PERSISTENT KNEE SWELLING IN A LUPUS PATIENT Pediatric Rheumatology Case Dr. Christine Bernal IIIB-4

Salient Features

Luisa, 16 y/o, female Diagnosed with SLE at 12 Prolonged fever Malar rash Photosensitivity Hair loss Oral ulcers Easy fatigability Anemia Neutropenia Thrombocytopenia (+) ANA (+) anti-dsDNA

In January 2009…. Pain on the L knee with swelling after a fall With fever and chills Self-medicated with Ibuprofen for 2 weeks, no improvement

PE Findings Ill-looking Wheelchair borne BP: 110/70 CR: 102/min RR: 24/min Temp: 39.8°C No rash or oral lesions Regular heart rate and rhythm No murmur or rub Regular heart rate and rhythm No murmur or rub Clear breath sounds Soft non-tender abdomen, no hepatosplenomegaly L knee – warm tender and swollen w/ limited ROM

ACR Criteria for SLE

presence of four or more of the following 11 criteria, serially or simultaneously, during any period of observation 1.Malar rash 2.Discoid rash 3.Photosensitivity 4.Oral ulcers 5.Arthritis (non-erosive) 6.Serositis (Pleuritis or Pericarditis) 7.Renal disorder persistent proteinuria > 500 mg per 24 hours (0.5 g per day) or > 3+ cellular casts 8.Neurologic disorder 9.Hematologic disorder hemolytic anemia with reticulocytosis leukopenia, < 4,000 per mm3 (4.0 _ 109 per L) on two or more occasions lymphopenia, < 1,500 per mm3 (1.5 _ 109 per L) on two or more occasions thrombocytopenia, < 100 _ 103 per mm3 (100 _ 109 per L) in the absence of offending drugs 10.Immunologic disorder 11.Antinuclear antibodies

In the patient… Malar rash Photosensitivity Oral ulcers Anemia Thrombocytopenia (+) ANA (+) anti-dsDNA L knee – warm tender and swollen w/ limited ROM