Hibernating LupusChun Tsu Lee1*, Tomoharu Suzuki2 and Aisha Lateef1,3
- *Corresponding Author:
- Chun Tsu Lee
Senior Resident, Division of General Medicine
1E Kent Ridge Road, 119228, Singapore
Tel: +65 67727692
E-mail: [email protected]
Received Date:: July 27, 2015 Accepted Date:: August 10, 2015 Published Date:: August 25, 2015
Citation: Lee CT, Suzuki T, Lateef A (2015) “Hibernating” Lupus. Rheumatology (Sunnyvale) 5:160. doi: 10.4172/2161-1149.1000160
Copyright: © 2015 Lee CT, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
We report a case of a 64-year-old Chinese lady, who was admitted for two weeks' history of fever, cough and breathlessness. She was diagnosed with community acquired pneumonia and treated with antibiotics. Her comorbidity include plaque psoriasis treated with topical steroids and oral methotrexate for 4 years by private physicians. Her symptoms persisted for weeks post-discharge. After workup, a diagnosis of basal interstitial lung disease with restrictive defect likely drug-induced was established. Her methotrexate therapy was switched to phototherapy. However, her psoriatic rashes worsened after phototherapy, thus, treatment was changed to subcutaneous injection of adalimumab. She then developed inflammatory arthritis, dry mouth and worsening dyspnoea and psoriasiform rashes. Repeat spirometry showed worsening of transfer factor (from 76% to 51%). In light of this peculiar development, her previous laboratory investigations performed in the other private hospitals were retrieved. They were remarkable for positive Anti-nuclear antibodies which were of homogenous pattern and high in titre with Anti-RO/SS-A positivity. Skin biopsy of the lesion displayed typical histology of psoriasis. This clinical scenario describes a case of psoriasis coexisting with "hibernating" lupus which was "awakened" by use of anti-TNF. With an assemblage of cutaneous signs, interstitial lung disease, arthritis without severe systemic involvement together with strong association with anti-Ro/SSa antibody, subacute cutaneous lupus erythematosus (SCLE) is suspected to be the most likely underlying lupus that remained dormant and smouldering until it was triggered and worsened by the use of adalimumab and phototherapy. These are the pitfalls associated with the diagnosis of connective tissue diseases which have protean manifestation. This is clinically significant as the diagnosis will affect the choice of immunosuppressants and biologics. The learning point is, in clinical practice, incongruity of enigmatic clinical and histo-pathological findings mandate critical scrutiny and second look as starting biologics without a clear clinical picture is potentially harmful.