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A Case of Ventricular Standstill in Hypertrophic Cardiomyopathy: The Role of AV Block and Beta-Blockers (2025)

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Type of publication:

Conference abstract

Author(s):

*Owolabi O.H.; *Yera H.O.; *Choy C.H.; *Htet K.; *Kundu S.

Citation:

Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2025. Manchester United Kingdom. 111(Supplement 3) (pp A30-A33), 2025. Date of Publication: 01 Sep 2025.

Abstract:

Introduction Atrioventricular (AV) nodal disease is a rare but serious complication of hypertrophic cardiomyopathy (HCM), often leading to conduction abnormalities. While atrial fibrillation is common, high-degree AV block (AVB) is rare. We present a case of hypertrophic obstructive cardiomyopathy (HOCM) complicated by ventricular standstill, emphasizing the need for early recognition and management. Case Presentation A 46-year-old man with a family history of HCM (mother with ICD) presented with exertional dyspnea, palpitations, and presyncope for six months. No family history of sudden cardiac death. Examination revealed HR 76 bpm, BP 115/75 mmHg, and an ejection systolic murmur. ECG showed ventricular hypertrophy, dagger-shaped Q waves, Twave inversions, first-degree AVB (280 ms), and ventricular ectopics (figures 1 and 2). Troponin and NT-proBNP were elevated. Echocardiography confirmed HOCM with severe septal hypertrophy, a maximal LVOT gradient of 43 mmHg, and systolic anterior motion of the mitral valve. Indexed left atrial volume was 48 mL/m2 (figures 3 and 4). CT coronary angiogram was normal. He was started on bisoprolol 2.5 mg OD and within 48 hours developed intermittent high-degree AVB (2:1, 3:1). Bisoprolol was discontinued due to worsening conduction abnormalities, but he later developed symptomatic complete heart block, necessitating emergency ICD placement (figure 5). He was started on bisoprolol 2.5 mg OD and within 48 hours developed intermittent high-degree AVB (2:1, 3:1). Bisoprolol was discontinued due to worsening conduction abnormalities, but he later developed symptomatic complete heart block, necessitating emergency ICD placement. Discussion HCM is the most common genetic heart disease, inherited in an autosomal dominant manner in 50% of cases. MYBPC3 mutations are frequently linked to high-degree AV block.1 While atrial fibrillation is common in HCM, highdegree AV block remains rare. First-degree AVB in HCM is increasingly recognized as a marker of disease progression and arrhythmic risk.1 Mechanisms include left atrial enlargement (predisposing to atrial fibrillation and thromboembolism) and myocardial fibrosis, promoting electrical instability.1 Our patient had a 3.1% five-year sudden cardiac death risk and developed high-degree AV block and ventricular standstill. This progression was likely exacerbated by bisoprolol, which slowed AV conduction in the setting of pre-existing firstdegree AV block. Beta-blockers, though essential in HCM management, should be used cautiously in patients with conduction abnormalities. This case underscores the need for personalized HCM management. First-degree AVB may identify high-risk individu- als requiring closer monitoring, medication adjustments, and early device therapy. Conclusion High-degree AV block and ventricular standstill are rare but significant complications of HCM. First-degree AVB may serve as an early risk marker linked to left atrial enlargement, fibrosis, and arrhythmias. Clinicians should monitor conduction abnormalities closely, especially when prescribing AV-slowing medications. Genetic evaluation, surveillance, and individualized treatment strategies are crucial for optimizing outcomes in HCM patients.

DOI: 10.1136/heartjnl-2025-BCS.33

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Lipid Management Post Myocardial Infarction: A Call for Improved Monitoring and Therapy Intensification (2025)

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Type of publication:

Conference abstract

Author(s):

*Bhambra G.; Kukoyi B.; Joshi M.; Tran P.; Lo T.; Ajiboye J.; Oyedeji O.

Citation:

Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2025. Manchester United Kingdom. 111(Supplement 3) (pp A210-A211), 2025. Date of Publication: 01 Sep 2025.

