The patient in this case presented in stable condition without major abnormal physical findings. Although her chest pain prompted presentation to the ED, this was found to be noncardiac and of lesser concern. Her workup revealed severe thrombocytopenia, which prompted further investigation, given that such low platelet counts can lead to hemorrhage, cerebrovascular events, and death. Even after determining a thrombotic microangiopathic process was occurring, the etiology was complicated by her known SLE, recent gastroenteritis, and newly diagnosed viral hepatitis C infection. The suspected gastroenteritis resolved, and stool study findings were negative, with no documented fever, leukocytosis, or other signs of sepsis. Viral hepatitis C may contribute to thrombocytopenia, but it does not account for an acute drop in both hemoglobin level and platelet count, as well as other abnormalities on laboratory findings.
Disseminated intravascular coagulation and antiphospholipid syndrome, two other etiologies for thrombocytopenia in patients with connective tissue disease, were unlikely, owing to the normal coagulation study findings and negative antiphospholipid panel results. Thus, an exacerbation of the patient's SLE most likely resulted in her presenting condition. In the past, her cutaneous manifestations of lupus were difficult to control, and she had been on multiple immunosuppressive agents, including prednisone, hydroxychloroquine, methotrexate, mycophenolate, and belimumab.
Cytopenias, including anemia, leukopenia or lymphopenia, and thrombocytopenia, are common manifestations of SLE; they may or may not be immune mediated. Almost 50% of patients with SLE have anemia; the most common etiologies are anemia of chronic disease and iron-deficiency anemia. Autoimmune hemolytic anemia is also observed, although Coombs test findings are positive in only 10% of patients with significant hemolysis.
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