Clinical case
presentation
Lupus nephritis
Case - 1
Name :- M
Age :- 35 years
Gender :- female
Occupation :- homemaker
Address :- bangalore
Chief complaints
Breathlessness since 15 days
Fever since 1 month
Lower limb swelling since 5 days
History of presenting illness
Fever since 1 month on and off ,moderate grade
not associated with cough , vomiting , loose
stools , rash , burning micturition.
Breathlessness since 15 days non progressive not
associated with orthopnea and PND.
Lower limb swelling since 5 days insidious
onset ,gradually progressed , no diurnal variation ,
not associated with abdominal distension , no facial
puffiness .
No complaints of hematuria , decreased urine
output , frothy urine.
Past history
Recently admitted in tamil nadu for the same.
Received blood tranfusion during admitted period.
No known comorbidities
General physical examination
Patient is conscious oriented .
Hr - 96bpm
Bp - 140/90
Spo2 - 97% on room air
Pallor – present
Edema – bilateral lower limb pitting type
edema
Lips :- cheilitis +
Lip ulcer +
Skin – purpuric rash on calf bilateral
Cyanosis ,icterus ,clubbing , lymphadenopathy are
absent
Systemic examination
Respiratory system :- bilateral vesicular breath
sounds , no added sounds.
Cardiovascular system :- S1 , S2 heard , no
murmers
Central nervous system :- higher mental function
normal , no neurological deficits.
Per abdomen :- soft non tender no organomegaly .
Musculoskeletal system :-
1)Bilateral knee joint swelling +
Non tender , normal range of movememt
2)bilateral ankle joint swelling +
Non tender ,normal range of movements
Previous investigations
14/5/22 12/5/22
Hb – 10 urea – 126
Pcv-29.7 creat – 3.8
Plt – 1.6 lakh uric acid –8.7
Serological markers
RNP/Sm :- 1+ Jo 1 :- neg
Sm- :- 1+ PCNA :- neg
SS-A :- 2 dsDNA :- 1+
Ro :- 2+ HISTONE :- 2+
SS-B :- neg NUCLEOSOME :- 2+
ANA M2 :- neg DNA tropoisom –1 :- neg
Scl 100 :- neg Rib P protein :- neg
Investigations ( after admission)
Hb- 6.6 urea -100
Tc – 5380 creat – 1.8
Esr- 43 uric acid – 6.7
Plt – 0.78 S/E - 142/3.9/116
s. alb – 1.8
2D ECHO :- good lv systolic function ( EF – 64%)
Grade 1 diastolic dysfunction
Moderate pericardial effusion
USG (A+P) :- IVC dilated , liver normal ,bilateral mild
increased renal cortical echotexture
Borderline enlargement of spleen
Mild pleural effusion
Mild pericardial effusion
Mild ascites
Urine routine
Alb – 2+
Blood – 3+
Rbc – 168
Urine pcr – 3.82
Patient was started on steroid pulse therapy that is
injection Solu-medrol once a day for 3 days.
Subsequently HCQ and cyclophosphamide were
added.
Pt was planned for renal biopsy after patient's hb
and platelet improvement to know the stage of
lupus.
Patient was admitted on 18/5/22 and on 26/5/22
Hb-10.5(after blood transfusion)
Plt – 1.09
Inr – 0.89
Pt was planned to do biopsy on 26/5/22 but on the
same day morning patient's saturation dropped to
93% on room air hence renal biopsy was deferred.
Advised hrct thorax ,cbc ,d-dimer , and serum
procalcitonin levels.
Serum procalcitonin – positive (7.55ng/ml)
Cbc showing
hb –9.0
Tc- 18890
DC- N98 M1 E1
Plt- 0.80
d
Ddimer-10.9 (0-0.5)
Patient was suscepted to have infection and all
immunosuppresants were withhold
Case 2
Name :- S
Age :- 20
Gender:- female
Patient is a known case of lupus nephritis (biopsy
proven) diffuse endocapillary proliferation with
membranous GN
ISN/RPS CLASS 4 G(A) +5
CHIEF COMPLAINTS
Generalized weakness since 1 day
Vomiting since 2 days upto 10 episodes
Loose stools 3episodes
Facial puffiness and lower limb swelling since 10 days
HOPI
Pt had vomiting since 2 days upto 10 episodes ,
vomitus contained food particles, non bile stained
non blood tinged decreased on medication.
Pt also complains of loose stools 3 episodes
associated with generalized weakness .
Patient also complains of facial puffiness and
lower limb swelling since 10 days insidious in
onset , progressive with no aggravating factors.
Patient gives history of discontinuing medications
prescribed for lupus nephritis since 1month after
which facial puffiness along with bilateral lower
limb swelling started to develop.
Past history
Patient was admitted on 19/4/19 in kims hospital in
view of facial puffiness , and was evaluated and
urine pcr was found to be 2.84 on 23/4/19 and anti
Sn , U1-nRNP antibody positive.
Further biopsy was done and found out to be lupus
nephritis with diffuse endocapillary proliferation
with membranous GN.
Patient was given pulse therapy from 9/5/2019 to
11/5/19 and was put on tab wysolone and hcq for
maintainance of remission , and was slowly
tapered.
Patient was symptomatically better and was on
regular follow up but since 1 month
she stopped medications and presented to kims
with previously mentioned complaints.
General physical examination
Hr – 68bpm
Bp – 130/90
Spo2 – 98%
Facial puffiness present
Bilateral pedal edema present
Systemic examination no abnormalities detected.
Previous investigations
Urine pcr
23/4/19 - 2.84 25/4/22 - 0.14
8/7/19 - 0.67 RFT was in normal
22/7/19 - 0.39 range since 2019.
23/8/19 - 0.62
22/9/19 - 0.19
30/10/19 - 0.22
Investigations on admission (24/5/22)
Hb-10.3
Tc-6290
Plt-2.71
Urea- 61
Creat – 1.1
Treatment
Injection solumedrol 500 mg once a day for 3
days.
Tab hcq 200mg 0-0-1 to continue
Tab mycorite – S 360 1-1-1 to continue
Tab amlong 5 mg 1-0-0 to continue
Other symptomatic treatment was given.
Pt was symptomatically better and was discharged
on 27/5/22.
Thank you
