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homogeneous pattern&#41;&#44; with anti-ds-DNA weakly positive&#44; while perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibody &#40;p-ANCA and c-ANCA&#44; respectively&#41; were negative&#46; Serum C3 and C4 levels were decreased &#40;30<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; respectively&#41;&#46; According to results&#44; a diagnosis of SLE presenting with acute pneumonitis was made&#46; On the 4th day&#44; the patient was started with 1<span class="elsevierStyleHsp" style=""></span>g intravenous methyl prednisolone once a day for 3 days&#44; followed by tablet hydroxychloroquine 400<span class="elsevierStyleHsp" style=""></span>mg daily and tablet prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg daily for 6 weeks with gradually tapering of prednisolone to a maintenance dose of 10<span class="elsevierStyleHsp" style=""></span>mg daily&#46; From two months after&#44; her chest X-ray has shown practical resolution &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; At six month later&#44; computed tomography described adhesions of the right side with no other specific abnormalities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Acute lupus pneumonitis &#40;ALP&#41; is an uncommon manifestation of lupus&#44; affecting less than 2&#37; of cases&#46; It is often life threatening once ventilator failure sets in&#44; with mortality rate of more than 50&#37;&#44; despite of the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The main pathology in ALP could be the acute alveolar capillary unit injury&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Lupus pneumonitis presents with acute onset of fever&#44; cough&#44; tachypnea and hypoxia&#46; The usual radiological sign of lupus pneumonitis is consolidation in one or more lung areas&#44; typically basal and bilateral&#44; often associated with pleural effusion and pulmonary arterial hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Our case was difficult to diagnose at first&#44; since the onset symptoms indicated infection etiology and do the relevant work up&#46; We have excluded infective pneumonia by repeated sputum analyses and single BAL fluid examination&#59; alveolar hemorrhage since there were no hemoptysias and Hemosiderin-laden macrophage was absent in BAL fluid&#46; The mainstay of acute lupus pneumonitis treatment is the systemic corticosteroids usage &#40;prednisone 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d divided accordingly&#41;&#44; although despite high-dose corticosteroid usage&#44; the lupus pneumonitis mortality remains high&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> If there is no response to oral corticosteroids within 72<span class="elsevierStyleHsp" style=""></span>h and the patient has marked tachypnea&#44; hypoxemia or suspected diffuse alveolar hemorrhage&#44; treatment should include intravenous corticosteroid pulse therapy &#40;i&#46;e&#46;&#44; 1<span class="elsevierStyleHsp" style=""></span>g methylprednisolone per day for 3 days&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The corticosteroid improvement was impressive in our case&#44; noticed on the very first day&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; acute lupus pneumonitis can be the initial manifestation of SLE&#46; ALS diagnosis is essential&#44; by excluding other causes of lung infiltration&#44; such are infective pneumonia &#40;bacterial&#44; mycobacterial&#44; fungal and viral&#41;&#44; organizing pneumonia &#40;OP&#41;&#44; alveolar hemorrhage&#44; pulmonary embolism and volume overload state&#44; due to either renal failure or to congestive heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Also&#44; it is critically important to differentiate ALP from diffuse alveolar hemorrhage &#40;DAH&#41; which may have similar clinical presentation&#44; laboratory immunology testing &#40;ANA&#44; anti-dsDNA&#41; and radiographic findings&#44; with almost equally grave prognosis&#46; ESR and CRP may be used to support clinical suspicion&#46; Unlike ESR&#44; CRP &#40;or hs-CRP&#41; elevation is only modest in active SLE without infection&#44; while a high hs-CRP level &#40;&#62;5&#8211;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; is a strong predictor of infection&#46; Also&#44; ESR&#47;CRP ratio ¿15 suggests lupus flare&#44; while ratio ¿2 suggests infection&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span>"
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Scientific letter
Systemic Lupus Erythematosus Presenting as Acute Lupus Pneumonitis
Lupus eritematoso sistémico manifestado como neumonitis lúpica aguda
Biljana Lazovica,
Corresponding author
lazovic.biljana@gmail.com

Corresponding author.