Abstract:

Background Lipid management is a cornerstone of secondary prevention in acute coronary syndrome (ACS). Despite established national guidelines, real-world practice often reveal gaps in lipid monitoring and intensification of lipid-lowering therapy. This study investigated these challenges in a large tertiary centre, proposing a streamlined pathway to address these gaps. Methods A retrospective analysis was conducted in 225 ACS patients (92 STEMI and 133 NSTEMI) from July-August 2023. We assessed lipid monitoring on admission and 2-3 months post-discharge, prescription rates of high-intensity statins and use of alternative lipid-lowering therapies. Multivariate logistic regression evaluated the relationship between highintensity statin initiation and lipid monitoring rates on admission and follow-up, adjusted for comorbidities. Results Initial guideline adherence was strong, with 83.1% having lipids checked on admission and 83.6% prescribed high-intensity statins (table 1). After adjusting for ACS type and comorbidities, patients started on high-intensity statin were nearly twice as likely to have lipids checked on admission (90.4% vs. 45.9%, p<0.001). Notably, patients not receiving high-intensity statins were more likely to have a prior history of ACS (43.2% vs 26.1%, p=0.035). Despite the perceived higher severity of STEMI, there was no significant difference in post-discharge lipid-checking rates between STEMI and NSTEMI patients (51.1% vs 53.4%, p=0.735). In terms of follow-up, only 52.4% of patients had lipids rechecked post-discharge, leaving almost half without adequate monitoring. Neither high-intensity statins nor ezetimibe initiation increased the likelihood of follow-up lipids. Among 118 patients with follow-up lipid assessment, 69.5% achieved target levels. However, of the 36 patients (30.5%) not meeting targets, only 3 (8.3%) had therapy intensified limited to the use of ezetimibe, highlighting a critical gap in care. Conclusion This study highlights the dichotomy between strong initial guideline adherence and significant lapses in follow-up care and therapy intensification. Whilst this single- centre study limits generalisability, several interesting observations emerged. The association between high-intensity statin prescription and admission lipid check highlights the importance of fostering a culture of guideline adherence, where attention to one aspect of care positively influences others. Patients with prior ACS were less likely to receive high-intensity statins, potentially due to perceived stability on existing regimen, leading to missed opportunities for therapy intensification. More strikingly, nearly half of the cohort lacked adequate lipid monitoring on follow-up with restricted use of lipid-lowering therapies. This highlights the need for a structured approach involving cardiac rehabilitation and primary care team via the proposed pathway (Figure 1) to ensure better lipid management in this high-risk cohort.

DOI: 10.1136/heartjnl-2025-BCS.206

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Surgical Treatment of Wrist and Hand Deformity in Children with Cerebral Palsy (2025)

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Type of publication:

Journal article

Author(s):

*Patel, Ravi; *Khan, Muhammad Murtaza; *Gurukiran, Gurukiran; Carsi, Maria Belen; Singh, Rohit Amol.

Citation:

Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 92(4):210-217, 2025 Aug.

Abstract:

Cerebral palsy (CP) is a complex disorder resulting from injury to developing brain. It involves multimodal and multidisciplinary approach that involves various disciplines of medical science. The entire focus of this approach is to provide patients with this disorder the best quality of life. Although CP can affect both upper and lower limbs, the functional expectation of upper limb is much higher and complex. This implies particularly to hand and wrist based on complex functional movements expected of them. This puts orthopaedic surgeons in a unique position in managing these patients. It is worth mentioning here that it is not about offering them a surgical intervention the emphasis should lie on the entire process of selection, evaluation, and intervention. All these steps need to be considered very thoroughly so that the best outcome is achieved based on patients' expectation at present and keeping the future consideration in mind as well. This paper focuses only on children with hand and wrist deformity. Although children have a great healing potential, but they have high functional demand and longer-life expectancy in general so getting things right for the first time should be of paramount importance. This paper tries to address this issue by reviewing the literature to help orthopaedic surgeons in developing an algorithm in their mind when offering intervention. The consideration of inclusion and exclusion criteria along with review of literature has been considered with this background in mind. This paper primarily addresses the surgical aspect of disease and steps that are critical in this regard. Follow up planning, long-term outcome, rehabilitation planning, use of conservative treatment has not been considered in this review.

DOI: 10.55095/achot2025/011

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Enhancing Sustainability in Endoscopically Assisted Naso-Jejunal Tube Insertion - A Novel Approach (2025)

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Type of publication:

Poster presentation

Author(s):

Bhargava K.; Bhargava C.; Dimitriadis S.; Sawyer M.; *Desai K.; Shekhar C.

