Case Presentation
The patient is a 40-year-old non-smoker female with a 17-year history of
infertility. She previously underwent hormone therapy; she developed
acute lower extremity weakness around six years ago, predominantly on
the right side. Her family history was negative for any kind of
connective tissue disorders or SLE. Additionally, the patient had a
history of severe headaches and flutter, for which she was referred to a
neurologist. She was admitted to the neurology ward because of her acute
presentation. During hospitalization, the initial examination determined
a decrease in Muscle Force (M/F) with a predominance for the right side,
a positive Marcus Gan test in the left eye, and the presence of a
sensory level in the C8 and T1 dermatomes, and abnormal cerebellar
tests.
Meanwhile, his other vision examinations were intact. According to the
clinical findings, the visual evoked potential (VEP) requested for her
was normal, and Magnetic resonance imaging (MRI) showed multiple plaques
of the brain and a longitudinally extensive spinal cord lesion (LESCL).
Glucose (Glu): 49mg/dl, Protein (Pro): 28mg/dl, Lactate dehydrogenase
(LDH): 34IU/L, White Blood Cells (WBC): 0 cells/µL, and Red Blood Cells
(RBC): 0 cells/µL, and there was no evidence of Oligoclonal banding
reported in the Lumbar puncture (LP) done for her suspicious
demyelinating disorders. Also, she developed Deep vein thrombosis (DVT)
in her right upper extremity.
Following a partial recovery, the patient was discharged with a
diagnosis of transverse myelitis in demyelinating disease. Due to her
relatively complete recovery over the last two years, the patient has
arbitrarily discontinued her medication and follow-up. The patient
presented with acute weakness in the lower extremities about a month ago
and was hospitalized in the neurology ward. Her blood pressure was
115/78, her pulse rate was 83 beats per minute, and her temperature was
36.6°C. Lung, heart, and abdomen examinations were unremarkable. M/f was
4.5 for the right upper extremities, 5.5 for the left upper extremities,
and 0.5 for the lower extremities during the initial examination; Marcus
Gunn was negative, and tendon reflexes were +3 for the right knee and +2
for the left knee. TM was detected during this hospitalization via MRI.
The patient had 12 doses of corticosteroids over six days and then six
plasmapheresis sessions, which did not considerably improve her general
health. Complement depletion, platelet depletion, proteinuria, positive
Anti-nuclear antibody (ANA), and anti-Double-Stranded deoxyribonucleic
acid (dsDNA) antibodies were detected in lab testing for suspicions
Rheumatic diseases. During hospitalization, the patient had shortness of
breath and was assessed for pulmonary artery Computed Tomography
Angiography (CTA) and echocardiography. Pulmonary Thrombo-Embolism (PTE)
was proposed in the CTA of her pulmonary arteries. In the echocardiogram
done for her, a lesion on the heart valves was seen, suggesting Lyman
Sachs endocarditis, and pericarditis was reported. They suspected SLE
and APS disorders according to the patient’s clinical condition and
imaging and testing results. The patient was referred to the
rheumatology ward. Her clinical diagnosis of lupus was validated through
clinical trials and diagnostics—the rheumatologist prescribed
Rituximab one gram every two weeks, which dramatically improved the
patient’s clinical condition. The patient is in good general condition
and has stable vital signs in subsequent follow-ups.