CGR 11: NOT JUST LUPUS

Abstract

We report the case of a 31-year-old Indian male who presented with acute renal failure and constitutional symptoms, in the context of a recent 2 month admission interstate and no significant family history. He had a diagnosis of systemic lupus erythematosus (SLE) made 2 years prior managed with mycophenolate mofetil, hydroxychloroquine and prednisolone, biopsy proven myositis (PL-12 positive) and radiological evidence of interstitial lung disease (RNP positive). His prolonged admission was with presumed first presentation lupus nephritis and sepsis, for which no organism was isolated, and was complicated by acute renal failure requiring filtration, hypocomplementaemia, haemolytic anaemia and thrombocytopaenia. Intravenous antibiotics, IVIg and three 1 g doses of rituximab were given, with failure to deplete the peripheral blood B cells. He improved with organ support in ICU and empirical antimicrobial therapy, and was discharged. On the index admission, he presented with a creatinine of 350 mmol/L, hypocomplementaemia (C3 0.49 g/L, C4 0.09 g/L), normocytic anaemia (76 × 109) without evidence of haemolysis, mild thrombocytopaenia (117 × 109), an inflammatory response (ESR 103 mm/h) and a bland urinary sediment with a protein-creatinine ratio of 54mg/mol. A renal biopsy demonstrated an interesting and unexpected finding, a monoclonal antibody therapy was given, and a further tissue biopsy yielded an alternative diagnosis.