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1、病案討論 -Systemic Lupus Erythematosus,曾素卿 2006/09,The case,General patient information Name:林 Age:40 Gender:female Education: highMarital status: marriedOccupation: office lady Admission date:94/04/22 Discharge date:94/04/25 Chart No:61591622,Chief complaintProgressive lower limb edema and gain of body
2、 weight for about 10 days,Present illness () A 40-year-old woman was a case of SLE and diagnosed at 南門醫院 at age 19. She was under treatment at 東元醫院 and had received several cycles of pulse therapy.She had operation history of endometriosis s/p on MMH in 1994 and pregnancy with abortion (due to fever
3、) for two times and an episode of interauterine death, followed by acute renal failure s/p hemodialysis for 3 months.,Present illness () She sustained from repeated cystitis and PIP in 2001/10 and followed by HPV infected vaginitis in 2002/7. Type lupus nephritis was told from renal biopsy at 台大醫院.
4、Mrs.Lin appeared to our clinic in 2004/2/6 with severe Raynauds phenomenom and digital vasculitic purpura which were also present over elbows, lower limbs and pretibial area.,Present illness ()She was admitted to received pulse therapy and cystitis with vaginitis treatment during 93/05/14-93/05/20.
5、She was admitted twice to our hospital due to finger and toe tips vasculitis and malar rash (2004/5, 2004/7) and herbal medicine induce flare.,Present illness ()Due to her eager for baby, she refused treatments as pulse and cytotoxics. However, recurrent lower limb edema with heavy proteinuria despi
6、te prednisolone and azathiprine. Hydroxychloroquine was withheld due to patients fear of skin hyperpigmentation.,Present illness ()Her laboratory tests resulted in dsDNA=31.9429562618503100322235617844.514410.940C3/C4=25/1026/10385750ESR=41759183725351575049alb=2.72.53.52.0 Uprotein=2.772.055.444.7g
7、/day,Present illness () aCLIgG=7.817.3GPL/ml(N9.8MPL/ml(50% of glomeruli aggressive immunosuppression is recommended.If untreated, develop end-stage renal disease (ESRD) within 2 years.,Discussion SLE with lupus nephritis class with peripheral vasculitis,Assessment:2.This patients with dangerous pro
8、liferative forms of glomerular damage and proteinuria (500 mg per 24 h) therefore, aggressive immunosuppression is indicated (usually systemic glucocorticoids plus a cytotoxic drug) but proteinuria is less likely to improve on lupus nephritis immunosuppressive therapies. Lupus nephritis tends to be
9、an ongoing disease, with flares requiring re-treatment over many years.,Discussion SLE with lupus nephritis class with peripheral vasculitis,Assessment:3.Treat with monthly intravenous cyclophosphamide,500 to 1000 mg/m2 body surface area for 6 months,along with high-dose corticosteroids (usually ini
10、tially pulse methylprednisolone,1000 mg/d for 3 days,followed by prednisone,40 to 60 mg/d,for the first month), may be benefit for this patient.,Discussion SLE with lupus nephritis class with peripheral vasculitis,Assessment:4. Due to her eager for baby, this patient refused treatments.Therefore con
11、sider other drugs like azathioprine or mycophenolate.,Discussion SLE with lupus nephritis class with peripheral vasculitis,Assessment:5. Azathioprine (a purine antagonist) added to glucocorticoids probably reduces the number of SLE flares and the maintenance glucocorticoid requirement; however, this approach requires several months to be effective, and cyclophosphamide is effective in a higher proportion of patients. Daily oral azathioprine may have fewer adverse effects than daily oral cyclophosphamide;,
