A 22‐Year‐Old Woman With Systemic Lupus Erythematosus Presents With Two Damaged Kidneys, One Seizure, No Platelets, and Many Possible Diagnoses

Abstract

A 22-year-old woman with a history of systemic lupus erythematosus (SLE) was admitted to the hospital with progressive edema. Two years before the hospitalization, a local rheumatologist diagnosed her with SLE based on a syndrome of oral ulcers, inflammatory arthritis, discoid lupus erythematosus lesions, and Raynaud's phenomenon. Serum analysis revealed high-titer antinuclear antibodies, the presence of anti-SSA, anti-SSB, anti-Sm, anti-RNP, antihistone, and anti-double-stranded DNA antibodies (anti-dsDNA), and low complement (C3 and C4) levels. Hydroxychloroquine and topical clobetasol ointment were started. One year later, the patient developed hypertension, hematuria, and proteinuria. A renal biopsy sample revealed active class III and class V lupus nephritis, and treatment with lisinopril, amlodipine, furosemide, and mycophenolate mofetil was started. After 6 months, renal function returned to baseline, and proteinuria decreased. The patient then moved away from her rheumatologist, fragmenting her outpatient care, and unbeknownst to her physicians, she lowered her dose of mycophenolate mofetil.Three months before presentation, the patient developed facial and lower extremity swelling, symptoms that worsened despite stopping her angiotensin-converting enzyme inhibitor and increasing oral diuretics. In the week before admission, she experienced frequent episodes of watery diarrhea with associated abdominal pain and decreased urinary output. On the fourth day of admission, she developed shortness of breath and exhibited a generalized tonic-clonic seizure.