Patient is a 20-year-old female with history of systemic lupus and a diagnosis of class IV lupus nephritis at age 11, who presents with SOB, and chest pain.
On her first presentation many years ago, she received induction therapy with cyclophosphamide and prednisone and ultimately transitioned to mycophenolate. She self-discontinued this treatment and prednisone and hydroxychloroquine a couple years later.
Approximately one year ago, she restarted hydroxychloroquine for arthralgias, and 6 months ago, she started oral prednisone 40 mg daily for arthralgia and sulfamethoxazoletrimethoprim for prophylaxis. She also was found to have new proteinuria (0.5 g/g) and was referred for nephrology outpatient evaluation.
She is now presenting with shortness of breath and pleuritic chest pain. She is found to be anemic, with Hb 5 g/dl, thrombocytopenic with platelets of 46 k/microliter.
She is started on pred 60 mg b.i.d. for presumed Evans syndrome with immune mediated hemolytic anemia and immune thrombocytopenia. Within the first week, she showed response in Hb/plt levels, but also rapid weight gain, ongoing arthralgias, and insomnia.
Recent Strep. Pneumo after starting prednisone
Prescription pain medication for severe pain
PredniSONE 60 mg PO BID
BP 138/97, heart rate 98, O2 98 RA
Severe obesity, abdominal striae
No cardiac rub, and otherwise unremarkable
Laboratory and other data:
CRP 68 mg/l
C3 60 mg/dl (90-180 mg/dl)
C4 4 mg/dl (10-40 mg/dl)
dsDNA titer 1:1280
Urine: protein to creatinine ratio 0.9 g/g
Urine sediment with numerous RBCs, few acanthocytes, 2 WBC casts