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 Table of Contents  
CASE REPORTS
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 37-39

Fever: A diagnostic dilemma


1 Department of Medicine, Assam Medical College, Dibrugarh, Assam, India
2 Department of Cardiology, Assam Medical College, Dibrugarh, Assam, India

Date of Submission07-Aug-2021
Date of Acceptance11-Feb-2022
Date of Web Publication18-Apr-2022

Correspondence Address:
Anshu Kumar Jha
Department of Cardiology, Assam Medical College, Dibrugarh 786002, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajoim.ajoim_16_21

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  Abstract 

Fever is one of the most common presentations of Systemic Lupus Erythematosus (SLE) (95%) but it is also associated with other manifestations. A 32-year-old female patient who presented with chief complaints of fever and burning micturition and during the course of the stay developed different manifestations like facial rash, leukopenia, proteinuria, and SLE was diagnosed on the antinuclear antibody (ANA) profiling of the patient and the clinical criteria. Here we present a case where the patient presented mainly with urinary tract infection which in turn acted as a trigger for immune reaction leading to the full-blown SLE.

Keywords: Antinuclear antibody, fever, SLE


How to cite this article:
Dihingia P, Kanta S, Jha AK. Fever: A diagnostic dilemma. Assam J Intern Med 2022;12:37-9

How to cite this URL:
Dihingia P, Kanta S, Jha AK. Fever: A diagnostic dilemma. Assam J Intern Med [serial online] 2022 [cited 2022 May 21];12:37-9. Available from: http://www.ajimedicine.com/text.asp?2022/12/1/37/343432




  Learning Points Top


  • Fever is an important symptom among patients with SLE but usually not the presenting complaint; hence, SLE should be considered as an important differential in the fever of unknown causes.


  • Common infections like urinary tract infections can also act as a trigger and further lead to activation of SLE.



  •   Case Report Top


    A-32-year-old female homemaker without any comorbidity, hailing from Assam, came with the chief complaint of fever for 1 month. It was gradual in onset, continuous type, and low grade. It was not associated with chills and rigors and got relieved on medication. The patient also complained of burning micturition for 15 days which was not associated with increased frequency or urgency, incontinence.

    Vitals were stable but on general examination the patient was sick looking with sunken eyeballs, dehydration, and was febrile on touch. Systemic examination was unremarkable.

    On investigation, patient had bicytopenia with hemoglobin of 7.0 g/dL, platelet count of 80,000 cells/mm3, WBC count of 4,600 cells/mm3, and ESR of 90 mm/h CRP 2.3 mg/dL. Routine urine examination showed 6–9 pus cells, Albumin – nil. Also, other causes of fever were ruled out including leptospira, typhi check, malaria, scrub typhus, dengue serology, and blood culture, which were all negative. Therefore, based on these findings a diagnosis of UTI was made and treatment for the same was started with antibiotic (ceftriaxone 1gm twice daily) empirically. Simultaneously urine was sent for culture and antibiotic sensitivity analysis. After a course of antibiotic which was given according to the urine culture and sensitivity report, burning micturition subsided but the fever persisted. And also during the course of the stay, the patient developed a facial malar rash [Figure 1].
    Figure 1: Malar rash on the patient’s face sparing the nasolabial folds

    Click here to view


    On repeating the blood counts bicytopenia developed into pancytopenia with the total WBC count dropping to 1,900 cells/mm3 and repeat urine R/E showed pus cells 1–2/HPF but albumin of 3+. Following this report, a 24-h urinary protein sample was advised which showed 4.16 gm protein/24hrs. Subsequently, WBC count decreased further. Based on the suspicion of autoimmune cause, antinuclear antibody (ANA) profiling was done and the patient was empirically started on prednisone of 1 mg/kg on suspicion of an autoimmune disease. And the patient responded to it with fever subsiding and WBC count increasing and later on the ANA reports were received, which showed the following results [Figure 2].
    Figure 2: Result of ANA profiling of the patient

    Click here to view


    Sm DNA +

    SS/Ro 60 ++

    SS/Ro 52 ++

    U1Sn RNP +

    And the diagnosis of Systemic Lupus Erythematosus with Lupus Nephritis (due to unavailability of renal biopsy at our institution) was made.

    As soon as the reports were available the SLEDAI score was calculated which was found to be 13. In view of disease activity and the current status of the patient, a Methylprednisone pulse of 1 g/day for 3 days was started following which the patient’s WBC count increased to 4400 and the urine R/E showed Albumin 1+. After this, the SLEDAI score was recalculated which came out to be 11.

    The patient was discharged with hydroxychloroquine and oral glucocorticoid (1 mg/kg). During her further visits to the hospital she went on to develop neurolupus which manifested as seizure supported by MRI. Now the patient is doing well with the maintenance dose of antiepileptic and low dose oral steroids.


      Discussion Top


    Fever is among one of the common symptoms in a patient of Systemic Lupus Erythematosus (SLE) (prevalence of 95%) and also fever is also considered in disease activity scoring but it is not usually the presenting symptoms.[1] Also, about 5% of pyrexia of unknown origin turns out to be due to SLE and other connective tissue diseases as documented by the study done by Timlin et al.[2] The presence of fever can be due to the disease activity or due to the presence of other infections. This was due to the disease activity as the fever did not subside even on starting antibiotics based on the urine culture and antibiotic sensitivity. As shown by Stahl et al.,[3] fever due to infection in a patient with is usually associated with leukocytosis and neutrophilia. Also in a study by Rovin et al.,[4] it was shown that the SLE fever subsides on starting of steroids and an SLE patient on steroids at a maintenance dose, fever is a rare occurrence.


      Conclusion Top


    By this case, we conclude that SLE forms an important differential diagnosis in a patient presenting with fever and also an indicator of the disease activity. Also even common infections like UTI caused by Escherichia coli can act as a trigger for the activation of the immune complex formation via the molecular mimicry pathway which is one of the ways of pathogenesis for initiation of SLE.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Hahn B Systemic lupus erythematosus. In: Jameson Fauci, Kasper Hauser, Longo Loscalzo, editors. Harrison’s Principles of Internal Medicine: Systemic Lupus Erythematosus. 20th ed. USA: Mc Graw Hills; 2019. p. 2515-26.  Back to cited text no. 1
        
    2.
    Timlin H, Syed A, Haque U, Adler B, Law G, Machireddy K, et al. Fevers in adult lupus patients. Cureus 2018; 10:e2098.  Back to cited text no. 2
        
    3.
    Stahl NI, Klippel JH, Decker JL Fever in systemic lupus erythematosus. Am J Med 1979;67:935-40.  Back to cited text no. 3
        
    4.
    Rovin BH, Tang Y, Sun J, Nagaraja HN, Hackshaw KV, Gray L, et al. Clinical significance of fever in the systemic lupus erythematosus patient receiving steroid therapy. Kidney Int 2005;68:747-59.  Back to cited text no. 4
        


        Figures

      [Figure 1], [Figure 2]



     

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