Moderate Sle With Lupus Nefritis
MODERATE SLE WITH LUPUS NEFRITIS
Blondina Marpaung, Faisal Sinurat
Rheumatology Division
Departement of Internal Medicine University of North Sumatra
ABSTRAK
Medical Faculty of University of North Sumatra
Lupus nephritis is one of the most serious manifestations of systemic lupus
erythematosus (LES) and usually appear within 5 years after diagnosis. Lupus nephritis
is histologically evident in most patients with SLE, even those who do not show clinical
manifestations of kidney disease. Symptoms of lupus nephritis is generally associated
with hypertension, proteinuria and renal failure.
Reported a case of systemic lupus erythematosus (SLE) with severe lupus
nephritis in a man 23-years old boy in the hospital Haji Adam Malik attending with a
swollen face since 2 weeks ago accompanied by abdominal enlargement and swelling in
the extremities. Patients also complained pallor and fatigue, joint pain, sores in the
mouth and gums encountered, red rash on the arms and legs encountered.
On physical examination found vital signs within normal limits, encountered
anemia, weakened vesicular breath sounds in both lower courts of the lungs, additional
sound not found. Ascites was found, discoid rash was found on both arms and legs,
accompanied by edema in both arms and legs.
On blood examination discovered hemoglobin level 9.7 mg / d, leukocytes 1,560
/uL; platelets 50,000 /uL. Urinalysis results obtained proteinuria 2 Positive, erythrocyte
sediment 2-3 / LPB, leukocytes 2-5 / LPB, urine protein 545 (+++) mg%, 24-hour urine
protein 5,450 mg, urea level 71 mg / dl, creatinine 1.31 mg / dl, uric acid 8.7 mg / dL,
albumin 2.1 g /dL, CRP qualitative: negative, ANA test 161 , anti ds-DNA: 409 ng / ml.
On chest x-ray found bilateral pleural effusion and bronkhopenumonia. In renal
ultrasound examination was found in accordance with nephrotic pattern.
Patients treated by injection of methylprednisolone puls therapy at a dose of 500
mg / day for 3 days, followed by administration of a dose of methyl prednisolone tablets
from 0.5 to 0.6 mg / day with Cellcef (Mycophenolate Mofetil) 2 x 500 mg, furosemide
injection, Captopril 2 x 6.25 mg. Diets high in protein (an extra egg white), and fluid
balance - 500 mL. After administration of methylprednisolone pulse therapy for 3 days
followed by administration of a cortico-steroid-sparing agent (MMF), proteinuria was
reduced, edema is reduced and the patient's condition improves.
Kata kunci: lupus nephritis, SLE, pulse therapy
PENDAHULUAN
1
Lupus nephritis is one of the most serious manifestations of systemic lupus erythematosus
(SLE) and usually appear within 5 years after diagnosis. Lupus nephritis is histologically
evident in most patients with SLE, even those who do not show clinical manifestations of
kidney disease. Symptoms of lupus nephritis is generally associated with hypertension,
proteinuria and renal failure.
In America, the prevalence of SLE is 1 case per 2000 inhabitants in the general
population. Because of the difficulty of diagnosis and likely many cases go undetected, most
researchers suggest that the prevalence may be closer to 1 case per 500 -1,000 population.
There is stil no prevalence data of SLE in Indonesia until now. Number of patients with SLE
in Indonesia according to the Lupus Foundation of Indonesia (YLI) up to 2005 is estimated at
5,000 people. 1,2
CASE REPORT
A man - 23-year old came to Haji Adam Malik Hospital Medan on April 16th 2014
with the main complaints is a swollen face (myxo-oedema ), This is experienced since 3
weeks before admission to the hospital. Swollen face, especially in the morning and
decreases in the afternoon. accompanied by swelling in the legs. Since two weeks ago the
patients also complained of enlargement of the abdomen. The patient complained of joint
pain, especially in the shoulders, arms and knees. The pain is constantly moderate intensity,
relieved by pain-killers, but reappeared when the patients stopped taking medication. Patients
also complained reddish spots on both of his arms, hands and fingers, and became evident in
the first week. Rash on the face was not found, hair loss was not found. Complaints of pain
in the face and skin with redness if exposed to the sun was not found. History of pain in the
mouth with sores on both corners of the lips was found. Pallor experienced since 3 months
ago and more pronounced in the next 2 weeks. The history of Melena, haematochezia,
History of Haematuria, bleeding gums, epistaxis denied by the patient. Bruises history bruises on the skin was not be found. Pale in the face accompanied with fatigue and dizziness
was found, especially during activity. History of disease like this before was denied by the
patient, history of family members who suffer from the diseases was not found.
