Case Presentation
The patient is a 40-year-old non-smoker female with a 17-year history of infertility. She previously underwent hormone therapy; she developed acute lower extremity weakness around six years ago, predominantly on the right side. Her family history was negative for any kind of connective tissue disorders or SLE. Additionally, the patient had a history of severe headaches and flutter, for which she was referred to a neurologist. She was admitted to the neurology ward because of her acute presentation. During hospitalization, the initial examination determined a decrease in Muscle Force (M/F) with a predominance for the right side, a positive Marcus Gan test in the left eye, and the presence of a sensory level in the C8 and T1 dermatomes, and abnormal cerebellar tests.
Meanwhile, his other vision examinations were intact. According to the clinical findings, the visual evoked potential (VEP) requested for her was normal, and Magnetic resonance imaging (MRI) showed multiple plaques of the brain and a longitudinally extensive spinal cord lesion (LESCL). Glucose (Glu): 49mg/dl, Protein (Pro): 28mg/dl, Lactate dehydrogenase (LDH): 34IU/L, White Blood Cells (WBC): 0 cells/µL, and Red Blood Cells (RBC): 0 cells/µL, and there was no evidence of Oligoclonal banding reported in the Lumbar puncture (LP) done for her suspicious demyelinating disorders. Also, she developed Deep vein thrombosis (DVT) in her right upper extremity.
Following a partial recovery, the patient was discharged with a diagnosis of transverse myelitis in demyelinating disease. Due to her relatively complete recovery over the last two years, the patient has arbitrarily discontinued her medication and follow-up. The patient presented with acute weakness in the lower extremities about a month ago and was hospitalized in the neurology ward. Her blood pressure was 115/78, her pulse rate was 83 beats per minute, and her temperature was 36.6°C. Lung, heart, and abdomen examinations were unremarkable. M/f was 4.5 for the right upper extremities, 5.5 for the left upper extremities, and 0.5 for the lower extremities during the initial examination; Marcus Gunn was negative, and tendon reflexes were +3 for the right knee and +2 for the left knee. TM was detected during this hospitalization via MRI. The patient had 12 doses of corticosteroids over six days and then six plasmapheresis sessions, which did not considerably improve her general health. Complement depletion, platelet depletion, proteinuria, positive Anti-nuclear antibody (ANA), and anti-Double-Stranded deoxyribonucleic acid (dsDNA) antibodies were detected in lab testing for suspicions Rheumatic diseases. During hospitalization, the patient had shortness of breath and was assessed for pulmonary artery Computed Tomography Angiography (CTA) and echocardiography. Pulmonary Thrombo-Embolism (PTE) was proposed in the CTA of her pulmonary arteries. In the echocardiogram done for her, a lesion on the heart valves was seen, suggesting Lyman Sachs endocarditis, and pericarditis was reported. They suspected SLE and APS disorders according to the patient’s clinical condition and imaging and testing results. The patient was referred to the rheumatology ward. Her clinical diagnosis of lupus was validated through clinical trials and diagnostics—the rheumatologist prescribed Rituximab one gram every two weeks, which dramatically improved the patient’s clinical condition. The patient is in good general condition and has stable vital signs in subsequent follow-ups.