Lupus Pneumonitis Masquerading As Community Acquired Pneumonia And Pulmonary Tuberculosis: A Case Report

Introduction Systemic lupus erythematosus (SLE) is characterized by production of antibodies against various nuclear antigens with involvement of multiple organs. Pulmonary manifestations of SLE can include a wide spectrum of diseases such as pleuritis, pneumonia, pulmonary embolism, pneumothorax and pulmonary haemorrhage. Lupus pneumonitis (LP) has an incidence of 1-8% and may be difficult to distinguish from pulmonary infections. We report a case of LP mimicking community acquired pneumonia (CAP) and pulmonary tuberculosis (PTB) admitted to the Internal Medicine ward in Hospital National Guido Valadares, Dili, Timor Leste. Case A 43-year-old female school teacher presented with cough and shortness of breath. She also had a history of fever and malar rash along with significant hair loss. On examination she was febrile and dyspneic, with anaemia, hair loss, malar rash, tachycardia, tachypnoea, and coarse crepitations on chest auscultation. Sputum for Gene Xpert MTB/RIF Ultra test, bacterial culture, and fungal stains were negative. She was initially treated with broad-spectrum antibiotics for CAP, while being investigated for TB. However, as she failed to respond to intravenous antibiotics, further evaluation was done. Anti-nuclear antibodies (ANA) and ds-DNA were strongly positive. Urine analysis revealed nephrotic-range proteinuria. High resolution computed tomography (CT) showed bilateral ground glass changes suggestive of lupus pneumonitis (LP). A diagnosis of SLE with LP was made and the patient was commenced on corticosteroids (pulsed methylprednisolone for three consecutive days, followed by oral prednisolone) which led to a dramatic clinical and radiological response. Conclusion SLE has a wide range of presentations. Keeping this in mind, even in countries where tuberculosis is endemic, the differential diagnosis of SLE and LP should be considered. Many challenges exist in the diagnosis and management of patients with SLE and its complications in resource-limited settings.