A 24-year-old woman had been complaining of multiple joint and muscular pains and stiffness in the morning. She also noted some hair loss and increased skin sensitivity to light. Her physical examination showed slight erythema around the cheek bones and some swelling in the joints of her hands.
Studies
Results
Routine laboratory work
Within normal limits (WNL), except for mild anemia
Urinalysis, p. 956
Profuse proteinuria and cellular casts
Antinuclear antibody (ANA), p. 88
1:256 (normal: <1:20)
Anti-DNA
398 units (normal: <70 units)
Anti-ENA
Positive (normal: negative)
Anticardiolipin antibody (ACA), p. 68
Immunoglobulin (Ig) G
96 g/L (normal: <23 g/L)
IgM
78 mg/L (normal: <11 mg/L)
Erythrocyte sedimentation rate (ESR), p. 221
75 mm/hour (normal: 20 mm/hour)
Immunoglobulin electrophoresis, p. 312
IgG
1910 mg/dL (normal: 565-1765 mg/dL)
IgA
450 mg/dL (normal: 85-385 mg/dL)
IgM
475 mg/dL (normal: 55-375 mg/dL)
Total complement assay, p. 172
22 hemolytic units/mL (normal: 41-90 hemolytic units/mL)
Diagnostic Analysis
The positive ANA and ACA tests strongly supported the diagnosis of systemic lupus erythematosus (SLE). The patient also had a facial rash suggestive of SLE. The elevated ESR indicated a systemic inflammatory process. The immunoelectrophoresis results were compatible with either RA or SLE; however, a decreased complement assay is commonly associated with SLE. The abnormal urinalysis indicated that the kidneys also were involved with the disease process. The patient was treated with steroids and did well for 7 years. Unfortunately, her renal function deteriorated, and she required chronic renal dialysis.
Critical Thinking Questions
2. Why is the ESR increased in inflammatory conditions?
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