1. 風濕免疫科案例 -- SLE 案例簡介 Ms. Chang, a 24 y/o female, visited your clinic because of abdominal pain. Shortly before this visit, she ever called at a local hospital where she was told to have high titer of ANA as well as a possible impression of SLE. Emergent evaluations on abdominal condition and laboratory examinations were conducted after admission. The impression of SLE was confirmed and the cause of abdominal pain was considered due to vasculitis. The associated conditions in this patient also included the presence of lupus nephritis. Here, we will extensively discuss about this common autoimmune disorder in young women regarding how the disease is diagnosed and how to treat the associated specific organ involvement. We will also discuss the pregnancy issue in this patient, a critical problem concerning the patient herself and her families.

2. 學習目標 How to diagnose a patient of SLE. How immune dysregulation causes SLE. Major associated conditions in a patient with SLE. Useful laboratory parameters for diagnosing and treating SLE patients. What are disease-modifying antirheumatic drugs? Their uses? Detection of possible major adverse events from drug administration. Prognosis of the disease and the factors affect prognosis The contribution from the family members to the patient’s health care. 風濕免疫科案例 -- SLE

3. 風濕免疫科案例 -- SLE 場景 (1): 病史 A 24 y/o female visits your clinic because of severe abdominal pain. She ever visited a local hospital few days ago due to similar complaints with an ineffective therapeutic response. The laboratory evaluations in that hospital revealed high titer of ANA and proteinuria. Abdominal examination revealed generalized rebounding tenderness over abdomen. There has been no pregnancy history, no related family history of autoimmune disorders, no history of taking oral pills as well as no history of joint pain. An IUD was noted in KUB evaluation. Mild anemic conjunctiva, no pitting edema of extremities. Neurological examinations were essentially negative. Both heart and lung conditions were negative for any significant disorders.

4. 風濕免疫科案例 -- SLE 討論 (1): Identify Ms. Chang’s problems. Generate diagnostic approaches that account for one or more of Ms. Chang’s problems. Differential diagnosis. The associated laboratory findings that may be of help for diagnosing the patient’s condition? The associated conditions that may happen in this patient Organizing therapeutic plan Treatment as a whole

5. 風濕免疫科案例 -- SLE 場景 (2): 身體檢查 Vital sign: BT 37.5 ℃, PR 90/min, RR 18/min, BP 116/76 mmHg, BW 50 kg; Conscious: clear with good orientation Eye: mild pale conjunctiva, no icteric sclera Neck: supple, no JVE, no palpable lymph node Chest: clear breathing sound, no rales Heart: regular heart beat, no murmur Abdomen: soft but generalized rebounding tenderness Back: no knocking pain over costo-vertebral angles Extremities: no leg pitting edema, no joint tenderness or joint swelling, neurological examination were essentially negative

6. 風濕免疫科案例 -- SLE 場景 (2): 檢驗檢查 Hb 11.0 gm/dl Hct 33% MCV 92 fl Platelet 50 K/μl WBC 5500/μl Seg 70% lym 12% Both renal and liver profiles are within normal limits Autoimmune survey revealed as follows. ANA (1: 1280), anti-Sm Ab (284 AU/ml), anti-ds DNA Ab (558 IU/ml), anti-RNP (84 AU/ml), anti-Ro (358 AU/ml), anti-La (204 AU/ml), anti-cardiolipin IgG (16 AU/dl), anti-cardiolipin IgM (12 AU/ml), complement 3 (26 mg/dl) and complement 4 (7 mg/dl). Urine analysis revealed proteinuria 4+ and the presence of RBC cast.

7. 風濕免疫科案例 -- SLE 案例討論 (2): What further examinations do you need to confirm your diagnostic hypotheses? How to evaluate the possible co-existing conditions in a patient of autoimmune disorder like Ms Chang? Therapeutic plan?

8. 風濕免疫科案例 -- SLE 場景 (3): 確認診斷與後續治療計畫 Under tentative diagnosis of mesenteric vasculitis, high dose of prednisolone was introduced to the patient and dramatic improvement of abdominal pain was observed. The likely presence of PID was treated with the removal of IUD. The severity of proteinuria reduced concurrently after prednisolone and DMARD treatment.

9. 風濕免疫科案例 -- SLE 討論 (3): What are the basis for your diagnosis in this patient? Possible tools for measuring disease activity? What are your on-going therapeutic plan? choices of therapies? The benefit and risk measurement in therapetuics Health education plans?

10. 風濕免疫科案例 -- SLE 場景 (4): 醫病溝通 The members of the patient’s family are quite confused with this autoimmune disorder and are highly concerned about her future prognosis, specifically the issues about pregnancy and the potential involvement of this disease in her babies. Whether the long term treatment is required and whether prednisolone can be omitted from the therapeutic lists are especially worried by her family. How to deal with these and the related issues?