An Undiagnosed Case of Systemic Lupus Erythematosus Presenting with Diminution of Vision

I. INTRODUCTION

SLE is an autoimmune multisystem disease which may lead to mortality. The author is presenting a case of bilateral disc edema found to be a case of SLE after systemic investigation. So all cases of disc edema should be investigated thoroughly for detailed evaluation. SLE has been detected in young even in 13 years with neuropsychiatric symptoms(1) especially in female population.

However very few cases has been reported in male patients too(2). Akhil et al reported two male patients presented with generalized body ache and skin involvement. The author is reporting a adult female with neuropsychiatric symptoms.

II. CASE REPORT

33 years female presented with blurred vision in both eyes for 5 days in both eyes. It was painless gradual onset, progressive in nature but not associated with floaters, flashes or redness. She had difficulty in opening her mouth with generalized body aches and joint pain for the last 7 months. She also complaint of vomiting on ingestion of any food during last 7 months. On ocular examination her uncorrected visual acuity is 6/36 and best corrected is 6/12 in right eye and 6/60 with no improvement in left eye. Her both eyebrows, eyelids, and anterior segment were normal with normal pupillary reflex. Both fundi showed blurred and elevated disc margin with dilated veins. There were cotton wool spots and flame shaped hemorrhage on juxta papillary region and around maculae. Maculae showed dull foveal reflex. The intraocular pressure in right eye is 21 and in left eye is 19. With these findings she is diagnosed with grade IV disc edema in both eyes and differential diagnosis papilledema. MRI brain and orbit showed normal scan. Macular OCT showed increased thickness in macula. With these findings the patient was admitted in ward and diuretic medicine was given intravenously. The patient complaint of abdominal pain so physician consultation was sent. She found to have splenomegaly on abdominal ultrasonography. Further blood investigation revealed hemoglobin 11.5 mg/dl. PCV- 34.5%, platelet-98000 cells/cu mm, urea- 56mg/dl. Autoimmune IFA test showed serum ds DNA positive with dilution of 1:10 primary intensity +1 and endpoint titer 1:10. Serum antinuclear antibodies were positive in primary dilution 1:80, primary intensity of IF 4+, homogenous ANA pattern and endpoint titer 1:640. ABS to extractable nuclear antigen (ANA BLOT) showed smith antibodies positive, U1 SM/ RNP antibodies positive/SS-A antibodies negative, RO-52 antibodies negative, SS-B antibodies negative, dsDNA strong positive, anti-histone antibodies positive, anti-centromere antibodies negative, SCL-70 IGG antibodies negative, PM-SCL antibodies negative, JO-1 antibodies negative, PCNA antibodies negative, Nucleosome antibodies positive, AMA-M2 Antibodies negative, ribosomal P antibodies positive.

III. DISCUSSION

SLE with severe disc edema has been reported by Shekhar(1)in 2018. Bettman has reported papilledema in a case of SLE in 1968 associated with asymptomatic intracranial hypertension (3).

The largest multicenter studies were reported by Z. Jin et al in 2021(4). They studied the population attribute factor (PAF) of risk factors of mortality. They found death is due to anemia, nonuse of antimalarial drug and hypoalbuminemia. SLE related ocular findings can be found in one-third of cases(5). According to the SLICC criteria for classification of SLE suggest us lupus nephritis alone in presence of at least one of the immunological variables or four criteria with one having a clinical criterion and one immunologic criterion is required to diagnose SLE(6). Neither clinical criteria alone nor positive serological test alone should be considered SLE.

Our patient meets the SLICC criteria for the diagnosis of SLE. Up to 50% of pt with active NP-SLE symptoms may have MRI findings as T2/FLAIR related focal white matter hyperintensities, cortical gray matter lesions, brain atrophy and basilar artery territory infarction(7). However, our case has normal MRI findings.

IV. CONCLUSION

Systemic lupus erythematosus is a multisystemic autoimmune disease which can present with different sign and symptoms. In this case the case presented with blurring of vision. So, authors emphasize on the detail evaluation of every cases of blurring of vision with disc edema.