Physical Examination and Workup
Upon physical examination, the patient is afebrile with a heart rate of 95 beats/min, a respiratory rate of 16 breaths/min, and blood pressure of 165/86 mm Hg. She has a normal mood and affect, good hygiene, and is in mild distress due to pain. Her pupils are round and reactive to light, and her extraocular movements are intact bilaterally. Oral mucous membranes are moist. Lungs are clear to auscultation bilaterally.
Her heart rhythm is regular, and no murmurs, rubs, or gallops are observed. The abdomen is soft with positive bowel sounds, although mild tenderness is noted upon palpation of epigastric region. Well-healing discoid lupus lesions are noted on lower extremities. She is alert and oriented without any neurologic deficits.
Her laboratory test findings are as follows:
Hemoglobin level: 9.3 g/dL (reference range, 11.6-15 g/dL)
Platelet count: 9000 (reference range, 150,000-450,000)
Creatinine level: 2.2 mg/dL (reference range, 0.59-1.04 mg/dL)
Alanine aminotransferase (ALT) level: 109 U/L (reference range, 7 to 56 U/L)
Aspartate aminotransferase (AST) level: 234 U/L (reference range, 9-32 U/L)
Total bilirubin level: 4.3 mg/dL (reference range, 0.1-1.2 mg/dL)
Troponin level: 0.32 ng/mL (reference range, 0-0.04 ng/mL)
Lactate dehydrogenase (LDH) level: 1948 U/L (reference range, 105-333 U/L)
Haptoglobin level: < 8 mg/dL (reference range, 41-165 mg/dL)
Two months prior, her hemoglobin level, platelet count, and creatinine level were within the reference range. Antinuclear antibody test findings are positive, with titer of 1:320. Anti-Sjögren's-syndrome-related antigen (SSA) findings are positive. C3, C4, and anti-dsDNA findings are normal. Her prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen level, and antithrombin III function are normal. She also has proteinuria and microscopic hematuria.
Her hepatitis panel is positive for hepatitis C virus infection, with confirmatory testing showing genotype 1a. This is a new finding, as her prior acute hepatitis panel 1 year ago was negative. A peripheral blood smear reveals schistocytes (Figure 2).
Stool studies for Escherichia coli, Salmonella, Shigella, Campylobacter, Clostridium difficile, ova, and parasites are negative. Blood and urine culture findings are negative. Coombs test results are negative, and antiplatelet antibody findings are negative. An antiphospholipid syndrome panel finding is negative. ADAMTS13 inhibitor findings are negative, ADAMTS13 activity is 61% (reference range, > 67%), and ADAMTS13 antibody level is 71 (reference range, < 18).
Ultrasonography of the abdomen and CT of the abdomen and pelvis reveals perinephric fat stranding around the bilateral kidneys without evidence of obstruction; it is otherwise unremarkable, with normal liver and spleen findings. Echocardiography reveals normal left and right ventricular function.
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