Citation:

Gut. Conference: BSG Annual Meeting, BSG LIVE 2025. Glasgow United Kingdom. 74(Supplement 1) (pp A287), 2025. Date of Publication: 01 Jun 2025.

Abstract:

Introduction Due to the high caseload and heavy reliance on plastic predominant equipment in endoscopy, single use consumables remain a significant contributor to endoscopy related CO2 emissions (CO2e). Naso-jejunal tube (NJT) is a flexible tube that enables post-pyloric feeding. Conventionally, NJT insertion is performed endoscopically utilising consumables (e. g. single use laryngoscopes). We aimed to calculate and compare the CO2e of the standard NJT insertion process (SNIP) and a proposed innovative NJT insertion process (INIP). Method We dismantled each consumable used in the SNIP and INIP and calculated their associated CO2e by multiplying their weights by pre-established greenhouse gas emission factors published by the government of the United Kingdom. We further contacted relevant manufacturers to include emissions related to packaging, travel and transport, where possible. Results The SNIP emitted 1.327kg CO2e, while the INIP emitted 0.113kg CO2e – yielding an 11-times lower carbon footprint. The most significant contributor to SNIP emissions was the utilisation of the single use laryngoscope (0.838kg CO2e). In contrast, the INIP enabled NJT insertion, independent of conventional single-use instrumentation. Conclusion Implementing the INIP approach for NJT insertions for hospital and community-based patients would provide a sustainable alternative to existing procedural standards. Based on current data, utilising the INIP as standard practice would reduce 5827.2kg of NJT associated CO2e per year, in the UK. Further epidemiological research on populations receiving enteral feeding is required to more accurately evaluate the INIP's environmental impact.

DOI: 10.1136/gutjnl-2025-BSG.454

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Developing a Triage Rag Tool to Standardise the Triage of Referrals Received by the Palliative Care Team in the Hospital Setting (2025)

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Type of publication:

Conference abstract

Author(s):

*Shellis K.; *Corbett E.; *West D.;

Citation:

BMJ Supportive and Palliative Care. Conference: Palliative Care Congress. Belfast Ireland. 15(Supplement 2) (pp A56), 2025. Date of Publication: 01 Mar 2025.

Abstract:

Background During 2022 we realised that we needed to standardise our approach to managing the referrals received to the specialist palliative care team in the acute hospital trust. This was something that had been highlighted in our previous CQC inspection and we understood the importance of assessing patients according to their acuity in a timely manner. Prior to the development of this tool there was no standardised way of triaging patients and often there would be variation in the responsiveness of the service. Aim of the triage RAG The purpose of this tool was to ensure we offered an equitable service to our patients across both of our hospital sites ensuring that those with the highest acuity had an urgent response time of 4 hours (red), those with moderate symptoms/concerns were seen in within 24 hours and those with low acuity were seen within 48 hours. Method The palliative care team worked together through our team meetings to review current literature and best practice. We devised the tool based on most common symptom presentations and most prevalent reasons for referral. We initially trialled this alongside our electronic referral form but we found that we also need a series of question prompts and therefore, this was added to our tool. The tool was trialled for an initial period of six months and following this the final version was presented at out Palliative and End of Life Steering group and subsequently adopted by the whole team. Results We are now able to monitor and report our triage times via our dashboard, we have a standardised way of prioriting our caseload and ensuring the right patients get the correct response from the acute specialist palliative care team, therefore improving patient outcomes.

DOI: 10.1136/spcare-2025-PCC.144

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Colorectal Cancer Mortality Rates in UK Shropshire County (2025)

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Type of publication:

Conference abstract

Author(s):

*Shah J.; *Shittu S.; *Goh Y.L.; *Ball W.;

Citation:

British Journal of Surgery. Conference: 49th ASiT Annual Surgical Conference. Belfast United Kingdom. 112(Supplement 10) (pp x64), 2025. Date of Publication: 01 Jun 2025.

