Your patient is a married 47 year old white female homemaker with 2 children and an 18 year history of systemic lupus erythematosus (SLE). She has no known allergies. The pt takes an occasional naproxen for joint pain and antacid for heartburn but no other prescription or OTC (over the counter) medication. She neither smokes nor drinks alcohol (ETOH). Except for lupus, the patient's medical history is unremarkable. She is 5 feet 5 inches in height and weighs 102 pounds which is a decrease in weight of 23 pounds since her last physical examination nearly a year ago. She has had several small patches of hair loss on her head and her joints often hurt. Her ESR (erythrocyte sedimentation rate) is elevated at 70. She has a red rash on the sun exposed parts of her skin that looks like a vasculitis. She has 4 brothers and 3 sisters. An older sister has rheumatoid arthritis (RA) and an aunt with pernicious anemia and her deceased mother had Graves disease.
She had been aware of these problems for approximately four months. A physical examination was conducted during which her PCP noted multiple rash-like lesions on sun-exposed areas of the body, primarily on the arms and legs. A tissue biopsy of one of the lesions was taken and microscopic examination of the tissue revealed vasculitis (white blood cells within the walls of the blood vessels). An ANA test was positive. The lungs were clear to auscultation, heart sounds were normal with a prominent S1 and S2, and there was no evidence of enlarged lymph nodes. Blood tests revealed an Hct of 23% and an RBC count of 3.5 million/mm3. She was also jaundiced with some yellowing within the sclera. Microscopic examination of a peripheral blood smear revealed that red blood cells were normal in shape, size, and color, ruling out iron, folate, and vitamin B12 deficiencies. The total WBC count was 5,500/mm3 and her Plt count was 350, 000/mm3. Urinalysis was normal. She was placed on predisone for two months, during which time all signs and symptoms of disease resolved.
What can be said about the patientâs Hct, RBC count, WBC count, and Plt count?
Your patient is a married 47 year old white female homemaker with 2 children and an 18 year history of systemic lupus erythematosus (SLE). She has no known allergies. The pt takes an occasional naproxen for joint pain and antacid for heartburn but no other prescription or OTC (over the counter) medication. She neither smokes nor drinks alcohol (ETOH). Except for lupus, the patient's medical history is unremarkable. She is 5 feet 5 inches in height and weighs 102 pounds which is a decrease in weight of 23 pounds since her last physical examination nearly a year ago. She has had several small patches of hair loss on her head and her joints often hurt. Her ESR (erythrocyte sedimentation rate) is elevated at 70. She has a red rash on the sun exposed parts of her skin that looks like a vasculitis. She has 4 brothers and 3 sisters. An older sister has rheumatoid arthritis (RA) and an aunt with pernicious anemia and her deceased mother had Graves disease.
She had been aware of these problems for approximately four months. A physical examination was conducted during which her PCP noted multiple rash-like lesions on sun-exposed areas of the body, primarily on the arms and legs. A tissue biopsy of one of the lesions was taken and microscopic examination of the tissue revealed vasculitis (white blood cells within the walls of the blood vessels). An ANA test was positive. The lungs were clear to auscultation, heart sounds were normal with a prominent S1 and S2, and there was no evidence of enlarged lymph nodes. Blood tests revealed an Hct of 23% and an RBC count of 3.5 million/mm3. She was also jaundiced with some yellowing within the sclera. Microscopic examination of a peripheral blood smear revealed that red blood cells were normal in shape, size, and color, ruling out iron, folate, and vitamin B12 deficiencies. The total WBC count was 5,500/mm3 and her Plt count was 350, 000/mm3. Urinalysis was normal. She was placed on predisone for two months, during which time all signs and symptoms of disease resolved.
What can be said about the patientâs Hct, RBC count, WBC count, and Plt count?
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A 26-year-old woman presented with painful, stiff knees of 4 weeks duration. She had a 6-year history of Raynaud's phenomenon. On examination, she had bilateral effusions in both knee joints, but all other joints were normal. She had no skin lesions, muscle tenderness, proteinuria or fever. The results of relevant investigations are shown in Table C10.1. On the basis of these, a diagnosis of Systemic Lupus Erythematosus (SLE) was made and the patient treated with aspirin for her painful knees. She improved over 4 weeks and then remained symptom-free for 5 years. During this time, her antinuclear antibody remained positive at 1/80, her DNA-binding activity varied from 40 to 80%, and her C3 and C4 levels were occasionally low. Later, she developed a bilateral, butterfly rash across her cheeks, blotchy rash on her hands and thighs, consistent with active vasculitis and also presented with proteinuria, hematuria and glomerular nephritis. Her Raynaud's phenomenon concurrently became much worse. Following treatment with prednisolone, the skin manifestations gradually disappeared and the steroids were tailed off.
This patient presented with arthritis and Raynaud's phenomenon. She is unusual in that the arthritis of SLE usually involves small joints, but it is important to note that she remained perfectly well without treatment for 5 years, despite persistently abnormal serology.
Table C10.1 Investigations in Case 10.8.
| C-reactive protein | 8mg/l (normal) |
| Rheumatoid factor | Negative |
| Antinuclear antibody | Positive (titer 1/80; IgG class) |
| dsDNA-binding activity | 80% (NR 0-30% binding) |
| Antibodies to extractable nuclear antigens | Negative |
| Serum complement levels | |
| C3 | 0.35g/l (NR 0.65-1.30) |
| C4 | 0.05g/l (NR 0.20-0.50) |
| Serum immunoglobulins | |
| IgG | 22.0g/l (NR 7.2-19.0) |
| IgA | 3.8g/l (NR 2.0-5.0) |
| IgM | 1.2g/l (NR 0.5-2.0) |
| Biopsy of normal, sun-exposed skin (lupus band test) | Granular deposits of IgG and complement at dermo-epidermal junction |
1) Explain the immunological basis of her disease condition and the significance of her elevated levels of antinuclear antibodies (ANA).
2) Explain as to what caused her glomerular nephritis, vasculitis and bilateral skin rash.
3) How would you categorize the type of hypersensitivity reactions causing the above disease?
4) Explain how prednisolone helped to treat the symptoms.
5) Explain the biochemical mechanism of action of aspirin in its interaction with cyclooxygenase. Which class of macromolecules are affected by this interaction (inhibition) and state briefly a major side effect that may develop as a result of extensive aspirin therapy.
