subjective
Ms. Rand, a 35 year old female, is seen in Nurse Sick Call for a Health Service Request Form complaining of a skin rash with lesions that occurred after she went on outside rec in the direct sun. She included that this has happened before when she spent time in the sun, but not recently, and definitely not this bad. She also stated that she has been very fatigued in the last six weeks, but doesn’t know if those issues are related. When asked, Ms. Rand stated that the lesions were itchy and painful. In the past when she had the “sun rash,” it was “smaller” and not too itchy. This time, it covers her cheeks and nose. She denies headache, nausea, dyspepsia, weight loss, unexplained fever, adenopathy, oral ulcers, arthralgia, myalgia, edema, and anxiety.
Ms. Rand further described that she has been overweight “all of my life.” She stated that her provider in the free world told her that she had Pre-Diabetes, and she has been treated for hypertension for the last 5 years. She is up to date on vaccines, Pap smears, and dental visits.
objective
Allergies
No known drug allergies; no known food allergies.
Current Medication
Hydrochlorothiazide/lisinopril 12.5 mg 10 mg daily
Physical Assessment
Vitals: T 97.8°F, P 82, R 18, BP 143/84, HT 5’6″, WT 211 lbs, BMI 34.1.
Psychiatric: Appropriate mood and affect; appears slightly anxious.
ENT/Mouth: TMs clear, no lesion or ulcers noted inside oropharyngeal mucosa
Neck: Supple, no lymphadenopathy noted.
Lungs: Clear to auscultation without adventitious sounds; good air movement throughout.
Heart: S1, S2, RRR, no murmurs, rubs or gallops auscultated.
Abdomen: Soft, non-tender to palpation, + bowel sounds all quadrants; not distended.
Skin, Hair, and Nails: Multiple erythematous patches and plaques with scaling noted on face and both hands. No abnormal findings with hair or nails.
Musculoskeletal: ROM within normal limit both bilateral upper and lower extremities .
Neurologic: A&Ox4, cranial nerves II – XII intact. No focal deficits noted.
Correctional Nurse Actions
Reassure Ms. Rand that you have found nothing alarming in your evaluation, except the red, scaly rash over her nose and on her cheeks. While you do have a Nursing Assessment Protocol for Rash, and could give her over-the-counter hydrocortisone per that Protocol, you realize that the fatigue is a symptom that requires an evaluation by the Provider, and perhaps diagnostic testing. You appropriately hold off on the topical hydrocortisone and schedule Ms. Rand for a Provider appointment that afternoon.
Provider Actions
The Provider evaluates Ms. Rand and there is no different findings from the assessment done by the RN conducting Nursing Sick Call (you). The Provider then formulates her Differential Diagnoses.
DIFFERENTIAL DIAGNOSES FOR MS. RAND
•Psoriasis is unlikely. In the characteristic rash of psoriasis, the lesions are circumscribed on an erythematous base with overlying silver scales. Pitting of the nails may also be present.
•Rosacea usually presents with erythema, papules, pustules, telangiectasia, and flushing of cheeks, nose, and forehead. A skin biopsy will show sebaceous hyperplasia. This is an unlikely diagnosis given the patient’s presentation.
•Polymorphic light eruption is a disorder of the skin that results in dermatosis. This condition is caused by sunlight and presents with itchy, eczematous papules, plaques, and urticaria. This rash usually develops within 24 hours of sun exposure. This is a consideration.
•Atopic dermatitis is a chronic skin condition that comes with pruritus, dry peeling skin, and erythema with or without oozing clear liquid of the skin. Atopic dermatitis usually presents at the flexural surface on upper and lower extremities and neck. This is unlikely given that the patient’s lesions seem to resolve without treatment within a few days.
•Systemic Lupus Erythematosus (SLE) is high on the differential. SLE is an autoimmune disorder that affects a wide range of organ systems. A common manifestation of SLE that may or may not have systemic involvement is a skin lesion known as Cutaneous Lupus. This is consistent with the patient’s complaint.
DIAGNOSIS
Systemic Lupus Erythematosus (SLE) manifested as Acute Cutaneous Lupus is the most likely diagnosis. Acute Cutaneous Lupus (ACLE) usually presents in patients in their 30s. These lesions can present with erythematous plaque that may be covered with scale and can be somewhat indurated. The lesions are actively inflamed and may cause pain, itching, or stinging. Once healed, these lesions may cause hypopigmentation or hyperpigmentation, often leaving patients with scars.
