2. A 40 year old female patient
presented with the complaints of:
1. Multiple recurrent erosions on
lips & buccal mucosa x 7 years
2. Multiple, raised red colored
lesions over chest, back, both
Upper Limbs & legs x 12 months
3. Aggravation of the symptoms
x 10 days
3. HISTORY OF PRESENT ILLNESS:
Oral lesions
• Multiple erosions and ulcers in the oral cavity and lips which
were intermittent and recurring.
• Associated with difficulty in chewing and talking.
Skin lesions
• Multiple, red colored lesions over body since 1 yr ; initially
over the chest which gradually increased in size, then
developed over B/L upper limbs & legs since 3 months;
associated with itching.
• H/o photosensitivity (lesions became red and painful on
sun exposure).
• H/o increased hair loss , joint pain in shoulders,
knee joints; not associated with swelling.
4. • H/o low grade, continuous fever x 2 days .
• No h/o headache , change in wt/appetite, epigastric
pain/nausea/vomiting, chest pain/palpitation/breathlessness,
sleep disturbances, altered behavior , B/B dysfunction, blood
transfusion, drug sensitivity .
PAST HISTORY: k/c/o hypothyroidism ; being
treated with medication.
• H/o repeated episodes of paralysis since 4 years (hypokalemia
with Renal Tubular Acidosis).
• No h/o TB/Asthma/HTN/any other major chronic illness.
FAMILY HISTORY: No h/o such illness in the
family.
MENSTRUAL HISTORY: H/o hysterectomy 5
years back.
OCCUPATIONAL HISTORY: used to
work in fields.
5. EXAMINATION
• GPE: conscious, co-operative, oriented to TPP, febrile
• PR: 80/min, regular, good volume, vessel wall not palpable
BP: 124/80 mmHg RR: 18/min
• O/E: multiple, erythematous, P- I- Cy- Cl- JVPNR LAP- PE-discoid
plaques with adherent scales
and well-defined hyperpigmented
border present over chest , lower
back, B/L upper limbs & legs.Carpet
Tack sign was positive. Grattage test
and Auspitz sign were negative.
• Oral mucosa: multiple ulcerations
and superficial erosions were present
on buccal mucosa and palate.
6. • Lips: multiple erosions were present over both lips ; associated with
crusting. Crust removal caused oozing of blood from the lesions.
• Nails :
Upper Limb Lower Limb
Plate Mild yellowish
brown colored
dystrophic nail
plate
NAD
Fold NAD NAD
Cuticle NAD NAD
CVS
CNS
Respi. Within normal limits
P/A
8. INVESTIGATIONS
KIDNEY BIOPSY: biopsy specimen sent for
evaluation.
ECG , X-Ray(chest) : Normal
COMPLETE HEMOGRAM:
Hb 10.4gm%
TLC 7500mm3
DLC 80/15/3/2/0
Plt 1.7 lac/mm3
PBF N/N
24-HOUR URINE:
U. Protein 1.6gm/day
HIV
HBsAg Negative
anti-HCV
ESR 112mm/hr
SKIN BIOPSY : showed epidermal atrophy
with follicular plugging. The dermis showed
moderate to dense chronic inflammatory
infiltrate.
SEROLOGICALMARKERS:
1.ANA by IF: +ve(1:640 titre); speckled pattern
2.Antibodies to dsDNA (patient refused
3.Complement (C3,C4)levels for the tests)
PBF for LE cell : Negative
RFT
LFT Normal
S. Electrolytes
RBS
9. PROBABLE DIAGNOSIS
40 year female patient with following findings:
Skin lesions characteristic of DLE (Discoid Rash)
Oral ulcers
Photosensitivity
Positive ANA titre
Proteinuria (>0.5 g/day)
--is a case of Systemic Lupus Erythematosus as per the
SLICC Criteria.
RTA with hypokalemic paralysis and speckled IF pattern of
ANA indicate:
? Overlap syndrome of SLE with secondary
Sjogren’s Syndrome
10. SYSTEMIC LUPUS ERYTHEMATOSUS
CHRONIC
CLE
SLICC Diagnostic Criteria :
CLINICAL CRITERIA IMMUNOLOGIC
CRITERIA
1. Acute cutaneous lupus
2. Chronic cutaneous
lupus
3. Oral or nasal ulcers
4. Non-scarring alopecia
5. Arthritis
6. Serositis
7. Renal dysfunction
8. Neurologic
dysfunction
9. Hemolytic anaemia
10.Leukopenia
11.Thrombocytopenia
(<100,000/mm3)
1. ANA
2. Anti-DNA
3. Anti-Sm
4. Antiphospholipid Ab
5. Low Complement (C3,
C4, CH50)
6. Direct Coombs’ test
• Occurs after sun exposure;
followed by systemic manifestatons
within few weeks
• Localised form: malar rash
• Generalised form: can involve
whole body; systemic
manifestations are present
ACUTE
CLE
• Subtypes include:
1.DLE(localised or generalised)
2.Hypertrophic DLE
3.Lupus profundus
4.Mucosal LE
5.Chilblain lupus
11. TREATMENT
CUTANEOUS
MANIFESTATIONS
~Avoid sun exposure
and use sunscreens
with high SPF.
~Cosmetic camouflage
can be used.
~Balanced diet low in
fat.
~ Topical steroids
~ Intralesional steroids
~Antimalarials
(hydroxychloroquine)
~ Oral steroids
SYSTEMIC
MANIFESTATIONS
~Conservative treatment
+ low dose
corticosteroids
~If organ threatening
SLE, high dose
corticosteroids with
immunosuppressive
drugs.
