An Atypical Initial Presentation of Systemic Lupus Erythematous With Bilateral Lower Extremity Edema and Unilateral Pleural Effusion.

Systemic lupus erythematosus (SLE) is an autoimmune condition more commonly observed in women of childbearing age. The most commonly reported initial presentations were fatigue, arthritis, and skin manifestations. However, due to the involvement of a variety of organs, diagnosis remains a challenge for physicians. Our patient is a 48-year-old lady who presented with severe bilateral lower extremity edema with non-resolving right lower lobe pneumonia and ipsilateral exudative pleural effusion. Her leg swelling was not responding to diuretics, and her pneumonia was not improving following a course of antibiotics. This unusual presentation prompted an autoimmune workup, which later revealed a diagnosis of SLE with class 5 lupus nephritis. Pleuritis, exudative pleural effusion, and lupus nephritis have been associated with autoimmune disorders in the literature, but this is an uncommon initial presentation in SLE without other clinical manifestations. Our case report highlights the challenges in the diagnosis of an atypical case of SLE and the need to maintain high clinical suspicion for SLE, especially in female patients with multiorgan involvement.

A case report of double negative anti-GBM disease.

Goodpasture's disease is a life-threatening autoimmune disease that can lead to end stage renal disease and death. We report a case of 61-year-old female who presented with deteriorating renal function. Initial laboratory investigations were negative for autoimmune antibodies including negative anti-neutrophilic cytoplasm antibodies and anti-glomerular basement membrane (anti-GBM) antibodies using both enzyme-linked immunosorbent assay and indirect immunofluorescence. However, renal biopsy was positive for linear IgG staining. Despite starting plasmapheresis and corticosteroids treatment, her renal functions continued to deteriorate and she was started on regular hemodialysis. This case highlights the challenging presentation and diagnosis of anti-GBM disease, which requires a high clinical suspicion necessarily for early diagnosis and treatment to improve survival rates.

Central diabetes insipidus and adipsia due to astrocytoma: diagnosis and management.

Adipsia and/or diabetes insipidus is rarely a direct complication of astrocytoma. We report a young man with recurrence of anaplastic astrocytoma who presented as severe hypernatremia. This case highlights key diagnostic and therapeutic challenges: (1) the interpretation of the response to exogenous vasopressin in a patient with steroid-induced hyperglycemia and (2) the potential risk of brain edema and herniation if excess water is prescribed along with vasopressin supplementation. The patient was successfully managed with prescribed fluid replacement, daily weights, and regular electrolyte monitoring but no exogenous vasopressin for 8 months until he succumbed to his tumor.