A 30 yo F with hx of migraine headaches presents with complaints of hair loss and intermittent hand, knee, and wrist pain.
Questions to Ask
- Onset of presenting symptoms?
- Characteristics of joint pain?
- Any other symptoms?
- Is the joint pain worse in the morning? How long does it last?
- Does the patient have hematuria?
- Any drug use? Supplements? Over-the-counter pain medications such as NSAIDs?
- Family history of autoimmune disease?
- Any rashes?
- Any chest pain when taking a deep breath?
- Any frothy/foamy urine?
History & Physical Exam
- Rash and joint pain started last week during a family trip to Florida.
- Hand pain is in her wrists and MCPs.
- No swelling but stiffness is worse for the first hour of the day
- Pain is mild but noticeable.
- She has never had these symptoms before.
- No focal alopecia, oral or nasal ulcers, chest pain, shortness of breath, or abdominal pain.
- Physical exam:
- Rash on the cheeks and nose, sparing the nasolabial folds
- Wrists and MCPs are tender but not swollen.
Diagnostic Workup
- Recommended initial labs: CBC with diff, CMP, ANA by IFA, anti-dsDNA, anti-Smith, SSA, SSB, complement (C3/C4) levels, ESR, CRP, urinalysis, urine protein/creatinine ratio
- Recommended imaging: echocardiogram
Referrals
- Refer to rheumatology (STAT)
- Refer to nephrology for kidney biopsy
- Refer to dermatology
Treatment & Management
- Given high pretest probability of lupus, and in the setting of a malar rash, can initiate treatment for acute flare of lupus
- Can start hydroxychloroquine (weight-based dosing not to exceed 5 mg/kg)
- Can also start topical steroid or systemic steroids to treat acute flare (e.g. prednisone 20 mg per day with a taper over ~6 weeks) for symptom relief
- Monitor blood sugars, blood pressure, volume overload
A 25 yo F with no significant PMH presents with a rash on her face in a malar distribution. She also complains of weight gain and pain in her hands.
Questions to Ask
- Onset of rash?
- Joint involvement? Bilateral?
- Is the hand pain and stiffness worse in the morning?
- Any other symptoms?
History
- She developed leg swelling 2 weeks ago.
- Also noticed that her face is swollen in the morning, especially around her eyes
- Has been getting progressively short of breath since then
- First noticed a bald spot on her scalp 2 months ago
- Has had intermittent arthralgias for 6 months
- Has noticed her urine has become foamy and slightly pink
Diagnostic Workup
- Recommended initial labs: CBC with diff, CMP, ANA by IFA, anti-dsDNA, anti-Smith, SSA, SSB, complement levels, ESR, CRP, RF, CCP (due to joint involvement), urinalysis, urine protein:creatinine
- Recommended imaging: hand X-rays – 3 views
- If urine studies are consistent with glomerulonephritis (GN), must rule out infection and recommend renal biopsy to evaluate for lupus nephritis; biopsy needed within 2 weeks, preferably sooner.
Referrals
- Given high pretest probability of lupus nephritis, workup should be expedited and patient should be urgently evaluated by a rheumatologist and a nephrologist
- If cannot be seen within a few days, refer for hospital admission
Treatment & Management
- Start hydroxychloroquine (weight-based dosing not to exceed 5 mg/kg)
- High-dose steroids for kidney involvement, 1 mg/1kg (to a max of 60 mg) daily, with taper plans based on kidney biopsy results
- Add immunosuppressive therapy (mycophenolate or cyclophosphamide) for lupus nephritis
- Patient must be monitored closely to ensure response to therapy and to evaluate for possible relapse