eurologic disorder
M alar rash
D iscoid rash

1
1
of R)
4 C
(A

. . . Systemic Lupus Erythematosus

Treatment
Biologic DMARDs
Non-biologic DMARDs
NSAIDs
Corticosteroids
Anti-malarials

. . . Systemic Lupus Erythematosus

Prognosis
Highly variable!
Benign Rapidly progressive
Fatal
Average 10-year survival rate:
Comorbidities >
: 90% Infection

Lipid Disorders
Hypertension
Diabetes Mellitus
Bone-related
conditions
Malignancies

CASE REPORT

WIP, , 15 y.o. May 12th, 2014

Main complaint: reddish rash on the
cheeks
The complain has been occured within
last month.
The rash more red when exposed to
sunlight.
Weakness (+) last months
Decreased appetite and BW (+)
Fever is found in this month, not too high
and fever relieved with fever relieving

Hair fall occured within six month

Pale experienced in this month
Spontaneous bleeding is not found.
History of previous transfusion at a
hospital outside as much as 8 bag,
transfusion performed 3 days ago

Physical Examination

Consciousness: Compos Mentis.

Body weight : 35 kg, Body Height : 149 cm.
Dyspnea, cyanosis, icteric, anemic, and oedema (-) Temp
37,0C Face macular papular rash
Head
Eye examination revealed light reflexes in both eyes,
pupils were isochoric, both inferior
conjunctival
palpebras were not pale.Examination of the ear and
nose showed no abnormalities.

Neck
Enlargement of lymph nodes (-)
Thorax
The chest was fusiform symmetrical, no retraction of chest
wall.
Heart rate was 112 beats per minute, regular, no murmur.
Respiratory rate was 24 times per minute, regular, no ronchi.
Abdomen Seopel, peristaltic was normal.
Hepar and lien was not palpable
Extremiti Pulse was 112 beats per minute, regular, pressure and volume
was normal, warm acral,
capillary refill time less than three
es
second
Blood pressure was 90/60 mmHg.

Hematology
Hemoglobin
(HGB)
Eritrosit (RBC)
Leucocyte
(WBC)
Hematokrit
Trombosit
(PLT)
MCV
MCH
MCHC
RDW
MPV

Complete Blood Count (CBC)

Unit
Result

Reference

g%

9.10

12.0-14.4

106/mm3

2.40

4.75-4.85

103/mm3

10.30

4.5-11.0

25.30

36-42

103/mm3

171

150-450

fL
Pg
g%
%
fL

105.40
37.90
36
22.20
9.50

75-87
25-31
33-35
11.6-14.8
7.0-10.2

Neutrofil
Limfosit
Monosit
Eosinofil
Basofil
Neutrofil
Absolut
Limfosit
Absolut
Monosit
Absolut
Eosinofil
Absolut
Basofil
Absolut

Difftel Count
%
77.30
%
11.70
%
8
%
2.70
%
0.300

37-80
20-40
2-8
1-6
0-1

103/L

7.97

2.7-6.5

103/L

1.20

1.5-3.7

103/L

0.82

0.2-0.4

103/L

0.28

0-0.1

103/L

0.03

0-0.1

Carbohydrate Metabolism

Kidney
Ureum

mg/dL

17.70

<50

Creatinin

mg/dL

0.35

0.57-0.87

Electrolyte
Natrium
(Na)
Kalium (K)
Chloride
(Cl)

mEq/L

132

135-155

mEq/L

3.4

3.6-5.5

mEq/L

104

96-106

Working Diagnosis: suspected SLE

Management:
Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein
Planning :
ECG
Rena function test (RFT)
Chest Radiography
ANA Test
Anti ds-DNA

May 12th , 2014

S : Malar rash on cheeks, fever (-)
O: Sens : CM ; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL = 87.5%
Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
Head
palpebra
conjunctiva
abnormalities.

(-/-).Ears, nose and mouth : no

Neck

Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 110 bpm, regular, murmur(-)
RR: 20 tpm, regular, ronchi(-).

Abdomen

Soepel, peristaltic (+) normal, liver/spleen: not felt

Extremities Pulse 110 bpm, regular, Pressure/Volume: adequate, warm

acral
CRT < 3
BP: 90/50 mmHg

A : suspected SLE
P:
Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein

May 13th , 2014

S : Malar rash on cheeks, fever (-)
O: Sens : CM
Head
Neck

; T: 36,9 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 109 bpm, regular, murmur(-)
RR: 22 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie 110 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 110/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein

May 14-16th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 100 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 100 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein

May 17th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 100 bpm, regular, murmur(-)
RR: 22 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 100 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein

May 18th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 100 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 100 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein
Methylprednisolone pulse 1000 mg/24h/IV (day 1)

May 19th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 104 bpm, regular, murmur(-)
RR: 26 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 104 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/80 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Diet MB 1800 kkal with 7 gr of protein
Diet methylprednisolone injection 1000 mg/24h/IV ( day 2)

