Abstract
Background and Aims
A significant contribution to the structure of mortality in SLE is made by infectious complications, which complicate the course of SLE and complicate the management of patients due to the impossibility of prescribing immunosuppressive therapy in full.
Method
A clinical case of successful achievement of LN remission in a patient with severe SLE and secondary APS is described, despite the development of secondary infectious complications and the inability to fully immunosuppressive therapy.
Results
A 42-year-old woman has been observed at the clinic from autumn 2013 to the present. Since the end of Aug.2013 she got a severe dyspnea, generalized edema, ulcers of the legs, blood pressure persistently increased to 180/110 mm Hg, diuresis decreased.
Laboratory examination at admission in Oct.2013: (table 1), polyserositis, non-inclusive thrombosis of the posterior tibial vein on the left.
An immunological examination: anti-dsDNA 101.6 U/L, ANA 5.2, C3 complement fragment 0.29 g/L, antibodies to beta-2-glycoprotein-1 55.7 U/ml, positive lupus anticoagulant.
Intravenous methylprednisolone at a dosе of 1000 mg/day for 3 days plus high dose CYC at a dosе of 800 mg/day for 1 days was started, followed by prednisone 60 mg/day. This intravenous pulsewas repeated after 3 weeks.
Renal biopsy in Nov.2013: diffuse proliferative glomerulonephritis with 7% cellular crescents, ISN/RPS class IV LN.
Positive dynamics in Dec.2013 (table 1).
By mid-Dec.2013, the patient had complaints of pain and limited range of motion in the right shoulder joint, the appearance of edema in this region. According to the puncture of the joint cavity, MRI, purulent arthritis of the right shoulder joint was diagnosed with the formation of intermuscular phlegmon of this area.
Sepsis was diagnosed. The patient underwent emergency surgical drainage of phlegmon, followed by repeated revisions of this area. Prescribed meropenem at a dose of 3 g/day.
Implementation of the complete immunosuppressive therapy protocol was impossible; a gradual decrease in the dose of prednisone per os was started. Due to the continued activity of SLE, in January 2014, a repeated intravenous pulse methylprednisolone without СYС was performed.
Since Dec.2013, the patient has not received cystostatics. But despite it positive dynamics in Feb.2014 (table 1) .
In Mar.2014 current treatment was hydroxychloroquine 400 mg/day, prednisone 15 mg/day, azathioprine 100 mg/twid.
After 2 years of complete remission of LN in April 2016: prednisone 10 mg/day, hydroxychloroquine 400 mg/day, azathioprine 50 mg/twid. After another 2 years of complete remission of LN in 2018: prednisone 5 mg/day, hydroxychloroquine 400 mg/day. During the observation, a complete clinical and laboratory remission of SLE was noted.
Laboratory examination at admission in Oct.2019: complete remission of SLE (table 1). The patient takes prednisone 5 mg/day, hydroxychloroquine 400 mg/day.
The patient has limited mobility of the right shoulder joint, but complete loss of function did not occur. According to the control MRI there are the formation of aseptic necrosis of the head of the right humerus.
Conclusion
Infectious complications remain one of the leading causes of mortality in patients with SLE. The uniqueness of this clinical case in the successful achievement of long-term complete remission of SLE, despite the secondary infectious complications. The success of achieving long-term remission of SLE is associated with the onset of immunosuppressive therapy as soon as possible from the debut of the disease, with the conduct in the maximum allowable volumes. The morphological picture with a small % cellular crescents was also a favorable factor.
Latissimus dorsi tendon transposition combined with shoulder joint proximal capsule plasty with peroneal longus tendon autograft in the treatment of patients with massive rotator cuff ruptures and proximal dislocation of the humerus head (clinical case)
