Rheuma Case: 24-year-old Woman with Pleuritic Chest Pain and Dyspnea

00:01 So today we're gonna talk about systemic lupus erythematosus.

00:05 First stop, let's do a case. A 24-year-old African American ballet student presents with pleuritic chest pain and dyspnea over the past three or four weeks.

00:15 Now her cough is dry, and it reproduces left-sided chest pain.

00:19 There's no chest pain with exertion, though she does get winded easily.

00:22 She also reports overwhelming fatigue, to the point that she has missed a number of classes over the past few weeks.

00:28 Now she admits to subjective fevers and weight loss.

00:31 And she also notes that she started taking bupropion about six weeks ago for symptoms of depression that have emerged during the school year.

00:40 Social history; she's a non-smoker, she rarely drinks alcohol, and she's had one male sexual partner for the past six months.

00:47 Family history; non-contributory.

00:49 And on review of systems she reports painful hand and knee arthralgias over the past week.

00:55 No rashes, no GI symptoms, no eye symptoms, and no dysuria.

00:59 So let's go through some key features of this case thus far.

01:03 First off, the time course.

01:05 It sounds like she's been having symptoms for the past three or four weeks and therefore we'd call it subacute.

01:10 Though over the past couple of days, it seems like some new symptoms have been added on as well.

01:14 In terms of the pattern of joint involvement, she's got painful hand and knee arthralgias.

01:20 At a minimum, we've got oligoarticular arthritis that we'll have take a closer look on physical exam to see if there's multiple joints involved.

01:27 Moreover, it sound symmetric, at least based on our limited history thus far.

01:32 Next stop, evidence of joint inflammation.

01:34 Again, we'll have to take a look at our physical exam to get more information.

01:38 And lastly, systemic involvement.

01:40 Yes, we've got all kinds of things happening here between subjective fevers, weight loss, coughing, overwhelming fatigue, there is something going on here other than just some knee and hand arthralgias.

01:51 Alright, let's move on to our physical exam.

01:54 First stop, it looks like she does have a low-grade temperature; 37.8 degree Celsius.

02:00 Heart rate at 92 and the blood pressure's fine.

02:03 Normal sclera, no lymphadenopathy, you do note a 5 mm shallow ulcer on the right upper buccal mucosa.

02:12 Regular rate and rhythm on her cardiovascular exam with a 2/6 systolic ejection murmur and a friction rub.

02:19 There's crackles at the left base when doing her lung exam, no dullness to percussion.

02:23 Abdomen's benign, neurologic exam is benign.

02:26 And then finally when we get to those joints, we find symmetric tenderness to palpation over numerous MCP and PIP joints bilaterally with mildly increased warmth and swelling.

02:38 Looks like this is gonna turn out to be polyarticular after all.

02:42 She has tenderness to palpation over joint lines of both knees without any evidence of an effusion.

02:47 And there's trace to 1+ pedal edema bilaterally.

02:50 On the skin exam we see subtle macular erythema over the bilateral malar regions of the face and no nail findings.

02:59 Boy this is a lot of data.

03:01 So looking at the blood tests thus far, we have a mild anemia with hemoglobin of 9.3, also mild leukopenia, white count of 3.8, and mild thrombocytopenia with a count of 98,000.

03:14 We have a mildly elevated creatinine of 1.2, liver function tests are also somewhat elevated with an elevated bilirubin of 3.7, and indirect bilirubin of 2.9.

03:24 Urinalysis is also lighting up, we have 2+ protein, 2+ RBCs, 1+ bilirubin, and rare red cell casts which certainly are giving us some important information.

03:35 Her ANA is outrageously elevated at 1:640 with a speckled pattern.

03:40 We have a positive rheumatoid factor, an elevated ESR, a positive VDRL, and a chest x-ray showing a small left-sided pleural effusion with an enlarged cardiac silhouette as well.

03:52 Wow, with all that information from the history, the physical, the laboratory data, and our radiographic imaging, what do you think is the most likely diagnosis? Alright, let's go through each one of these in turn starting with drug-induced lupus.

04:09 Now drug-induced lupus unlike systemic lupus erythematosus is actually less likely to occur in a young Africa-American woman.

04:18 It's most often occurring in older people over the age of 50 and not African-Americans.

04:25 Of course you're gonna look for certain culprit medications and it could be kinda tricky here.

04:29 Remember the different medications involved here, they're listed here.

04:32 Methyldopa, etanercept, diltiazem, sulfasalazine, hydralazine, isoniazid, and procainamide.

04:39 And if you have a little trouble in remembering that and I know I do, I like to think of the MEDSHIP.

04:44 And here it is, a ship that brings you certain medications and also a host of lupus like symptoms.

04:51 In turns out that drug-induced lupus looks completely like systemic lupus erythematosus.

04:57 The only difference is the serologic testing is gonna be somewhat different as we'll see in a later slide.

05:02 So we'll have to leave that one on our list for now acknowledging that you don't typically think of bupropion as one of the medications that causes drug-induced lupus.

05:12 So as I suggested just a moment ago, while drug-induced lupus tends to happen in non-black older men and women, system lupus erythematosus most often occurs in young black women.

05:25 The gender ratio is pretty significant, that's a 9:1 ratio favoring women getting this disease.

05:31 So that's certainly something we're gonna keep in mind, she's the perfect phenotype for this condition and we'll definitely have to keep SLE on our list.

05:39 Next stop, polyarteritis nodosum.

05:42 Well, this is definitely a disease in which people present sick.

05:45 They can have multiple systems involved and we're certainly seeing a lot of things happening to our young patient.

05:51 It typically presents with constitutional and systemic symptoms, most commonly involving the GI tract, possibly an acute kidney injury and often a leukocytosis rather than a leukopenia as we're seeing in our patient.

06:03 This is a medium vessel vasculitis and interestingly enough why it affects many different systems, it actually rarely affects the lungs.

06:12 So the fact that she's presenting with pulmonary symptoms might stir us a little a bit away from polyarteritis nodosum.

06:18 That being said, we should just add that polyarteritis nodosum is often associated with active hepatitis B.

06:25 We're not getting any history of that in our patient thus far.

06:27 And just -- as an aside often times men who present with PAN are presenting with testicular pain.

06:33 Either way, the fact that she has so many systems involved right now, we're gonna have to keep this one in our list as well.

06:39 Moving on to rheumatoid arthritis.

06:42 Again, another disease that can present with multiple systems involved.

06:46 Typically you're going to have symmetric wrist and PIP involvement and we are told that she is having fairly symmetric symptoms.

06:54 Her rheumatoid factor is positive which of course supports rheumatoid arthritis.

06:59 We're gonna need an anti-CCP to really rule that in or rule that out.

07:04 And lung involvement is not unusual for rheumatoid arthritis.

07:07 The one caveat though is that you don't typically get this kind of pleural effusion serositis pleuritic cough type thing with rheumatoid arthritis.

07:15 You're more likely to have either just benign rheumatoid nodules or potentially progressive interstitial lung fibrosis.

07:22 Either way, RA stays on our list.

07:25 Next up is syphilis.

07:27 Now, syphilis which we don't see quite as often anymore, can affect nearly every organ and people can certainly present with constitutional symptoms especially early on with primary syphilis.

07:38 Arthritis, a variety of different skin lesions including painless oral ulcers, renal involvement, syphilis stays on our list.

07:45 Not to mention we have a +VDRL which is a non-specific but a sensitive test for syphilis. So syphilis stays.