A 19-year-old previously healthy man presents with intermittent diarrhea, fever, and weight loss with pleuritic left-sided chest pain for 1 month. What does the chest x-ray show?
Figure. (Please click to enlarge)
Image. Chest x-ray (please click to enlarge)
A 19-year-old previously healthy man is brought to the emergency department (ED) by his mother for 3-4 months of experiencing intermittent diarrhea and fevers up to 100.8°F with an associated 50-lb weight loss. The fevers are frequent, but not daily. He has also been having pleuritic left-sided chest pain for approximately 1 month. He denies cough, abdominal pain, vomiting, blood loss, or other complaints. He has been to other hospitals multiple times and no diagnosis was made but his symptoms continue to worsen.
Vital signs were normal except for a temperature of 100.3°F orally and a pulse of 121 beats/min. Physical exam was normal except for thin body habitus and tachycardia.
Laboratory studies: WBC low at 2.2x109/L, Hb low at 11.2 g/dL, albumin low at 2.9 g/dL, otherwise CBC and chemistries WNL.
Chest x-ray: See image above (please click to enlarge)
âPlease click here for answers and diagnosis.
Further testing: He was found to have ascites and underwent paracentesis with 1.2 L fluid removed. A malignancy and infection disease workup were both negative. CRP level was elevated at 40 mg/L, however, ESR was normal. The ANA titer was positive at 1:640, anti-dsDNA at 1:640, anti-Smith at 1:160, and anti-RNP at 1:200. He also developed new renal insufficiency (creatinine level peaked at 2.1 mg/dL) with microscopic hematuria.
Discharge diagnoses: Serositis (pleural effusions, ascites), leukopenia, anemia with thrombocytosis, and microscopic hematuria with new acute kidney injury with results of a renal biopsy showing lupus nephritis.
Conclusion: Following initiation of steroids, there was noticeable improvement in symptoms and lab work.
Please click here for discussion.
Lupus can present in many ways and is rarely diagnosed de novo in the ED, though it may be suspected. This patient had a number of symptoms that were actually more concerning for an underlying chronic infection or even a malignancy than lupus. In this case the chest pain was due to serositis from lupus.
Systemic lupus may present with a variety of signs and symptoms. There is a useful mnemonic, “LUPUS RASH”, in the highlighted area of the Figure to the right (please click to enlarge) that may be helpful to remember most of them.
The diagnosis of lupus is complex and beyond the scope of this brief review. Some of the antibody tests often ordered as part of the workup are listed in the highlighted area of the Figure above (please click to enlarge), which also has other useful details in summary format.
Additional information is availabe at: The Emergency Medicine 1-Minute Consult pocket book