Diagnosis And Management of Systemic Lupus Erythematosus Discussion

Patient ZA Case Study

The initial differential diagnoses for this patient include rheumatoid arthritis, systemic lupus erythematosus, and several viral infections, including Cytomegalovirus, Epstein Barr virus, and Parvovirus B19 (Vaillant et al., 2023). The additional history of present illness (HPI) that I would ask the patient about includes the onset of the symptoms, which joints were affected first, which symptoms presented first, and the duration of the illness. For rheumatoid arthritis, the patient often presents with small joint involvement in the hands and feet before large joints are involved (Chauhan et al., 2023). Joint swelling, pain, and morning stiffness are common symptoms that a patient with rheumatoid arthritis might experience (Chauhan et al., 2023). In systemic lupus, I would inquire about any skin lesions and rashes typical of systemic lupus erythematosus, such as malar rash on the cheeks and nasal bridge (Vaillant et al., 2023). I would inquire about oral and nasal ulcers alongside the constitutional systems, such as fever and fatigue. The infection would typically involve a fever and the patient’s symptoms. They would require definitive tests such as antigen and polymerase chain reaction tests to identify the definitive virus causing the patient’s symptoms.    Diagnosis And Management of Systemic Lupus Erythematosus Discussion

Given the patient’s laboratory test with anemia, positive antinuclear antibody (ANA) and anti-cyclic citrullinated peptide (anti-CCP), elevated acute phase proteins C-reactive protein and erythrocyte sedimentation rate, and rheumatoid factor, the most pertinent diagnoses for this patient are rheumatoid arthritis and systemic lupus erythematosus. The presence of joint pain and swelling, morning stiffness, anemia of chronic disease and thrombocytosis, elevated acute phase proteins, elevated rheumatoid factor, and positive ANA, anti-CCP, and anti-citrullinated protein autoantibodies (ACPA) are assessment data that are common with rheumatoid arthritis (Chauhan et al., 2023). Other signs could include joint deformity and synovial fluid assessment revealing elevated immune cell count. For systemic lupus erythematosus, cutaneous rash or lesions are common, followed by musculoskeletal and renal pathologies such as lupus nephropathy, which commonly presents with proteinuria (Vaillant et al., 2023). The patient also demonstrates anemia of chronic disease, which, together with systemic inflammation, can explain the constitutional symptoms such as fatigue and generalized malaise (Vaillant et al., 2023). The laboratory data would reveal positive ANA, anti-double stranded deoxyribonucleic acid (anti-dsDNA) in 60 to 70% of the cases, anti-Smith antibodies in less than 30% of patients, and low complement C3 and C4 levels, which are consumed in the systematic inflammation (Vaillant et al., 2023). Therefore, in the management of the diseases, I would use recommended clinical practice guidelines for older adults by accredited institutions such as the Japan College of Rheumatology (JCR) and the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR).

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JCR recommends methotrexate as first-line therapy for rheumatoid arthritis, with glucocorticoids used as an adjunctive therapy (Sugihara et al., 2024). EULAR 2019 guidelines on systemic lupus erythematosus management recommend the administration of hydroxychloroquine (not exceeding 5mg/kg actual body weight) and glucocorticoids (less than 7.5 mg/day) as first-line treatment of mild disease (Fanouriakis et al., 2021). Therefore, I would start the patient on hydroxychloroquine and glucocorticoids as the initial treatment and wait to initiate immunomodulatory drugs such as methotrexate for maintenance therapy as I taper off the glucocorticoid dose. The non-pharmacological interventions would include protection from sunlight, encouraging exercise to control body weight, and vaccination against common pathogens to ensure that the patient does not develop infections while in an immunocompromised state using long-term glucocorticoids (Fanouriakis et al., 2021). I would educate the patient regarding the causes of their diseases, the potential complications for each diagnosis, and the need to take medication as prescribed to achieve therapy goals, which include patient survival, protection from organ damage, and optimization of health-related quality of life (Fanouriakis et al., 2021). Lastly, I recommend twice monthly follow-up to assess for response to treatment and drug adverse effects. Upon follow-up, I would determine the patient’s symptoms for improvement and take blood pressure, lipids, and glucose measurements to assess for some of glucocorticoid’s adverse effects. If the patient demonstrates improvement, I would maintain the treatment and slowly tap the glucocorticoids, but if there is no improvement, I would consider adding methotrexate or azathioprine to the patient’s treatment regimen. Diagnosis And Management of Systemic Lupus Erythematosus Discussion

References

Chauhan, K., Jandu, S. J., Brent, H. L., & Al-Dhahir, A. M. (2023). Rheumatoid arthritis. Reassure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441999/

Fanouriakis, A., Tziolos, N., Bertsias, G., & Boumpas, T. D. (2021). Update on the diagnosis and management of systemic lupus erythematosus. Annals of the Rheumatic Diseases, 80(1), 14-25. https://ard.bmj.com/content/80/1/14

Sugihara, T., Kawahito, Y., Kaneko, Y., Tanaka, E., Yanai, R., Yajima, N., Kojima, M., & Harigai, M. (2024). Systematic review for the treatment of older rheumatoid arthritis patients informing the 2024 update of the Japan College of Rheumatology clinical practice guidelines for managing rheumatoid arthritis. Modern Rheumatology, roae026. https://doi.org/10.1093/mr/roae026

Vaillant, J. A. A., Goyal, A., & Varacallo, M. (2023). Systemic lupus erythematosus. Treasure Island, FL: StatPearls Publishing.

Case Study:

Patient ZA is a Caucasian male, 65 years of age, presenting to the primary care physician with complaints of fatigue, generalized weakness, bilateral knee and ankle swelling, and joint pain, making it difficult for him to ambulate. He also reports generalized malaise. Family history includes father, diagnosed with Lupus at 60 and mother diagnosed with Rheumatoid Arthritis at 35. He reports that as a veteran, he stayed physically active all his life and the new onset generalized joint pain and swelling really bothers him. He is 6 feet 1 inch tall and weighs 170 pounds, with a calculated BMI of 23.1 kg/m2. Vitals Signs: BP 138/87, HR; 87, RR, 16, Oxygen Saturation: 99%, Temperature: 97 Diagnosis And Management of Systemic Lupus Erythematosus Discussion

What are your initial differentials?
What additional HPI and ROS findings are your seeking or ruling in or ruling out?
What are common symptoms (what the patient says) (per system) for the differentials you are considering?

Patient ZA

CMP- Pertinent levels

BUN-8

Creat-1.1

ALT: 12

AST: 30

ALBUMIN:

CBC – Pertinent levels

HGB- 12

HCT- 38

WBC- 7

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To gain additional information, Patient ZA is referred for additional blood work. The results of this blood work indicate:

CRP-100
ESR- 200
ANA- positive
Rheumatoid factor- 30
Anti-CCP- positive
UA- 2+ hematuria noted; other wise all other tests are unremarkable.
What is your actual diagnosis(es) (Most pertinent)?
What assessment data/signs are common with this type of patient/diagnosis
What guidelines will you use to assist in your planning?
What is your initial treatment plan for each diagnosis (pharmacologic, nonpharmacologic, etc)? Diagnosis And Management of Systemic Lupus Erythematosus Discussion
What is your initial education for each diagnosis?
When do you recommend follow up? What is your plan upon follow up? (if improvement/ If no improvement) Diagnosis And Management of Systemic Lupus Erythematosus Discussion