UNUSUAL PRESENTATION OF LUPUS NEPHRITIS IN A 22 YEAR OLD MALE : A CASE REPORT

Abstract

Systemic lupus erythematosus (SLE) is an autoimmune disease in which organ and cell undergo damage initially mediated by tissue binding autoantibodies & immune complexes.In most patients, autoantibodies are present for a few years before the rst clinical symptoms appears. It is ve to six times more prevalent in women than in men .Nephritis is usually the most serious manifestation of SLE, particularly because nephritis and infection are the leading cause of mortality in the rst decade of disease. We present a case of a 22 yr old male who came with complaint of bilateral pedal oedema and pufness of face since 1 month . On examination, patient was stable hemodynamically with pulse of 88 per minute, blood pressure of 110/80 millimeter of mercury with room air saturation of 99 percent and jugular venous pressure of 6-7 millimeters of water. He also had pallor in lower palpebral conjunctiva and bilateral pitting pedal oedema.There was no clubbing, icterus,cyanosis or lymphadenopathy. His routine blood investigations showed anaemia , leucocytosis , elevated creatinine, hyperkalaemia , hypoalbuminemia, iron deciency ,urine routine microscopy suggestive of RBC cast 60-70/high power eld . Complement C3 and C4 were low, ANA positive grade 3(1:1000) homogeneous and cytoplasmic speckled, ANA BLOT positive for dsDNA, nucleosome, Histones, Sm/RNP,Mi2b.His ultrasound (USG) revealed bilateral bulky kidney and heterogeneous with raised cortical echogenicity and normal size. His renal biopsy was done which showed diffuse lupus nephritis(ISN/RPS2018 modication)class IV and indices(modied NIH) of activity 15/24 and chronicity 2/12, necrotizing vascular lesions along with evidence of vascular immune deposits in diffuse immunoorescence studies and associated inammatory cells are noted. Patient received intravenous pulse therapy of methyl prednisolone 1gram for 5 days with monitoring of kidney function test. Patient was put on cyclophosphamide with hemodialysis for immunosuppression because patient was not responding to steroids, as seen by rising serum creatinine and urea levels and declining urine output. The patient improved dramatically, urine output increased and serum creatinine and urea decreased, therefore haemodialysis was discontinued, and the patient was managed conservatively and discharged on oral prednisolone with a monthly cyclophospmide injection.