Chief symptom
A 30-year-old woman with diabetes mellitus and recently diagnosed severe lupus nephritis and renal insufficiency was admitted for a renal biopsy and anticipated initiation of immunosuppressive therapy.
History of the present illness
The patient had been admitted to the hospital 2 months previously for evaluation of weight loss, diffuse myalgias, arthralgias, nausea, vomiting, facial rash, lower extremities, and facial edema. Evaluation revealed acute renal insufficiency, with a creatinine level of 5.2 mg/dl and an active urinary sediment with 4Ο© proteinuria, 2Ο© hematuria, and red blood cell casts. Tests for antinuclear antibodies (ANAs), antibodies to Sm antigen, and antibodies to RNP were positive. Tests for antibodies to doublestranded DNA, SSA, SSB, and glomerular basement membrane were negative, as was testing for antineutrophil cytoplasmic antibodies. Both C3 and C4 levels were low (Table 1). A kidney biopsy was scheduled and intravenous (IV) pulse therapy with methylprednisolone was started. However, on the second day of her admission, the patient signed out of the hospital against medical advice. Her creatinine at discharge was 4.8 mg/dl.
Over the next 2 months, the patient developed progressively worsening body aches, nausea, vomiting, and edema in the lower extremities and face. The facial rash persisted and a new rash on her upper and mid-back appeared. She had been using ibuprofen 600 mg up to 4 times a day for 3-4 days prior to readmission.
Medical history
Her medical history was notable for diabetes mellitus, which was incidentally diagnosed a few months before this admission, when she presented to the hospital for evaluation of a genital infection and was found to have elevated blood glucose tests in the range of 400 -700 mg/dl with glycosylated hemoglobin of 13.9 mg/dl. She had a brief hospital admission and insulin therapy was prescribed.