Abstract:

Aim: Evaluate outcomes of patients dying within 12 months from diagnosis of colorectal cancer in Shropshire County. Method(s): Single-centre retrospective review of patients who died within 12 months of diagnosis between 2020-2024.Each patient's hospital records were reviewed, and data were collected on patient demographics, performance status, time from referral to imaging, diagnosis, MDT, death and treatment intent. Result(s): A total of 103(44 male: 59 female) patients,with a mean age at referral of 74 (range 32 – 96) years old. Most patients had a performance status of 1 and lived in their own home (92%). 60% of patients lived in Shrewsbury, 34% in Telford and 9% in Wolverhampton. Referral sources were mainly from GP (55%), emergency admission to SAU (20%) and AMU (16%).74% of GP referrals were seen within two weeks. All patients underwent CT imaging. Endoscopic procedures were performed in 57% of patients. The average age of death is 75 (range 34 – 97) years old, most commonly from distant metastatic sigmoid cancer. The average time between diagnosis and death was 4.4 months.Treatment intent was palliative in 90% (BSC in 44% and oncology in 56%).59% who were referred to oncology received palliative treatment. Eight patients were treated with curative intent but died due to sepsis and multiorgan failure(2), died prior to commencing treatment (1), complications from treatment (3) or declined treatment (2). Conclusion(s): This snapshot audit demonstrates that patients in Shropshire County newly diagnosed with colorectal cancer were elderly, aged over 70 years old with significant cardiovascular co-morbidities and performance status of at least 1.

DOI: 10.1093/bjs/znaf128.248

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Complications After Hydrocele Repair: Solving a Persistent Challenge (2025)

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Type of publication:

Conference abstract

Author(s):

*Lu Y.; *Abdellatif M.; *Desai C.; *Ali-Naja N.; *Han L.A.; *Kells L.; *Kachrilas S.;

Citation:

British Journal of Surgery. Conference: 49th ASiT Annual Surgical Conference. Belfast United Kingdom. 112(Supplement 10) (pp x179-x180), 2025. Date of Publication: 01 Jun 2025.

Abstract:

Aim: Surgical intervention remains the gold-standard treatment for large or symptomatic hydroceles. Although hydrocele repair is a relatively minor procedure, complications such as haematoma and infection can have significant consequences. This study aims to evaluate the rates and severity of complications and explore strategies to minimise them following hydrocele repair Method: Aretrospective analysis was conducted of all hydrocele surgery performed in January 2021 to December 2022. Complication outcomes were classified using Clavien-Dindo grading. Result(s): A total of 85 hydrocele operations were included in the study, with an average patient age of 54.5. Post-operative complications occurred in 22 (25.88%) patients, including infection, haematoma and recurrence. Amount these, 7 complications (8.24%) were classified as Clavien-Dindo grade II, and 13 (15.29%) as grade III. No grade IV or V were recorded. Of the 22 patients with complications, 11 (12.94%) of them experienced recurrent hydroceles. Conclusion(s): Complications following hydrocele repair are relatively common, warranting further investigation. Comprehensive pre-operative counselling is essential to set realistic expectations and address potential risks with patients. Our centre implemented prophylactic antibiotics in high-risk group and the use of intra-operative betadine wash as potential solutions.

DOI: 10.1093/bjs/znaf128.718

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Standardising the administration of joint injections across the Wolverhampton NHS Trust: a service improvement project in rheumatology through the lens of medical education (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.; Agunbiade T.; Chalam S.V.

Citation:

Future Healthcare Journal. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 12(2 Supplement) (no pagination), 2025. Article Number: 100432. Date of Publication: 01 Jun 2025.

Abstract:

