Skip to content

From the American College of Rheumatology

Rheumatology for Primary Care
  • Symptoms
    • Fever
    • Joint Pain
    • Muscle Pain and/or Weakness
    • Rashes
    • Raynaud’s Phenomenon
  • Diseases
    • ANCA-Associated Vasculitis
    • Behcet’s Syndrome
    • Crystalline Arthropathies
    • Drug and Medication-Induced Rheumatic Diseases
    • Giant Cell Arteritis
    • Henoch-Schönlein Purpura
    • IgG4-Related Disease
    • Juvenile Dermatomyositis
    • Juvenile Idiopathic Arthritis
    • Kawasaki Disease
    • Mixed Connective Tissue Disease
    • Multisystem Inflammatory Syndrome in Children
    • Myositis
    • Polyarteritis Nodosa
    • Polymyalgia Rheumatica
    • Rheumatoid Arthritis
    • Sarcoidosis
    • Sjogren’s Disease
    • Spondyloarthritis
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
  • Case Studies
    • ANCA-Associated Vasculitis
    • Behcet’s Syndrome
    • Crystalline Arthropathies
    • Giant Cell Arteritis
    • Henoch-Schönlein Purpura
    • IgG4-Related Disease
    • Juvenile Dermatomyositis
    • Juvenile Inflammatory Arthritis
    • Kawasaki Disease
    • Mixed Connective Tissue Disease
    • Myositis
    • Pediatric Fevers
    • Polyarteritis Nodosa
    • Polymalgia Rheumatica
    • Raynaud’s Phenomenon
    • Rheumatoid Arthritis
    • Sarcoidosis
    • Sicca/Sjogren’s Disease
    • Spondyloarthritis
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
  • Labs
  • Meds
    • Commonly Used Rheumatology Meds
    • Treatment Considerations
    • Addressing Patient Fears About Rheumatology Medications
    • Medications by Diseases
  • Resources
    • Resources
    • Vaccination Considerations – Pediatrics
    • Vaccination Considerations – Adults
    • Glossary of Terms
    • ACR Clinical Guidelines
    • ACR Education Center
    • Rheumatology Provider Directory

Systemic Lupus Erythematosus Case Studies

Home ยป Systemic Lupus Erythematosus Case Studies
Systemic Lupus Erythematosus Case Studies
  • Case 1

  • Case 2

  • Case 1

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
  • Case 2

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

Related Links

SLE Overview

 

ACR Lupus Guideline

 

ACR Reproductive Health Guideline

 

SLICC Criteria for SLE 2012

 

Lupus Education and Training for Primary Care Providers

 

Self-management Tools for People Living with Lupus

We Want Your Input

Find what you needed? We would love your feedback so that we can ensure the site meets the needs of primary care providers.

Give Feedback
Primary Care2024-05-21T13:47:59+00:00

American College of Rheumatology Information

About ACR

ACR Contacts

Authors

This product was funded by a medical grant from Pfizer. The content was written by a physician work group. See Authors

© Copyright American College of Rheumatology 2025 | All rights reserved | See ACR Policies

Page load link
Go to Top