A challenging case that needs modification of treatment according to evolution of the problem

1. Chair:- Prof. Dr. C Jayakumar
Presented by:- Dr Shybin Usman

2.  Maya
 31 years old
 Housewife
 2 Children

3.  Referred from local hospital
 c/o fever of 1 month duration
 Treatment till then unsuccessful
 Common infective causes ruled out
 Next line of workup started

4.  Pt had :-
 Arthritis
 Oral ulcers
 Serositis (pleural and pericardial effusions)
 Anaemia + High LDH + DCT positivity
 Anti ds-DNA positivity

5. Systemic Lupus
Erythematosus

6.  Started on steroids
 Pt afebrile by end of 1st week
 General condition improved

7.  New c/o cough and recurrence of fever
 Pt in 2nd week as IP
 Lt sided chest pain
 Scanty expectoration

10.  Pt on steroids
 New onset cough and pleuritic pain
 New patches on chest X-Ray
 First suspect:-
 INFECTIVE AETIOLOGY
 Added antibiotics
 CT chest taken

13.  Consolidation with air bronchogram in the
apicoposterior segment of left upperlobe
 Minimal right pleural effusion with basal
atelectasis
 Moderate pericardial effusion

14.  After 2 weeks of antibiotic therapy
 Bouts of fever persisting
 Cough persisting
 Chest pain has become right sided
 Repeat chest X-Ray

16.  Suspicion shifted to the next accused:-
Lupus Pneumonitis

17.  Steroid dose hiked
 Fever disappears
 Cough subsides
 Chest pain subsides
 Chest X-Ray repeated after 1 week

19.  Pt discharged
 Repeat chest X-Ray @ 2 weeks follow-up

21. An overview

22.  Common
 Pleurisy in 33%
 Pleural thickening
 Effusions :-
 Small, bilateral
 Exudate
 ANA, anti ds-DNA & LE cells in fluid

23.  Dyspnoea with lung volume loss
 CXR –
 Small clear lung fields
 Bilateral high diaphragm
 Theories –
 Diaphragmatic dysfunction
 Multiple small infarcts (due to vasculitis)

24.  Dramatic and severe complication
 10% patients
 SLE flare associated
 Fever, dyspnoea, hypoxemia
 Haemoptysis rare
 Tachypnea, crackles (fine/coarse)
 CXR – Diffuse infiltrates (mimic ARDS)
 Diffuse alveolar inflammation, vasculitis and
haemorrhage

25. Lupus Pneumonitis Acute Infection
CRP ↑ ↑↑
CO Transfer ↑/↓ N
BAL Haemosiderin laden Infective Organism
macrophages
Definitive investigation :- Open-lung biopsy

26.  Rx :-
 High dose Steroids / Immunosuppressants
 Mortality ≈ 50%

27.  Atelectasis (rarely clinically significant)
 Bronchiolitis obliterans
 Interstitial fibrosis (rare)
 Restrictive PFT
 Thromboembolism