Khajuria Bhavik, Khajuria Mansi, Agrawal Yashwant
1Michigan State University College of Osteopathic Medicine, East Lansing, MI; 2University of British Columbia, Vancouver, Canada; and 3Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI.
Am J Ther. 2016 Jul-Aug;23(4):e1072-3. doi: 10.1097/MJT.0000000000000270.
A 29-year-old woman presented with diffuse anasarca and shortness of breath. Workup revealed a creatinine of 3.3 and a glomerular filtration rate of 17. The patient was also found to be pancytopenic with evidence of hemolytic anemia. A renal biopsy showed evidence of stage IV lupus nephritis with rapidly progressive glomerulonephritis. Her lupus was further classified as ANA negative and anti-dsDNA positive. Mycophenolate and triweekly hemodialysis were started along with a steroid burst of methylprednisolone 1 g for 3 days followed by prednisone 60 mg daily. Four days after discharge, the patient represented with a witnessed 3-minute seizure involving bowel incontinence, altered mental status, and tongue biting. She was given 2 mg intravenous lorazepam and loaded with 1000 mg levetiracetam for seizure prophylaxis. Magnetic resonance imaging of the head revealed bilateral posterior hemispheric subcortical edema, and the diagnosis of posterior reversible encephalopathy syndrome was made. Mycophenolate was immediately discontinued and replaced with cyclophosphamide. Strict blood pressure control below 140/90 mm Hg was maintained initially with intravenous nicardipine drip and then transitioned to oral nifedipine, clonidine, losartan, and minoxidil. A repeat head magnetic resonance imaging 8 days later showed resolved subcortical edema consistent with the patient's improved mental status. No permanent neurologic sequelae were recorded as a result of this hospital episode.
一名29岁女性出现全身水肿和呼吸急促。检查发现肌酐为3.3，肾小球滤过率为17。该患者还被发现全血细胞减少，并伴有溶血性贫血证据。肾活检显示有IV期狼疮性肾炎伴快速进展性肾小球肾炎的证据。她的狼疮进一步分类为抗核抗体阴性和抗双链DNA阳性。开始使用霉酚酸酯和每周三次血液透析，同时给予1克甲基强的松龙冲击治疗3天，随后每日给予泼尼松60毫克。出院后四天，患者出现一次发作，持续3分钟，伴有大便失禁、精神状态改变和咬舌。给予她2毫克静脉注射劳拉西泮，并给予1000毫克左乙拉西坦进行癫痫预防。头部磁共振成像显示双侧半球后部皮质下水肿，并诊断为后部可逆性脑病综合征。立即停用霉酚酸酯，改用环磷酰胺。最初通过静脉滴注尼卡地平将血压严格控制在140/90毫米汞柱以下，然后过渡到口服硝苯地平、可乐定、氯沙坦和米诺地尔。8天后重复进行头部磁共振成像显示皮质下水肿消退，与患者改善的精神状态一致。此次住院未记录到永久性神经后遗症。