, Mirjana Zlatkovic-Svendab,c, Damir Jasarovica,c, Dejan Stevanovica,c
a University Clinical Center “Zemun”, Belgrade, Serbia
b Rheumatology Institute, University of Belgrade, Serbia
c School of Medicine, University of Belgrade, Serbia
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic lupus erythematosus &#40;SLE&#41; is an autoimmune chronic systemic disease involving skin&#44; joints and&#47;or internal organs&#44; such as lungs&#44; brain and heart&#46; SLE affects predominantly women &#40;female to male ratio 10&#58;1&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Pulmonary manifestations of SLE can include a wide spectrum of diseases&#46; The most common is lupus pleuritis&#46; Less common is parenchymal involvement&#44; presenting either as acute lupus pneumonitis &#40;ALP&#41; or chronic interstitial lung disease&#46; Possible pulmonary manifestations of SLE are pneumonia&#44; pulmonary embolism&#44; pneumothorax&#44; acute reversible hypoxemia&#44; shrinking lung syndrome and pulmonary haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> It is believed that pulmonary complications are the consequence of the immune complex mediated injury&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old woman was presented to the Emergency Department&#44; having severe breath shortness&#44; high temperature and chest pain&#46; She has been suffered from systemic lupus erythematosus for 20 years&#44; and for the last six months was using 10<span class="elsevierStyleHsp" style=""></span>mg Prednisone and Methotrexate 5<span class="elsevierStyleHsp" style=""></span>mg once weekly&#46; At the examination&#44; she was found to have elevated body temperature 38&#46;1<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; tachycardia &#40;120<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#41; and elevated blood pressure &#40;160&#47;90<span class="elsevierStyleHsp" style=""></span>mm Hg&#41;&#46; Her appearance was anorexic&#44; diaphoretic&#44; dyspnoeic&#44; slightly disoriented&#46; Her pupils were round equally with good light reaction&#44; and her extraocular muscles were intact&#46; She had neither neck adenopathy&#44; nor jugular venous distention or meningismus&#46; Precordial examination has shown no murmurs&#44; rubs or gallops&#46; Her breath sounds were decreased&#44; with the right side percussion dullness&#46; She had 2&#43; pitting edema to the midcalf&#46; Examined neurologically&#44; she had mild confusion but was nonfocal otherwise&#46; Routine blood examination revealed normochromic normocytic anemia &#40;haemoglobin&#58; Hgb 11&#46;1<span class="elsevierStyleHsp" style=""></span>gm&#47;dL&#41;&#44; white blood cells&#58; WBC count 24<span class="elsevierStyleHsp" style=""></span>600&#47;&#956;L&#44; platelets count 68<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;L and an erythrocyte sedimentation rate &#40;ESR&#41; 120<span class="elsevierStyleHsp" style=""></span>mm in the 1st hour&#46; Serum biochemistry revealed C-reactive protein &#40;CRP&#41; 3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; whereas unremarkable results were reported from urine analysis and urinoculture&#46; Arterial blood gas analysis showed hypoxemia with respiratory alkalosis&#46; Chest radiograph showed consolidation of the right upper lobe and a mild right-sided pleural effusion on the right side &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Sputum culture&#44; blood culture&#44; sputum microscopy for acid fast bacilli&#44; Mantoux test and HIV serology were negative&#46; Treatment of the patient was started with empiric intravenous antibiotics &#40;cefriakson&#44; ciprofloksacin and metronidazole&#41; accompanied with supportive care&#46; On the 3rd day of the therapy&#44; patient had high body temperature of 40<span class="elsevierStyleHsp" style=""></span>&#176;C and the control chest X-ray has revealed the encapsulated pleural effusion on the right side &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; A diagnostic thoracocentesis was performed&#44; yielding 60<span class="elsevierStyleHsp" style=""></span>mL of yellow&#44; slightly cloudy fluid&#44; showing a red blood cell-RBC count of 2&#46;0<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;L and&#44; WBC count of 340&#47;&#956;L &#40;15&#37; leukocytes&#44; 71&#37; neutrophils&#44; and 13&#37; monocytes&#41;&#59; pH 7&#46;48&#59; glucose 58<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; total protein 2&#46;46<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; lactate dehydrogenase 12<span class="elsevierStyleHsp" style=""></span>545<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; adenosine deaminase 51&#46;3<span class="elsevierStyleHsp" style=""></span>units&#47;L&#59; Ziehl-Neelsen stain negative&#59; Gram stain and culture negative and Mycobacterium DNA polymerase chain reaction negative&#44; with no malignant cells&#46; Bacterial cultures were negative&#46; Fiber-optic