A 26-Year-Old Woman With Pleural Effusion, Hydronephrosis, and Ascites

Kaleem Ullah Toori, MB BS; Sumaira Nabi, MB BS; Sadaf Khattak, MB BS; Herbert S Diamond, MD


August 16, 2018

The patient's ascitic fluid examination showed an exudative picture with predominant lymphocytes which is typical for both SLE and tuberculous ascites; however, ascitic fluid analysis in this patient did not reveal any evidence of infectious disease or malignancy. The CA 125 levels were elevated; however, this is not specific for ovarian carcinoma, and this marker may be elevated in immune or rheumatologic disease or in chronic inflammatory processes involving the peritoneum.[15]

Pakistan is a TB-endemic country. This past history of tuberculosis as well as her clinical, radiologic, and laboratory data initially pointed towards genitourinary tuberculosis and tuberculous peritonitis, which warranted a trial of antituberculous therapy. However, after 3 weeks the patient had not improved, and she developed a nondeforming arthralgia involving the small joints of the hands. An alternate diagnosis was sought at that point.

A persistently high ESR, high titers of ANA with a homogenous pattern, and very high titers of anti-double stranded-DNA antibodies along with low complement levels are highly suggestive of SLE. Although her presentation with polyserositis, symptoms suggesting intestinal obstruction, high fever and hydronephrosis was unusual, she fulfilled the Revised American Rheumatism Association Criteria for SLE on the basis of arthritis, serositis, and renal involvement in the form of persistent proteinuria and high titers of ANA and anti-double stranded-DNA.[16]

This patient was initially treated with high-dose corticosteroids and cytotoxic therapy and then maintained on oral steroids. Periodic follow-up on a monthly basis with laboratory testing, including CBC with ESR, renal function and urinalysis were ordered to monitor the response and adverse reactions to therapy and to detect signs and symptoms of new organ-system involvement. The response to treatment was good and no adverse drug reactions were documented.

In conclusion, SLE can be challenging to diagnose. Rheumatologic disease should be strongly considered in situations where findings are nonspecific and the work-up has failed to reveal a definite diagnosis.


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