Abstract: PUB402
Diagnostic Challenges and Multidisciplinary Management in Atypical Lupus Nephritis
Session Information
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Baloch, Israr, Lehigh Valley Health Network, Allentown, Pennsylvania, United States
- Maynard, Sharon E., Lehigh Valley Health Network, Allentown, Pennsylvania, United States
Introduction
SLE is a complex autoimmune disorder affecting multiple organs, with LN being one of its most severe complications, potentially leading to significant morbidity due to renal impairment and progression to ESRD. Diagnosing LN is challenging, especially in patients not fully meeting SLE criteria. This case report discusses a 40-year-old male with LN, highlighting diagnostic challenges and the importance of multidisciplinary management.
Case Description
40M with PMH significant for migraines, tobacco, and NSAID use presented with bilateral hand swelling, pain, and poor dentition. Denies dry mouth, fever, diarrhea, rash, and weight loss. Found to have positive ANA and AKI. Initial labs showed serum creatinine of 1.58, 200 mg proteinuria, no hematuria or pyuria. Diagnosis of LN was initially considered, but pt did not meet full criteria for SLE, and AKI was attributed to NSAID use. AKI resolved after discontinuing NSAIDs, and pt was sent home for a 5-month follow-up. However, at the follow-up visit, serum creatinine increased, along with worsening proteinuria. Repeat labs showed serum creatinine of 1.38 and UPCR of 2 g. Repeat serological workup now remarkable for +ANA, low C3 and C4, and elevated ESR, platelets, and CRP. New cardiac murmur noted on PE. Given rapidly worsening renal function and proteinuria, pt started on prednisone 60 mg daily and MMF 500 mg BID, with renal biopsy planned due to concerns for RPGN. A new murmur raised concerns for SBE, prompting an Echo and BCx. TEE revealed MV vegetations, but BCx remained -ve. Further serologic workup revealed positive APLA. Hem recommended warfarin, with Lovenox bridging for NBTE. Renal Bx revealed findings consistent with LN; however, limited sampling prevented precise classification within LN, and activity/chronicity indices could not be calculated. Pt was also started on atovaquone for PJP ppx with plans for close outpatient follow-up.
Discussion
This case underscores the importance of considering LN in patients with suggestive clinical and laboratory findings, even if they do not meet full SLE criteria. Careful medication management and a multidisciplinary approach are essential in managing complex cases like this one. The patient's outcome highlights the potential for successful treatment with a coordinated, patient-centered approach.