bronchoscopy with bronchoalveolar lavage &#40;BAL&#41; fluid analysis has shown epithelial cells&#46; Since the patient had a continuously high body temperature up to 39<span class="elsevierStyleHsp" style=""></span>&#176;C and round rash emerging over the left elbow&#44; anti-nuclear antibody &#40;ANA&#41; testing was performed and was positive &#40;titer 1&#58;1280&#44; homogeneous pattern&#41;&#44; with anti-ds-DNA weakly positive&#44; while perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibody &#40;p-ANCA and c-ANCA&#44; respectively&#41; were negative&#46; Serum C3 and C4 levels were decreased &#40;30<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; respectively&#41;&#46; According to results&#44; a diagnosis of SLE presenting with acute pneumonitis was made&#46; On the 4th day&#44; the patient was started with 1<span class="elsevierStyleHsp" style=""></span>g intravenous methyl prednisolone once a day for 3 days&#44; followed by tablet hydroxychloroquine 400<span class="elsevierStyleHsp" style=""></span>mg daily and tablet prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg daily for 6 weeks with gradually tapering of prednisolone to a maintenance dose of 10<span class="elsevierStyleHsp" style=""></span>mg daily&#46; From two months after&#44; her chest X-ray has shown practical resolution &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; At six month later&#44; computed tomography described adhesions of the right side with no other specific abnormalities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Acute lupus pneumonitis &#40;ALP&#41; is an uncommon manifestation of lupus&#44; affecting less than 2&#37; of cases&#46; It is often life threatening once ventilator failure sets in&#44; with mortality rate of more than 50&#37;&#44; despite of the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The main pathology in ALP could be the acute alveolar capillary unit injury&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Lupus pneumonitis presents with acute onset of fever&#44; cough&#44; tachypnea and hypoxia&#46; The usual radiological sign of lupus pneumonitis is consolidation in one or more lung areas&#44; typically basal and bilateral&#44; often associated with pleural effusion and pulmonary arterial hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Our case was difficult to diagnose at first&#44; since the onset symptoms indicated infection etiology and do the relevant work up&#46; We have excluded infective pneumonia by repeated sputum analyses and single BAL fluid examination&#59; alveolar hemorrhage since there were no hemoptysias and Hemosiderin-laden macrophage was absent in BAL fluid&#46; The mainstay of acute lupus pneumonitis treatment is the systemic corticosteroids usage &#40;prednisone 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d divided accordingly&#41;&#44; although despite high-dose corticosteroid usage&#44; the lupus pneumonitis mortality remains high&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> If there is no response to oral corticosteroids within 72<span class="elsevierStyleHsp" style=""></span>h and the patient has marked tachypnea&#44; hypoxemia or suspected diffuse alveolar hemorrhage&#44; treatment should include intravenous corticosteroid pulse therapy &#40;i&#46;e&#46;&#44; 1<span class="elsevierStyleHsp" style=""></span>g methylprednisolone per day for 3 days&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The corticosteroid improvement was impressive in our case&#44; noticed on the very first day&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; acute lupus pneumonitis can be the initial manifestation of SLE&#46; ALS diagnosis is essential&#44; by excluding other causes of lung infiltration&#44; such are infective pneumonia &#40;bacterial&#44; mycobacterial&#44; fungal and viral&#41;&#44; organizing pneumonia &#40;OP&#41;&#44; alveolar hemorrhage&#44; pulmonary embolism and volume overload state&#44; due to either renal failure or to congestive heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Also&#44; it is critically important to differentiate ALP from diffuse alveolar hemorrhage &#40;DAH&#41; which may have similar clinical presentation&#44; laboratory immunology testing &#40;ANA&#44; anti-dsDNA&#41; and radiographic findings&#44; with almost equally grave prognosis&#46; ESR and CRP may be used to support clinical suspicion&#46; Unlike ESR&#44; CRP &#40;or hs-CRP&#41; elevation is only modest in active SLE without infection&#44; while a high hs-CRP level &#40;&#62;5&#8211;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; is a strong predictor of infection&#46; Also&#44; ESR&#47;CRP ratio ¿15 suggests lupus flare&#44; while ratio ¿2 suggests infection&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span>"
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ISSN: 03002896
Original language: English
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