Bilateral Pleuritis as the Initial Symptom of Systemic Lupus Erythematosus: A Case Series and Literature Review

Abstract

We documented four cases of systemic lupus erythematosus (SLE) presenting with pleuritis as the initial disease manifestation. The diagnosis was challenging because, atypically, all patients were elderly and 3 of the 4 patients were men. Furthermore, SLE pleuritis, characterized by lymphocytic pleural effusion and high ADA activity, is difficult to differentiate from tuberculous pleurisy. A detailed physical examination, blood tests, and urinalysis are therefore indispensable to ensure an accurate diagnosis. We also reviewed the previously published case reports on SLE patients presenting with pleuritis and discussed the relevant findings.

Respiratory Manifestations in Systemic Lupus Erythematosus

“…Of note, it is the only SLE manifestation of the respiratory system included in the diagnostic criteria [ 5 ]. Pleuritis, with or without pleural effusion, can be the first manifestation of SLE in the 3% and 1% of SLE patients, respectively [ 113 , 114 ]. Pleural involvement can be present also in overlap syndromes like rhupus syndrome [ 115 ].…”

“…LE cells can be seen showing a low sensibility (about 40%) and a specificity of 80%. However, none of these characteristics are specific to SLE pleuritis [ 10 , 49 , 113 , 115 , 116 , 117 ]. Differential diagnosis may be difficult, since SLE patients can have pleural effusions for many reasons including infections, renal and cardiac failure, pulmonary embolism, and rarely malignancies.…”

“…An association of IVIg and cyclosporine has been used in chronic, refractory pleural effusion. Chest drainage, pleurodesis and/or pleurectomy are rarely necessary in severe refractory cases [ 51 , 113 , 117 , 118 , 119 ].…”

Systemic Lupus Erythematosus with Uncommon Manifestations

“…Anamnesis, pemeriksaan fisik, dan penunjang yang baik termasuk analisis cairan pleura merupakan hal yang fundamental untuk mengidentifikasi etiologi spesifik dari efusi pleura. 7,8 Pada kasus ini analisis cairan pleura menunjukkan tes Rivalta positif yang berarti efusi pleura eksudativa dan sitologi menunjukkan sel menyerupai sel LE.…”

“…Hal tersebut membuat klinisi sulit membedakan SLE dari efusi akibat TB, emboli paru, gagal jantung, efusi parapnemoni, dan efusi akibat sindrom nefrotik. 8 Titer komplemen yang rendah dan peningkatan titer ANA amat menunjang SLE sebagai etiologi efusi. Manifestasi neuropsikiatri SLE (NPSLE) pada pasien ini melibatkan sistem saraf pusat dan dominan psikiatrik dibandingkan gejala neurologis.…”