Lupus Case Study

Danielle Swanson
Introduction to Lupus
Chronic autoimmune disease

Can target different areas of the body
Skin, joints, kidneys, heart, lungs, blood vessels,
brain

More common in women than men

2-3 times more common in African Americans
than Caucasians.
Lupus
Most common symptoms
Arthritis
Extreme fatigue
Fever
Skin rash
Kidney issues
Anemia
Mouth ulcers
Sensitivity to sunlight


Types of Lupus
There are 5 different types of lupus
Discoid Lupus Erythematosus (DLE)
Subacute Cutaneous Erythematosus (SCLE)
Drug-Induced Lupus
Neonatal Lupus
Systemic Lupus Erythematosus (SLE)
Discoid Lupus Erythematosus
Chronic skin disorder
Presents with scaly plaques on the skin that may
result in scarring
Sun exposure can exacerbate the disease
16% increased risk of developing SLE within 3
years of diagnosis
Treatments include corticosteroids, antimalarial
agents and sunscreen
Subacute Cutaneous Erythematosus
Chronic skin disorder
Presents with non-scarring skin lesions in areas
exposed to the sun
Usually found in people with Sjorgren syndrome
An autoimmune disease in which the glands that
produce saliva and tears are destroyed
Treatments includes sun avoidance, topical
corticosteroids, and antimalarial agents
Drug-Induced Lupus
According to the Lupus Foundation of America
there are approximately 46 medications
currently being used that can cause drug-
induced lupus
Medications for heart disease, thyroid disease,
hypertension, antibiotics, and oral
contraceptives can all cause lupus
Symptoms are usually resolved shortly after the
medication is discontinued
Neonatal Lupus
Occurs in newborn babies of women with SLE or
Sjorgrens sydrome
Has occurred in newborns of mothers with no
disease at all
Symptoms include skin rash, liver issues, and
low blood counts at birth
Symptoms often resolve a few months after birth
In rare cases, the baby may develop congenital
heart block
Systemic Lupus Erythematosus (SLE)
When initially diagnosed the most common
symptoms include extreme fatigue, skin rash,
joint pain, and unexplained fever
Generally characterized by cycles of flares
ranging from mild to serious followed by a
period of remission
One of the more serious symptoms of SLE is
Lupus Nephritis
Affects ~40% of people diagnosed with SLE


SLE Classification
Involves a list of 11 criteria developed by the
American College of Rheumatology

A person must present with 4 out of the 11
symptoms for diagnosis

SLE Criteria
# Symptom Description
1 Malar Rash Red/purple butterfly-shaped rash across the
cheekbones and bridge of the nose. Can be raised
or flat. Usually not painful.
2 Discoid Rash Patchy redness on the skin that may cause
permanent scarring.
3 Photosensitivity Skin rash caused by a reaction to sunlight
exposure. Two-thirds of people with lupus are
sensitive to UV or fluorescent lighting.
4 Oral Ulcers Can occur in the mouth and nose but are usually
pain-free.
5 Non-erosive arthritis Must affect 2 or more peripheral joints.
Inflammation must occur or at least 6
consecutive weeks. >90% of people with SLE
experience arthritis.
SLE Criteria Cont
# Symptoms Description
6 Pericarditis or Pleuritis Inflammation of the lining around the
heart or lungs. Characterized by sharp
chest pain and shortness of breath.
7 Renal Disorder Consistent proteinuria >0.5g/day or the
presence of cellular casts in the urine.
8 Neurologic Disorder Seizures or psychosis
9 Hematologic Disorders Anemia with a WBC count of
<4,000/mm
3
or a blood platelet count of <1,500/mm
3
10 Immunologic Disorders Anti-Double-Strand DNA, anti-Smith or
antiphosolipid antibodies, or a false-
positive for syphilis.
11 Positve Antinuclear
Antibody Test
Least accurate criteria. 90-95% of people
with positive results do not have lupus.
SLE Maintenance
There is no current cure

SLE treatment depends of the symptoms the
patient experiences and how severe they are

Joint pain, fatigue, and skin rashes can often be
treated with NSAIDs
Antimalarial Agents
Generally used to treat malaria
Have shown to improve muscular and joint pain,
skin rashes, pericarditis, pleuritis, and relieve
fever and fatigue in people with SLE
Also help reduce flare-ups and prevent the
spread of lupus to other organs if started early
on
Work by modulating the immune system
without predisposing the person to infection
Corticosteroids
Prescribed when earlier treatments have failed
Used when symptoms are more serious
Such as those that affect the kidneys, lungs or
heart
Reduce inflammation in the body
Long-term use can have negative side effects
including Cushings syndrome, weight gain,
increased susceptibility to infection, stomach
irritation, muscle weakness
Biologics
Belimumab FDA approved biologic for
moderate SLE symptoms

Studies to test biologics usually used for
rheumatoid arthritis are being done for
treatment of lupus

A combination of any of these treatments can be
used to treat SLE
Medical Nutrition Therapy
No established MNT diet for a person diagnosed
with lupus

It is important to eat a well-balanced, heart-healthy
diet, as there is an increased risk of heart disease

It is possible to treat many of the individual
symptoms through nutrition therapy
If the patient is diagnosed with lupus nephritis, a renal
diet may be necessary
Medical Nutrition Therapy
Joint pain and inflammation are common symptoms
of SLE
An anti-inflammatory diet may be helpful
High in fresh fruits, vegetables, whole grains, lean
protein
Low in saturated fats, refined grains and processed-
convenience foods
Omega-3 fatty acids have anti-inflammatory effects
on the body
Spices such as cinnamon, ginger and curry also have
anti-inflammatory effects
Medical Nutrition Therapy Cont
Long-term corticosteroid use makes bones more
susceptible to osteoporosis.
A diet rich in calcium and Vit D may be beneficial

