Late-Onset SLE Case Underscores Possibilities of Unusual Presentation

Systemic lupus erythematosus (SLE) is most commonly associated with women of younger and middle ages, but a new case report highlights the reality that some patients develop the disease much later, and with surprising manifestations.

The report, published in Cureus, involves a 69-year-old Hispanic male with a diagnosis of late-onset SLE with lupus nephritis. The authors say the case demonstrates the importance of investigating for SLE even when a patient is not considered a likely candidate for the disease.

The authors explained that late-onset SLE is a subtype of the disease that presents when patients are older than 50 years.

“Although it is rare and infrequent, the term ‘late-onset SLE’ or SLE in the elderly has been used to differentiate it from the classic SLE,” they wrote. “However, in the case of male geriatric patients, the diagnosis is often overlooked due to the low incidence and atypical manifestations of the disease.”

In patients with lupus nephritis, overlooking SLE can prove costly, given its association with high rates of morbidity and mortality, they noted.

In the case at the center of this report, a patient with a history of hypertension, hyperlipidemia, Hashimoto’s thyroiditis, autoimmune hepatitis, and chronic kidney disease, among other conditions, sought emergency medical care because of a persistent fever, chills, and cough. The patient was initially given antibiotics and underwent a series of tests. However, chest x-rays did not indicate pneumonia, and so empiric antibiotics were discontinued.

Meanwhile, the patient’s renal function was raising concern.

“A 24-hour urine collection revealed a urine protein/creatinine ratio of 4.31 g/g and a urine microalbumin/creatinine ratio of 1872 mg/g,” the authors wrote. His creatinine level soon increased to 4.0 mg/dL, and he was found to have a strongly positive antinuclear antibody screen and mildly elevated antinuclear ribonucleoprotein levels; other levels were normal.

A kidney biopsy was ordered, and the patient began taking methylprednisolone. The biopsy showed the patient had a full house immunofluorescence pattern, and lupus nephritis was diagnosed.

The patient was prescribed mycophenolate mofetil (CellCept) and prednisone, which led to renal stabilization and improved urine output. By 1 week after discharge, the patient’s creatinine level had dropped to 2.8 mg/dL.

Khan and colleagues said the case is a good reminder of the important differences between classic and late-onset SLE.

“Late-onset lupus differs from early-onset lupus in gender and ethnic prevalence, clinical presentation, organ involvement pattern, disease severity, and prognosis,” they wrote. “These differences are due to age-related variation in environmental and/or host factors responsible for disease expression and to variation in sex hormones.”

Lupus nephritis is considered an atypical presentation in late-onset SLE, but the investigators said it warrants aggressive management due to the risk of end-stage renal disease.

They concluded that it is “critical” for clinicians to investigate for SLE if a patient has full-house immunofluorescence in biopsy.

“This should be done regardless of the patient’s age, sex, race, or absence of extrarenal manifestations, as illustrated in this case report,” they wrote.

Reference

Khan A, Sawant T, Deen Z, Humayun W, Humayun Y. Systemic lupus erythematosus in the elderly that debuts with an organic manifestation of lupus nephritis. Cureus. Published online September 3, 2022. doi:10.7759/cureus.28746