The rash associated with ACLE has been referred to as the maculopapular rash of SLE, photosensitive Lupus dermatitis, and SLE rash. The type of skin involvement can be helpful to understand the underlying severity of the disease and determine if the problem is limited to the skin or systemic lupus. ACLE refers to the typical photosensitive malar rash described in this case and is strongly associated with more severe and systemic disease. This rash is classically associated with exposure to sunlight. Of patients presenting with ACLE, roughly one quarter have already been diagnosed with Systemic Lupus and another 18% will subsequently be diagnosed with SLE.
Diagnostic Tests/Imaging
Complete Blood Count with differential to evaluate for leukopenia, anemia, and/or thrombocytopenia associated with SLE.
Erythrocyte Sedimentation Rate, which is a general marker of inflammation that may indicate active SLE but is nonspecific and can be elevated for multiple reasons.
Complete Metabolic Panel, which includes measurement of sodium, total protein, BUN, and creatinine to assess for renal involvement.
Antinuclear Antibody Test, which is positive in virtually all patients with SLE, making it highly sensitive; if negative should investigate other etiologies.
Anti-double stranded DNA, has a high specificity for SLE and positive test helps to confirm disease.
Rheumatoid Factor to screen for autoimmune condition, particularly RA.
Urinalysis may be done, which may reveal hematuria, pyuria, proteinuria, and/or cellular casts indicative of renal involvement.
PLAN
Ms. Rand is prescribed a topical steroid for the acute lesions on her face. The Provider explains that she will order other medication depending upon the results of the blood tests, drawn at the encounter, but the most likely diagnosis is Systemic Lupus Erythematosus. An appointment was made with the Provider for the following day to discuss the lab results, and to conduct patient education based upon those results.
The Next day’s Appointment
Ms. Rand’s blood tests were positive for ANA, double stranded DNA, and rheumatoid factor. All the other results were within normal limits. Ms. Rand was started on oral hydroxychloroquine 200 mg BID, and an urgent referral to a Rheumatologist was scheduled. She was also referred to an Ophthalmologist for a retinal exam.
Patient Education
Patient Education topics for Ms. Rand include an explanation of SLE; the importance of sun safety; staying active to help with fatigue and joint pain; strategies to manage an acute Lupus flare-up; and treatment options. The potential adverse effects of hydroxychloroquine were discussed, as was the importance of a retinal exam annually.
References
Gelber AC, Levine SM, Darrah E. Chapter 24: Inflammatory rheumatic diseases. In: Hammer G, McPhee S, eds. Pathophysiology of Disease: An Introduction to Clinical Medicine, 8th ed. http://accesspharmacy.mhmedical.com/content.aspx?bookid=2468§ionid=198225005
Grönhagen CM, Fored CM, Granath F, Nyberg F. Cutaneous lupus erythematosus and the associated with systemic lupus erythematosus: a population-based cohort study of 1088 patients in Sweden. Br J Dermatol. 2011;164(6):1335–1341. doi:10.1111/j.1365-2133.2011.10272.x
Kamen DL. Environmental influences on systemic lupus erythematosus expression. Rheum Dis Clin North Am. 2014;40(3):401–412, vii. doi:10.1016/j.rdc.2014.05.003
Merola JF. Overview of cutaneous lupus erythematosus. UpToDate. https://www.uptodate.com/contents/overview-of-cutaneous-lupus-erythematosus – last visited on September 28, 2020
Sciascia S, Radin M, Roccatello D, Sanna G, Bertolaccini ML. Recent advances in the management of systemic lupus erythematosus. F1000Res. 2018;7:F1000 Faculty Rev-970. doi:10.12688/f1000research.13941.1
Sontheimer CJ, Costner MI, Sontheimer RD. Lupus erythematosus. In: Kang S. et al., eds. Fitzpatrick’s Dermatology. 9th ed http://accessmedicine.mhmedical.com/content.aspx?bookid=2570§ionid=216036810
Wallace DJ, Gladman DD. Clinical manifestations and diagnosis of systemic lupus erythematosus. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-systemic-lupus-erythematosus-in-adults
Wijesinghe, Sampath. (2021). 101 Primary Care Case Studies: A workbook for clincal and bedside skills. Springer Publishing Company. Kindle edition.
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