Systemic lupus erythematosus (SLE) is an autoimmune disease that is characterized with autoantibodies production with on and off clinical course. It can affect any age or gender, but it has a particular tendency to affect young females, with a female-to-male ratio of about 9:1 (1)
SLE can affect almost every organ system with a diverse scale of manifestations. The disease severity can vary from a very mild illness to a systemic life-threatening illness (2–4). Although manifestations can affect almost every system in the body, cardiac and lung manifestations have a significant impact in patients’ everyday life and outcome. Respiratory affection can affect the lung, pleura or lung vasculature with various degrees of affection from an asymptomatic illness to severe respiratory compromise.
Case history / examination
A 16-year-old female has presented to our accidents and emergency department complaining of fever and coughing of blood for 3 days. Her condition started three days prior to admission with a gradual-onset, high-grade fever that was associated with rigors. She also had productive cough of red bloody sputum. There was no associated chest pain, shortness of breath, syncopal attack nor lower limb edema.
On review of her systems including GI, GU and CNS, she reported burning epigastric pain with no abdominal distension, nausea, vomiting, diarrhea nor constipation. There was no weight loss nor change in her appetite.
When it comes to her past medical history, she reported that she had been diagnosed with systemic lupus erythematosus (SLE) 5 months ago when she sought medical advice regarding recurrent facial rashes and small joints pain. Her SLE has been immunologically confirmed using anti-double stranded DNA antibodies (100 IU/mL) and ANA factor (400 IU/mL) for which she currently takes prednisone 5 mg once daily and hydroxychloroquine tabs 200 mg tabs twice daily with good adherence to treatment and regular follow-up since then. Apart from SLE, she reported no DM, HTN or any other coagulation or autoimmune diseases and she has never been hospitalized before. Her family history is unremarkable.
Her examination revealed a tachypneic drowsy patient with a Glasgow coma scale (GCS) of 8. There was a photosensitive malar rash over her cheeks. Cardiac examination was normal with no murmurs and her lung auscultation revealed no abnormalities. Abdominal examination was normal and her musculoskeletal system examination was completely normal with no joints swellings or deformities. Her vitals at time of admission were as follows: PR: 110 bpm, RR: 24, BP: 80/50 mmHg and SaO2 of 81% on Room Air.
Differential diagnosis and investigations
Up to this point, we have made a diagnosis of massive PE clinically on the basis of her modified well’s score of 5.5 (HR>100, Hemoptysis as well as no alternative diagnoses more likely than PE) in addition to the hemodynamic instability that our patient has suffered from which cannot be explained by any cardiac condition (given her normal cardiac exam and normal echocardiography excluding cardiac causes of her hemodynamic instability). A very high levels of d-dimer (10000) have supported that diagnosis. Nevertheless, we were not able to do the CT pulmonary angiography scan of the chest due to financial and logistic causes as well as the patient’s hemodynamic instability. A transthoracic echography was normal ruling out cardiac causes of possible presentation.
Treatment, outcome and follow-up
When it comes to the treatment provided to our patient, we divided it into 2 phases. First, is the phase of stabilization in which the patient was resuscitated using saline infusion that resulted in raising her BP to 110/70 as well as an IV bolus of hydrocortisone 200 mg every 6 hours. Second, is the maintenance phase in which the patient was commenced on hydroxychloroquine, meropenem and pantoprazole. We also provided adequate analgesia in addition to zinc and vitamin C supplements.
24 hours after admission, her fever improved, and the hemoptysis as well as the epigastric pain subsided. Nonetheless, she was still drowsy with a GCS of 11 and SaO2 of 90% off oxygen. Her vitals were as follows: PR= 110, BP= 100/60, RR= 28. We continued the same management plan but replacing hydrocortisone with methylprednisolone 500 mg, Clexane 6000 IU S.C every 12 hours with quinine, doxycycline and also adding N-acetylcysteine to the regimen. We also added vitamin D and Iron tablets.
On the third day of admission, calcium carbonate tabs 500 mg every 8 hours were also added to aid with managing her hypocalcemia (Serum Ca = 7.1 mg/dL, Procalcitonin = 1.5). She also received a packed red cell for a few days during her admission resulting in her Hb level been raised from 6.9 to 10.6 gm/dL. Over the next few days and by the 8th day of admission, her fever subsided and she gradually regained her normal mental status and level of consciousness. Her vitals were also stabilized and they were as follows: PR= 75, BP=120/70, RR=14 and SaO2 of 98% off oxygen. Her nasal swab for COVID came back negative and she was then discharged on oral cefditoren, hydroxychloroquine, prednisone, iron tablets, omeprazole as well as calcium carbonate. She has been followed up a month later without complications.