On physical examination found sensorium compos mentis, blood pressure of 120/60
mmHg, pols 84 x / min, frequency of breathing 22 x / min. Anaemia was found, weakened
vesicular breath sounds in both lower field of the lungs, additional sound not found. In
abdominal examination, ascites was found. Tenderness in the shoulder joint and joints in
2
both hands and tenderness in both of knee joints was found. Discoid rash found on both arms
and legs, accompanied by edema in both arms and legs.
Routine blood examination found : hemoglobin level 9.7 mg / dL, hematocrit 28%,
leukocytes 1,560 / uL, platelets 50,000 / mm3, MCV: 81 fl, MCH: 27.7 ρg, MCHC: 34.4 g%,
counts (%): Neutrophils 51.3; Lymphocytes 35.3; Monocytes 12.8; Eosinophils 0; 0.6
basophils. Peripheral blood morphology suggest: Anemia normokrom + Leukopenia +
Thrombocytopenia. Hemostatic function; Bleeding Time: 3'30 "minutes, Fibrinogen 100.0
mg / dL, D-dimer was 352 ng / mL, Ferritin 1517.91 ng / mL, Iron 25μg / dL, TIBC 195 mg /
dL. Hepatitis Immunoserology test, non-reactive for HBsAg, Anti-HCV Non-Reactive, Anti
HIV (3 Methode) Non-Reactive, Anti HIV (Rapid I) Non-Reactive, Auto immune
examination of ANA test 161, Anti-ds DNA 409, Qualitative CRP
Blondina Marpaung, Faisal Sinurat
Rheumatology Division
Departement of Internal Medicine University of North Sumatra
ABSTRAK
Medical Faculty of University of North Sumatra
Lupus nephritis is one of the most serious manifestations of systemic lupus
erythematosus (LES) and usually appear within 5 years after diagnosis. Lupus nephritis
is histologically evident in most patients with SLE, even those who do not show clinical
manifestations of kidney disease. Symptoms of lupus nephritis is generally associated
with hypertension, proteinuria and renal failure.
Reported a case of systemic lupus erythematosus (SLE) with severe lupus
nephritis in a man 23-years old boy in the hospital Haji Adam Malik attending with a
swollen face since 2 weeks ago accompanied by abdominal enlargement and swelling in
the extremities. Patients also complained pallor and fatigue, joint pain, sores in the
mouth and gums encountered, red rash on the arms and legs encountered.
On physical examination found vital signs within normal limits, encountered
anemia, weakened vesicular breath sounds in both lower courts of the lungs, additional
sound not found. Ascites was found, discoid rash was found on both arms and legs,
accompanied by edema in both arms and legs.
On blood examination discovered hemoglobin level 9.7 mg / d, leukocytes 1,560
/uL; platelets 50,000 /uL. Urinalysis results obtained proteinuria 2 Positive, erythrocyte
sediment 2-3 / LPB, leukocytes 2-5 / LPB, urine protein 545 (+++) mg%, 24-hour urine
protein 5,450 mg, urea level 71 mg / dl, creatinine 1.31 mg / dl, uric acid 8.7 mg / dL,
albumin 2.1 g /dL, CRP qualitative: negative, ANA test 161 , anti ds-DNA: 409 ng / ml.
On chest x-ray found bilateral pleural effusion and bronkhopenumonia. In renal
ultrasound examination was found in accordance with nephrotic pattern.