Alfalfa sprouts should be completely avoided
after diagnosis of SLE.
The amino acid, L-canavanine, found in alfalfa has
been proven to cause symptom flares in lupus
according to the Lupus Foundation of America
SLE and Celiac Disease
A recent study compared the risk of developing SLE in
people with Celiac Disease.
Followed 29,048 Celiac Disease patients for 5 years -
Resulted in 54 patients diagnosed with SLE
Suggests a 3x higher risk of developing SLE in people with
CD as compared to the general population
Another study suggests that it is possible that people
with SLE actually have undiagnosed CD.
Followed 3 patients who had been treated for SLE for many
years. After elimination gluten from their diet, all 3
patients no longer experienced symptoms of SLE, abnormal
lab tests returned to normal, and SLE medications were no
longer necessary.
These studies suggest that eliminating gluten from the
diet may be beneficial when an SLE diagnosis is
suspected.

Introduction to Patient
JA is a 32 year old female
Admitted with abdominal pain and poor appetite
for approximately one week

56 (168cm), 121 lbs (55kg)

BMI 19.5 (healthy range)

Reports to follow a renal diet at home, however
compliance is questionable

Past Medical History
SLE
End-Stage Renal Failure secondary to SLE
Chronic abdominal pain
Gastroparesis
Chronic anemia
Hypertension
Hiatal hernia
Appendectomy
TPN dependency
Past Medical History Cont
JA was diagnosed with SLE approximately 16
years ago
Has been receiving hemodialysis for end-stage
renal failure 3 times per week for about 2 years
She lives at alone and works from home
She has no history of smoking or alcohol abuse,
but is suspected of narcotic dependency from
long-term use for pain
Her father died of myeloma and had a history of
renal failure
Current Medications
Epoetin used to stimulate red blood cell
production. Often prescribed to dialysis patients
due to chronic anemia

Morphine prescribed for chronic pain

Zofran antiemetic prescribed secondary to
multiple vomiting episodes

Prednisone corticosteroid used as long-term
treatment for SLE
Abnormal Lab Values
Lab Test Value Normal Range
Lipase 456 0-160 units per liter
Na 130 135-145 mEq/L
BUN 32 6-20 mg/dL
Cr 6.8 0.6-1.1 mg/dL
Alb 1.6 3.4 5.4 g/dL
eGFR 9 90-120 mL/min/1.73m
2
Mg 1.2 1.7 2.2 mg/dL
Reason for Admission
JA was admitted for abdominal pain and poor oral
intake

The patient was kept NPO after admission due to
continuous nausea, abdominal pain, and no bowel
movement for approximately one week

JA was found to have gastroparesis
Condition where the muscles of the stomach do not
function properly resulting in delayed stomach
emptying
Gastroparesis is not uncommon in SLE patients, the
reason is not completely understood, but may be due
to long term medication use

Medical Course
On 4/21 JA was admitted and kept NPO
secondary to nausea and vomiting
After gastroparesis diagnosis, a nasogastric tube
was placed for continuous low wall suction
On 4/24 the NGT was removed and the diet was
advanced to clear liquids. She still felt nauseas
but was no longer vomiting. By dinner that day
her diet was advanced to full liquids
The morning of 4/25 JA had a BM and the diet
was advanced to GI Soft. She tolerated the diet
well with no N/V


Medical Course Cont
The labs were re-done the afternoon of 4/25. The renal-
related labs remained the same since admission. The
lipase had decreased to 202 which was much closer to
the healthy range

There was discussion of possible discharge on 4/28

The morning of 4/28, after eating breakfast, she had a
large amount of coffee ground emesis so the discharge
was cancelled

JA was then kept NPO from 4/28-5/2. On 5/3 the diet
was advanced to clear liquids and was tolerated well

On 5/4 the diet was advanced to GI Soft and a 3-Day
Calorie Count was hung
Medical Course Cont
The information for the calorie count was not
recorded on 5/4. On 5/5 the calorie count showed
JA consumed about 1400calories and 50g protein
showing a great improvement in appetite

Per the chart, the plan was to continue the calorie
count for one more day and JA would most likely be
discharged in 1-2 days as long as her intake
remained good without nausea

My recommendation was to advance the diet to 2gm
Na as tolerated because her renal diet compliance is
questionable, her Phos and K were WNL, and she
has a history of poor PO intake.

Conclusion
Lupus is a very complex disease that effects
people in many different ways.

Although there is no established therapeutic diet
for Lupus, it is possible to lessen some of the
common symptoms and flare-ups through
simple diet changes.

Through a combination of medication an diet, it
is possible to live a fairly normal life with SLE.
References
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3. Lin, J. (2014, April 7). Subacute Cutaneous Lupus Erythematosus (SCLE) . Subacute Cutaneous Lupus Erythematosus (SCLE). Retrieved , from
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7. Illiades, C. (2009, April 6). Managing Your Diet to Keep Lupus in Control - Lupus Center - EverydayHealth.com. EverydayHealth.com. Retrieved , from
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11. Steroids. (n.d.). Johns Hopkins Lupus Center. Retrieved , from http://www.hopkinslupus.org/lupus-treatment/lupus-medications/steroids/

12. Anti-Malarial Drugs. (n.d.). Johns Hopkins Lupus Center. Retrieved , from http://www.hopkinslupus.org/lupus-treatment/lupus-
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