May 20th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 92 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 92 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Diet MB 1800 kkal with 7 gr of protein
Methylprednisolone injection 1000 mg/24h/IV ( day 3)
Ampicillin injection 1 gr/12h/IV Skin test
Chloramphenicol injection 750 mg/6h/IV

May 20th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 92 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 92 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Diet MB 1800 kkal with 7 gr of protein
Methylprednisolone injection 1000 mg/24h/IV ( day 3)
Ampicillin injection 1 gr/12h/IV Skin test
Chloramphenicol injection 750 mg/6h/IV

May 21th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 88 bpm, regular, murmur(-)
RR: 22 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 88 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Ampicillin injection 875 mg/6h/IV (day 1)
Chloramphenicol injection 875 mg/6h/IV ( day 1)
Diet MB 1800 kkal with 7 gr of protein

May 22th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 92 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 92 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Ampicillin injection 875 mg/6h/IV (day 2)
Chloramphenicol injection 875 mg/6h/IV ( day 2)
Diet MB 1800 kkal with 7 gr of protein
The patient was CPA chemotheraphy 550 mg -1100 mg in 250 cc
Nacl 0.9%

May 23th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 98 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 98 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Ampicillin injection 875 mg/6h/IV (day 3)
Chloramphenicol injection 875 mg/6h/IV ( day 3)
Methylprednisolone 4 mg 3-3-3
Hydrochloroquine 2100 mg
Diet MB 1500 kkal with 70 gr of protein

May 24th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 96 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 96 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : SLE
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Amoxiclav 3CII
Ranitidine Injection 40 mg/8h/IV
Antasida 21 tab
Methylprednisolone 4 mg 3-3-3
Hydrochloroquine 2100 mg
Diet MB 1500 kkal with 70 gr of protein

May 25-28th , 2014

S : Malar rash on cheeks, fever (-),pale (-)
O: Sens : CM
Head
Neck

; T: 37 oC ; BW: 35 kg, BL : 149 cm ; BB/BL =87.5%

Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebra

conjunctiva (-/-).Ears, nose and mouth : no abnormalities.
Enlargement of lymph nodes (-)

Thorax

Symmetrical fusiformic, retraction (-),

HR: 96 bpm, regular, murmur(-)
RR: 24 tpm, regular, ronchi(-).
Abdomen Soepel, peristaltic (+) normal, liver/spleen: not felt
Extremitie Pulse 96 bpm, regular, Pressure/Volume: adequate, warm acral
CRT < 3
s
BP: 100/70 mmHg
A : Lupus Nephritis
P : Bed rest
IVFD D5% NaCl 0,45% 20 gtt micro
Amoxiclav 3CII
Ranitidine Injection 40 mg/8h/IV
Antasida 21 tab
Methylprednisolone 4 mg 3-3-3
Hydrochloroquine 2100 mg
Diet MB 1500 kkal with 70 gr of protein

Discussion
Theory

Case

Lupus most commonly

The patient, WIP is a 15
affects women, with a
female to male ratio of 4:1. years old girl suffering
The prevalence of SLE is highest
in women aged 14 to 64 years.

from SLE

Asians with SLE had

higher rates of renal
involvement

The patient has proteinuria,

and the renal function tests
showing abnormal results
clearly suggesting renal
involvement

History of hypertension, drug

allergy, sun-reactive skin type,
smoking, and a family history of
SLE were all significantly
associated with an increasing

Patient did not admit

having any of the risk
factors

Theory
The characteristic malar or
butterfly rash involves the
cheeks and nasal bridge.

Less common findings include

sub-acute psoriasiform or
annular skin lesions, bullous or
urticarial lesions, and alopecia.

Musculoskeletal findings
include arthralgia, arthritis,
tendinitis, and myositis.

Case
This patient have a
manifestation butterfly
rash.
History of photosensitivity
(-).
This patient had alopecia
with history of easily
pulled-off hair preceding
the onset of alopecia.
Arthralgia was the main
complaint she had when
she was first admitted to
the hospital

Theory

Case

Renal disease is manifested by

hypertension, peripheral edema,
retinal vascular changes, and other
clinical manifestations associated
with electrolyte abnormalities,
nephrosis, or acute renal failure.

The patient blood pressure is

mostly normotension, but she
has peripheral edema with low
plasma albumin, and she also
experience electrolyte
abnomalities in some courses of
the disease.

Clinical presentation can include

nonspecific symptoms (eg, severe
fatigue, fever, weight loss, and
lymphadenopathy).

She had fluctuating fever

and had also lost her
weight (42 kg before sick
35 kg)

Haematologic disorder
as part of the ARA
criteria
Immunologic disorder
as part of the ARA

Anemia

Anti dsDNA was positive

Conclusion

This paper reports a case of a 15 years old female

diagnosed with Systemic Lupus Erythematosus due to
lupus nephritis. A comprehensive work up had been done
to confirm the diagnosis. The treatment for this patient
includes methylprednisolone for suppressing the
autoimmunity, hydroxychloroquine.