Systemic Lupus ErythematosusUrgent

26-year-old woman with SLE, stopped hydroxychloroquine; 2 weeks of facial swelling, frothy urine, joint pain; BP 160/100, creatinine 1.8, urine PCR 3.2 g/g with red cell casts; C3/C4 low, anti-dsDNA high

• Rising creatinine, red cell casts
• Haemoptysis
• Seizure or psychosis
• Pericardial rub with hypotension
• Fever on immunosuppression

• Infection (sepsis, TB, opportunistic)
• Drug-induced lupus (hydralazine, procainamide, isoniazid — anti-histone)
• TTP (schistocytes)
• Vasculitis
• Pre-eclampsia (in pregnancy)

• Admit: Nephritis with AKI or nephrotic range, serositis with effusion, severe cytopenias, neuropsychiatric lupus, suspected infection on immunosuppression
• ICU: Alveolar haemorrhage, catastrophic APS, tamponade, status epilepticus, sepsis
• Dialysis: AKI with refractory K⁺, overload, acidosis

• Hydroxychloroquine for every SLE patient (≤5 mg/kg/day) — it lowers flares, thrombosis and death; annual eye screening after 5 years.
• Glucocorticoids are a bridge, not maintenance — ≤5 mg/day and off if possible (EULAR 2023).
• Early belimumab or anifrolumab when hydroxychloroquine plus low-dose steroid are not enough.

• Give pulse steroids before excluding infection when fever is present
• Stop hydroxychloroquine (flares and mortality rise)
• Use a DOAC for antiphospholipid syndrome with arterial events or triple positivity
• Use mycophenolate or cyclophosphamide without contraception

• Missing infection
• Missing nephritis (always check urine)
• Stopping hydroxychloroquine
• Long high-dose steroids

Ward for organ flares; ICU for alveolar haemorrhage, CAPS, tamponade or sepsis. Rheumatology/nephrology within 2 weeks.