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Difficulty: EasyRheumatology and Immunology

A 34-year-old woman presents to the outpatient department due to left-sided chest pain and shortness of breath for the past 3 days. The chest pain is sharp and noticeably worsens when she takes a deep breath or coughs. She also reports feeling persistently fatigued and sad for the past month. Her medical history is significant for systemic lupus erythematosus (SLE) and bipolar disorder. Her current daily medications include hydroxychloroquine, prednisone 5 mg, and quetiapine. Her temperature is 37.8°C (100.0°F), blood pressure is 120/78 mmHg, and heart rate is 88/min. Cardiopulmonary examination reveals a pleural friction rub on the left side, with no murmurs, gallops, or jugular venous distention. A chest radiograph demonstrates a small left-sided pleural effusion without any pulmonary infiltrates. An electrocardiogram is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Administer intravenous furosemide and topical nitroglycerin
  2. B
    Administer the live-attenuated intranasal influenza vaccine
  3. Prescribe an oral nonsteroidal anti-inflammatory drugAnswer
  4. D
    Discontinue quetiapine and start fluoxetine monotherapy
  5. E
    Initiate empiric therapy with oral levofloxacin

Answer

Prescribe an oral nonsteroidal anti-inflammatory drug
The correct course of action is to prescribe an oral nonsteroidal anti-inflammatory drug. This patient is presenting with acute serositis (specifically pleuritis), which is a common hallmark of systemic lupus erythematosus (SLE) flares. It classically presents with pleuritic chest pain, a pleural friction rub on auscultation, and potentially a small, exudative pleural effusion. For mild to moderate SLE serositis that is not organ-threatening, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or indomethacin are the standard and most appropriate first-line therapy.

Step-by-Step Solution

1
Evaluate the clinical presentation and physical exam findings.
The patient has sharp, pleuritic chest pain, a pleural friction rub, and a small pleural effusion without pulmonary infiltrates.
Identifying these classic signs helps localize the pathology to the pleura.
2
Correlate the findings with the patient's medical history.
The presentation is consistent with acute lupus serositis (pleuritis), a common manifestation of an SLE flare.
SLE frequently causes inflammation of serosal surfaces, including the pleura and pericardium.
3
Determine the most appropriate initial management for this specific condition.
An oral nonsteroidal anti-inflammatory drug (NSAID) is the standard initial therapy.
Mild serositis in SLE responds well to NSAIDs. If symptoms were severe or refractory, increasing the systemic corticosteroid dose would be the next step.

Key Concept

Mild to moderate serositis in systemic lupus erythematosus is typically treated initially with nonsteroidal anti-inflammatory drugs (NSAIDs).
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Topics

Rheumatology and Immunology

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