Patients treated by injection of methylprednisolone puls therapy at a dose of 500
mg / day for 3 days, followed by administration of a dose of methyl prednisolone tablets
from 0.5 to 0.6 mg / day with Cellcef (Mycophenolate Mofetil) 2 x 500 mg, furosemide
injection, Captopril 2 x 6.25 mg. Diets high in protein (an extra egg white), and fluid
balance - 500 mL. After administration of methylprednisolone pulse therapy for 3 days
followed by administration of a cortico-steroid-sparing agent (MMF), proteinuria was
reduced, edema is reduced and the patient's condition improves.
Kata kunci: lupus nephritis, SLE, pulse therapy
PENDAHULUAN
1
Lupus nephritis is one of the most serious manifestations of systemic lupus erythematosus
(SLE) and usually appear within 5 years after diagnosis. Lupus nephritis is histologically
evident in most patients with SLE, even those who do not show clinical manifestations of
kidney disease. Symptoms of lupus nephritis is generally associated with hypertension,
proteinuria and renal failure.
In America, the prevalence of SLE is 1 case per 2000 inhabitants in the general
population. Because of the difficulty of diagnosis and likely many cases go undetected, most
researchers suggest that the prevalence may be closer to 1 case per 500 -1,000 population.
There is stil no prevalence data of SLE in Indonesia until now. Number of patients with SLE
in Indonesia according to the Lupus Foundation of Indonesia (YLI) up to 2005 is estimated at
5,000 people. 1,2
CASE REPORT
A man - 23-year old came to Haji Adam Malik Hospital Medan on April 16th 2014
with the main complaints is a swollen face (myxo-oedema ), This is experienced since 3
weeks before admission to the hospital. Swollen face, especially in the morning and
decreases in the afternoon. accompanied by swelling in the legs. Since two weeks ago the
patients also complained of enlargement of the abdomen. The patient complained of joint
pain, especially in the shoulders, arms and knees. The pain is constantly moderate intensity,
relieved by pain-killers, but reappeared when the patients stopped taking medication. Patients
also complained reddish spots on both of his arms, hands and fingers, and became evident in
the first week. Rash on the face was not found, hair loss was not found. Complaints of pain
in the face and skin with redness if exposed to the sun was not found. History of pain in the
mouth with sores on both corners of the lips was found. Pallor experienced since 3 months
ago and more pronounced in the next 2 weeks. The history of Melena, haematochezia,
History of Haematuria, bleeding gums, epistaxis denied by the patient. Bruises history bruises on the skin was not be found. Pale in the face accompanied with fatigue and dizziness
was found, especially during activity. History of disease like this before was denied by the
patient, history of family members who suffer from the diseases was not found.
On physical examination found sensorium compos mentis, blood pressure of 120/60
mmHg, pols 84 x / min, frequency of breathing 22 x / min. Anaemia was found, weakened
vesicular breath sounds in both lower field of the lungs, additional sound not found. In
abdominal examination, ascites was found. Tenderness in the shoulder joint and joints in
2
both hands and tenderness in both of knee joints was found. Discoid rash found on both arms
and legs, accompanied by edema in both arms and legs.
Routine blood examination found : hemoglobin level 9.7 mg / dL, hematocrit 28%,
leukocytes 1,560 / uL, platelets 50,000 / mm3, MCV: 81 fl, MCH: 27.7 ρg, MCHC: 34.4 g%,
counts (%): Neutrophils 51.3; Lymphocytes 35.3; Monocytes 12.8; Eosinophils 0; 0.6
basophils. Peripheral blood morphology suggest: Anemia normokrom + Leukopenia +
Thrombocytopenia. Hemostatic function; Bleeding Time: 3'30 "minutes, Fibrinogen 100.0
mg / dL, D-dimer was 352 ng / mL, Ferritin 1517.91 ng / mL, Iron 25μg / dL, TIBC 195 mg /
dL. Hepatitis Immunoserology test, non-reactive for HBsAg, Anti-HCV Non-Reactive, Anti
HIV (3 Methode) Non-Reactive, Anti HIV (Rapid I) Non-Reactive, Auto immune
examination of ANA test 161, Anti-ds DNA 409, Qualitative CRP