SLE - IT'S ATYPICAL CLINICAL PRESENTATION

G.Ravi Kiran, Dr.V. Chandrashekar, Dr. Bikshapathi Rao

Department of General Medicine, MGM Hospital
Kakatiya Medical College, Warangal, Telangana

Introduction
Hypokalemic periodic paralysis (HPP) is a form of metabolic myopathy, characterized by hypokalemia,
acute flaccid paralysis, and potentially fatal episodes of muscle weakness through the involvement of the
respiratory muscles, and cardiac arrhythmias. It can be a primary disorder or secondary with causes like
renal tubular acidosis (RTA), Distal RTA (dRTA) is the most common form & it's association with
autoimmune diseases is well documented

Case Presentation

Investigations

A 34 year old female patient presented with C/C

Low grade fever & weight loss - 5 months,
Weakness of both lower limbs - 15 days ,
Inability to walk - 6 days,
Past History:
Patient had history of similar weakness of lower
limbs 1 episode - 45 days back, She is Not a Known
Case of HTN, DM, Asthma, Epilepsy, Tuberculosis.
Examination:
She was Conscious & Coherent (GCS :15) & patient
is Asthenic, Pale, Oral Cavity: Normal
PR - 48/m, BP-90/60 mm hg (Supine position),
RR - 26/m regular there is clinical evidence of
B/L Pleural effusion
Tenderness of right wrist & b/l PIP joints,
neurologically patient has power of 1/5 in lower
limbs, 4/5 in upper limbs, reflexes are absent in
lower limbs and depressed in upper limbs,
Rest of systemic examination was normal

ECG: Bradycardia, Prominent U waves &

Prolonged QTc interval.
Serum electrolytes: Na+: 136 mEq/l, K+: 1.6
mEq/l, Cl -: 115 meq/l and HCO3 =10.8 mEq/l,
Ca+2: 8.2mg/dl, Serum anion gap = 11.8
GRBS: 110mg/dl , ABG: pH = 7.24, TCO2 = 11.7
mmol/l, pCO2 = 25.1 mmHg, pO2: 118.9 mmHg,
HCO3 =10.8 mmol/l, O2 sat = 97.9 %, & Hct:33%
24hr urine K+: 58 mEq/day
24- hour urine calcium: 98mg/day
24 hr total urinary protein: 511mg
Urine pH: 6.18 Urine anion gap: + 89
Urine culture: Negative ,
Haemogram: Hb: 9gm %, TLC: 3,600/mm3,
Platelets: 96000/mm3, ESR - 80mm/1st hr,
Urine Acidification Test Confirmed dRTA
HIV, HBsAg: Non Reactive,
CXR PA: - B/L pleural Effusion,
2D Echo: pericardial effusion, EF: 62%,
USG abdomen: moderate ascitis & b/l pleural
effusion, Monteux test: < 5mm induration,
Fluid analysis: Exudative - ADA levels (12 IU/dl:
pleural Fluid & 22 IU/dl: ascitic fluid,),
Thyroid profile: TSH: 8.14 IU/ml , T3: 0.85 ng/ml
T4: 5.4 g/dl, Serum PTH: 33pg/ml .
Serum LDH: 145 IU/l, Coomb's Test: -ve
Anti ANA Ab: +ve & ANA profile: (Line Immuno
assay) - Strongly positive for Anti sm, dsDNA,
Nucleosomes, Rib p-prot Ab. Patients was Diagnosed
as having SLE (as per ACR & SLICC Criteria)

Discussion
dRTA is associated with autoimmune diseases such
as primary Sjgren syndrome (5%-12%) & SLE
(1.8%-7%)

Treatment & Followup

Patient was kept on Steroids & Hydroxychloroquine
at discharge, patient on followup after 40 days
showed improvement & No episode of HPP till
3months followup