Abstract: 26 yo man with 2 month history of plaques face and chest
HPI: The patient is a 26-yr-old healthy Libyan student who presented with a two month history of erythematous plaques on the face and chest. He first noticed the reddish plaques on the chest and subsequently spread to the face. Presently, it also involves the elbows and knees. It is asymptomatic and does not appear to be transient. It does not seem to be aggravated by sunlight, heat, cold or physical activity. He is otherwise well and is not on any long term medications/herbs/OTC.
O/E: Shows few erythematous raised annular plaques 1-2 cm on the anterior chest wall, forehead, cheek, extensor surfaces of the elbows and knees. They do not blanch with pressure. There are a few patches of alopecia with underlying erythematous skin noted on the occipital scalp.
Lab: Blood counts and biochemistry were normal. VDRL was negative. Anti-nuclear antibody serology was 1:320 titre.
Path: Skin biopsy results: Section shows skin composed of epidermis and dermis. Hyperkeratosis and atrophied epidermis are seen. There is basal layer degeneration. Pigment laden macrophages are seen in the upper dermis. Perivascular lymphocytic infiltrates are seen in the upper and mid dermis. No granulomas are seen.
Diagnosis: Lupus erythematosus
Plan: The immediate plan is to institute oral prednisolone 30mg daily and hydroxychloroquine 400mg daily with advise on sunblocks. However, on examination by ophthalmologist, he found maculopathy in this patient and raised the question of suitability of hydroxychloroquine in this patient.
Which type of LE would this patent fit into. Subacute LE?
Which steroid sparing agent would you use? cellcept or imuran?
Comment by Richard Sontheimer, M.D.