Introduction: The Rheumatology Resident Doctors' Forum identified a pressing need to standardise steroid injection training due to varying experience and confidence levels among resident doctors. Many expressed a strong interest in learning injection techniques but faced barriers in accessing training and achieving formal competency. Addressing this gap had the potential to enhance service delivery, support professional development and reduce patient wait times. General practice trainees also highlighted the value of joint injection skills in primary care, helping to alleviate pressure on rheumatology services. The Dreyfus model of skill acquisition describes five levels of competency in skill development, ranging from 'novice' to 'competent' and eventually 'expert'.1 The model shows how individuals progress from rule-based, analytical thinking to experience-driven mastery of a skill.1 A recent study demonstrates that structured training can enhance competency in procedural skills, such as joint injections.2 Methods: A SMART aim was used to design learning outcomes. Fourteen applicants were selected at random. Pre-course surveys collected quantitative and qualitative data on performance challenges, confidence, and baseline knowledge. Process mapping (Fig 1) and radar diagrams (Fig 2) highlighted gaps for intervention. Four trained rheumatology doctors, supervised by a consultant, led a teaching program. Virtual meetings guided plan-do-study-act (PDSA) cycles and driver diagrams to ensure constructive alignment. The goal was to advance learners from the Dreyfus level of 'Novice 1' to 'Competent 1'. The course, conducted in the clinical suite, used training mannikins of knees and shoulder joints, providing real-time feedback. Teaching combined interactive lectures, small-group sessions and individualised feedback. Formative assessments maximised educational impact. Post-course data were compared to baseline, with quality improvement (QI) sustainability tools used to draw portal diagrams, highlight improvement gains and discuss long-term impacts of the project. Results and discussion: Initially, 50% of participants were novices, with none having ever injected a shoulder joint. Confidence in consenting patients increased from 14% to 100% post-course. 64% of participants were unfamiliar with medications used for injections, while 28.6% were unsure of the evidence base. Post-course, both categories improved to 100%. Additionally, 43% initially lacked confidence in clinical decision-making regarding safe joint injection. There was a 100% increase in overall confidence surrounding decision-making (43% 'strongly confident' and 57% 'confident'). All doctors passed the criterion-referenced standard assessment, acquiring formal recognition of skills in their portfolios. The course was oversubscribed and received excellent feedback. QI tools, including radar diagrams, process mapping, and PDSA cycles, had a crucial role in refining training and driving measurable improvements. The structured application of QI methodology successfully upskilled doctors, advancing them from 'Novice' to 'Competent'. Simulation-based learning, combined with real-time feedback, proved to be a highly effective strategy for accelerating skill development while enhancing clinical decision-making and confidence. By integrating this training into departmental inductions, the initiative ensured sustainability and continuous professional development, benefiting both individual practitioners and the wider healthcare service. Conclusion(s): The project led to significant improvements in confidence and competency. It demonstrated sustainability through reproducibility and was incorporated into the rheumatology departmental induction. Positive feedback highlights the course's broader applicability in QI-driven medical training.

DOI: 10.1016/j.fhj.2025.100432

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Normal creatinine-kinase levels in post-COVID myositis: insights into localised muscle involvement (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.S.; *Elshehawy M.; *Olarewaju J.; Askari A.

Citation:

Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100437. Date of Publication: 01 Jul 2025.

Abstract:

Introduction: Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2; coronavirus 2019; COVID-19) has been increasingly implicated in post-infectious inflammatory complications, including varied presentations of inflammatory myopathies.1,2 Most literature highlights severe, systemic muscle involvement requiring immunosuppression, whereas localised myositis with normal creatine kinase (CK) levels remains underrecognised.3 This case presents a rare instance of localised paraspinal and proximal thigh myositis post-COVID-19, where CK levels remained normal, despite significant muscle involvement. Method(s): A 41-year-old previously healthy man presented with severe diffuse back and leg pain, muscle cramps, and low-grade fever for 2 weeks after confirmed COVID-19 infection. Examination revealed proximal thigh weakness (MRC Grade 3/5) and tenderness without neurological deficits. Investigations, including blood tests, magnetic resonance imaging (MRI), computed tomography (CT), autoimmune screening, echocardiography, blood cultures and electromyography (EMG) studies. were conducted.1 Management required evaluating the progression of symptoms in the light of test results to identify the aetiology of disease, considering differential diagnosis and early establishment of localised vs systemic inflammatory myopathy.2 The patient was diagnosed as post-viral myositis with a normal CK. Empirical intravenous piperacillin-tazobactam was discontinued after infection was excluded. Simple analgesia and vitamin D sufficed for symptom control. The patient showed resolution of fever, significant improvement in muscle pain and normalisation of inflammatory markers, preventing the need for immunosuppression. Results and Discussion: Laboratory findings showed elevated C-reactive protein (237 mg/L), white cell count (12.0 x 109/L), and neutrophilia (9.4 x 109/L). Alkaline phosphatase (192 U/L) and gamma glutamyl transferase (202 U/L) were mildly elevated, while CK levels were normal (22 U/L, peaking at 56 U/L). MRI revealed diffuse oedema in posterior paraspinal muscles without abscess or infection, and CT imaging confirmed intermuscular oedema in paraspinal and proximal thigh muscles without systemic involvement. Autoimmune screening (antinuclear antibodies, weakly positive; extractable nuclear antigen antibodies and anti-neutrophil cytoplasmic antibodies, negative) and echocardiogram were unremarkable. Blood cultures showed no growth and EMG displayed a myopathic pattern in the right shoulder. This case provides insight into an atypical presentation of post-COVID 19 myositis, where the CK level remains normal despite muscle weakness.3 It evaluates the diagnostic and management challenges in this scenario. Other differentials include amyopathic dermatomyositis (ADM). However, differentiating localised post-viral myositis from ADM is essential, because ADM presents with cutaneous manifestations, which are absent in this case. A detailed history of recent viral illness and advanced imaging (eg, MRI) are critical for identifying myositis and excluding systemic or infectious causes.1Conclusion(s): This case highlights that post-viral localised myositis can present with significant muscle involvement despite normal CK levels, necessitating MRI for diagnosis.1,3 Early rheumatology input can optimise management by differentiating self-limiting inflammatory myopathies from those requiring immunosuppression.

