Case 1
1) The correct answer is A.
The patient meets both the ACR classification criteria for SLE (1997 update of 1982 criteria) and the 2012 SLICC classification criteria for SLE.
She fulfills 4 of 11 ACR classification criteria for SLE (> 4 needed to meet criteria): +ANA, immunologic disorder (+dsDNA, hypocomplementemia), hematologic disorder (thrombocytopenia, leukopenia on > 2 occasions, lymphopenia on > 2 occasions), malar rash, and oral ulcers.
She also fulfills 6 of 17 SLICC classification criteria for SLE (> 4 needed with at least 1 immunologic and 1 clinical criteria met): +ANA, +dsDNA, hypocomplementemia, leukopenia/lymphopenia, thrombocytopenia, acute cutaneous lupus (malar rash), oral ulcers.
2) The correct answers are: A and B.
Thrombocytopenia in SLE has multiple possible etiologies, including ITP, TTP, the antiphospholipid antibody syndrome, as well as medication toxicity, viral infection, and malignancy. Liver disease, including AIH, can lead to hypersplenism, splenic sequestration of platelets, and consequently thrombocytopenia. However, she has normal liver function tests and normal synthetic function on laboratory analysis, no splenomegaly on exam, and no stigmata of chronic liver disease, making AIH extremely unlikely.
Case 2
3) The correct answer is A.
All of the above need to be addressed with further evaluation.
The patient has classic symptoms for pleuropericarditis (pleuritic chest pain worsened with lying flat and relieved with leaning forward). However, particularly in patients with SLE, the differential for cardiopulmonary processes is broad, and it is critical that multiple potential etiologies be considered. There is a markedly increased risk of cardiovascular disease (4-fold increased risk). Pulmonary embolism is also more common in patients
4) The correct answers are A and B.
Given the lack of pulmonary infiltrates on chest x-ray, bacterial pneumonia is less likely. Despite the normal cardiac silhouette and lack of ECG changes, pericarditis remains possible and an echocardiogram is indicated. A pulmonary embolism also still needs to be considered.
CT angiogram of the chest is negative for pulmonary embolism. Echocardiogram shows a small pericardial effusion and is otherwise unremarkable
5) The correct answers are A and B.
The patient has classic symptoms for pericarditis and a small effusion on echocardiogram supporting this diagnosis. Therapeutic approaches include: increasing corticosteroid dose (PO or IV if necessary), colchicine, and consideration of NSAID therapy (to be employed with caution in this patient with a history of lupus nephritis). In the outpatient setting, depending on his response, a change to his baseline immunosuppressive regimen may be indicated. However, there is not an indication for use of rituximab in this setting.