Late-onset SLE case highlights possibilities of unusual presentation

Systemic lupus erythematosus (SLE) is most commonly associated with middle-aged and younger women, but a new case report highlights the fact that some patients develop the disease much later and with surprising manifestations.

The report, published in priest, involves a 69-year-old Hispanic man with a diagnosis of late-onset SLE with lupus nephritis. The authors say the case demonstrates the importance of investigating SLE even when a patient is not considered a likely candidate for the disease.

The authors explained that late-onset SLE is a subtype of the disease that presents when patients are over 50 years old.

“Although rare and infrequent, the term ‘late onset SLE’ or SLE in the elderly has been used to differentiate it from classic SLE,” they wrote. “However, in the case of male geriatric patients, the diagnosis is often overlooked due to the low incidence and atypical manifestations of the disease.”

In patients with lupus nephritis, ignoring SLE can be costly, given its association with high rates of morbidity and mortality, they noted.

In the case at the center of this report, a patient with a history of hypertension, hyperlipidemia, Hashimoto’s thyroiditis, autoimmune hepatitis, and chronic kidney disease, among other conditions, sought medical attention from emergency due to persistent fever, chills and cough. The patient was first given antibiotics and underwent a series of tests. However, chest X-rays did not indicate pneumonia, so empiric antibiotics were discontinued.

Meanwhile, the patient’s kidney function was a concern.

“A 24-hour urine collection revealed a urine protein to creatinine ratio of 4.31 g/g and a urine microalbumin to creatinine ratio of 1872 mg/g,” the authors wrote. His creatinine level rose rapidly to 4.0 mg/dL, and he was found to have a strongly positive antinuclear antibody screen and mildly elevated antinuclear ribonucleoprotein levels; the other levels were normal.

A kidney biopsy was ordered and the patient was started on methylprednisolone. The biopsy showed that the patient had a complete immunofluorescence pattern and lupus nephritis was diagnosed.

The patient was prescribed mycophenolate mofetil (CellCept) and prednisone, which resulted in renal stabilization and improved urine output. One week after discharge, the patient’s creatinine level had fallen to 2.8 mg/dL.

Khan and his colleagues said the case is a good reminder of the important differences between classic LES and late LES.

“Late-onset lupus differs from early-onset lupus in gender and ethnic prevalence, clinical presentation, pattern of organ involvement, disease severity, and prognosis,” they wrote. “These differences are due to age-related variation in environmental and/or host factors responsible for disease expression and variation in sex hormones.”

Lupus nephritis is considered an atypical presentation of late-onset SLE, but the researchers said it warrants aggressive management because of the risk of end-stage renal disease.

They concluded that it is “critical” for clinicians to investigate SLE if a patient shows complete immunofluorescence on biopsy.

“This should be done regardless of the patient’s age, gender, race, or lack of extrarenal manifestations, as illustrated in this case report,” they wrote.

Reference

Khan A, Sawant T, Deen Z, Humayun W, Humayun Y. Systemic lupus erythematosus in the elderly that begins as an organic manifestation of lupus nephritis. priest. Published online September 3, 2022. doi:10.7759/cureus.28746

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