DOI: 10.1016/j.clinme.2025.100437

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Complex lupus management: when multiple organs demand precision (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.S.; Askari A.; *Chand S.

Citation:

Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100376. Date of Publication: 01 Jul 2025.

Abstract:

Introduction: Systemic lupus erythematosus (SLE) is a complex autoimmune disease with a wide spectrum of severity, ranging from mild manifestations to life-threatening organ damage. Its multisystem involvement poses a significant treatment challenge, because interventions targeting one organ system may inadvertently impact another. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) is a widely used tool for assessing disease activity, with a score above 12 indicating severe disease. However, studies estimate that approximately 20% of patients present with severe manifestations at diagnosis. One of the most serious complications of SLE is lupus nephritis, which is classified into six classes by the International Society of Nephrology/Renal Pathology Society (ISN/RPS), ranging from Class I (minimal-mesangial lupus nephritis) to Class VI (advanced-sclerosing lupus nephritis). We present a case of a patient newly diagnosed with severe SLE and lupus nephritis, characterised by high disease activity and multisystemic involvement. This case highlights the complex treatment considerations necessary when managing severe lupus.

Method(s): A 62-year-old woman presented with flu-like symptoms followed by a malar rash, mouth ulcers, fatigue, alopecia and pancytopenia. She was diagnosed with SLE with lupus nephritis confirmed by renal biopsy, and SLE on skin biopsy. Management required significant consideration because of high disease activity (SLEDAI 16) complicated by pancytopenia and liver dysfunction. Therapeutic options were systematically evaluated to balance efficacy and safety given the patient's pancytopenia, liver dysfunction and renal involvement. Mycophenolate mofetil (MMF), effective for lupus nephritis, was excluded because of its potential to worsen pancytopenia. Azathioprine, suitable for mild renal involvement, was ruled out because of liver dysfunction. Cyclophosphamide, typically used for severe SLE, was contraindicated because of its haematological and hepatic toxicity. Tacrolimus was considered for renal SLE, given the biopsy Class of I, but was unsuitable for non-renal lupus without MMF. Belimumab, an FDA-approved agent with steroid-sparing effects and a favourable safety profile, was considered but deemed challenging because of its slower onset of action and approval barriers. Hydroxychloroquine (300 mg daily) and corticosteroids (40 mg prednisolone) were ultimately chosen as the safest and most effective initial therapy. Close liaision with the renal team was essential to optimise management. Results and Discussion: Laboratory results revealed low complements (C3 0.38 g/L, C4 0.03 g/L), pancytopenia (WBC 1.2 x 109/L, platelets 126 x 109/L), elevated ferritin (5,490 mug/L), and positive dsDNA. Skin biopsy was consistent with SLE and renal biopsy confirmed lupus nephritis (ISN/RPS Class I). CT-TAP imaging showed axillary lymphadenopathy without malignancy. This case highlights the challenges of managing multisystemic lupus presenting with renal and non-renal SLE symptoms of varying degree, in a patient not already established on baseline treatment. Hydroxychloroquine and corticosteroids formed the cornerstone of treatment, while other options were systematically excluded based on contraindications. Multidisciplinary collaboration was pivotal in tailoring therapy.

Conclusion(s): There are two key learning points highlighted in this case. First, that treating multisystemic lupus requires understanding the degrees of individual organ involvement to determine immunosuppressive needs. Second, that management decisions should balance efficacy and toxicity, guided by interdisciplinary input6 and renal biopsy findings to inform immunosuppression.

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