Comprehensive Medical Case Studies: Diagnostic and Treatment Study Notes

Clinical Case 1: Infective Endocarditis Following Dental Intervention

A $26$-year-old patient presented with a high fever reaching $39^{\circ}C$, profuse sweating, and a hemorrhagic rash distributed across the arms and legs. Accompanying cardiac symptoms included palpitations and a stinging chest pain located behind the sternum and at the heart apex. This pain, which irradiated to the left arm and scapula, typically persisted for $1-1.5$ hours before resolving spontaneously. The patient also reported a feeling of heaviness in the left subcostal region and general weakness. The medical history revealed that these symptoms, including a sub-febrile temperature and chills, began approximately three weeks after a tooth extraction. Physical examination identified pale skin and slightly icteric sclera, alongside small hemorrhagic rashes on the limbs. Auscultation noted vesicular breathing without rales. The apex beat was found to be enlarged and localized in the $5$th intercostal space along the middle-clavicular line. The heart borders were determined as follows: the right border was at the right sternal side, the left border coincided with the apex beat, and the upper border was in the $3$rd intercostal area. Cardiac assessment revealed rhythmic sounds, though $S_1$ at the apex and $S_2$ at the aorta were diminished. A diastolic decreasing murmur was heard specifically at the Botkin-Erb point. The heart rate ($HR$) was regular at $86/\text{min}$, and the blood pressure ($BP$) was recorded at $100/50\,mm\,Hg$. Abdominal palpation showed a soft, painless abdomen with a liver measuring $14-11-8\,cm$. The spleen was palpable at the rib arc and was painful upon examination.

The primary syndromes identified in this case include hemorrhagic syndrome (indicated by the rash), intoxication syndrome (fever and sweating), hepatosplenomegaly syndrome (enlarged liver and painful spleen), and cardiomegaly syndrome (enlarged apex beat and shifted borders). The most probable diagnosis is Infective Endocarditis, justified by the Duke criteria including valvular regurgitation, fever above $38^{\circ}C$, vascular/immunological signs (hemorrhagic rash), and a clear predisposition from a cardiac lesion following a dental procedure. Differential diagnosis should consider vasculitis, viral hemorrhagic fever, various liver diseases, angina pectoris, and rheumatic fever. Additional examinations should include blood cultures, a full blood analysis (which might show normochromic normocytic anemia, neutrophilia, and increased $ESR/CRP$), urinalysis (to check for microscopic hematuria), a chest $X$-ray ($CXR$) to confirm cardiomegaly, and an echocardiogram to detect vegetations larger than $2\,mm$. Management involves intensive antibiotic therapy with Penicillin $G$, Ceftriaxone, or Vancomycin depending on the causative organism. Symptomatic treatment includes antipyretics such as acetaminophen and salicylates for chest pain. Surgical intervention, such as prosthetic valve installation or abscess drainage, may be required.

Clinical Case 2: Progressive Arterial Hypertension and Hypertensive Crisis

Patient $M$, aged $48$, complained of severe headaches, attacks of muscle weakness, frequent urination, and morning facial edema, along with a decrease in visual acuity. The anamnesis indicated that the disease had progressed for $17$ years, starting with a moderate blood pressure increase during pregnancy that persisted and worsened after delivery. Over the last six years, the patient's blood pressure often reached ranges of $200/100\,mm\,Hg$ to $240/140\,mm\,Hg$. Two previous hypertensive crises resulted in a loss of consciousness. For the past year, the patient experienced periodic limb paresthesia and failed to respond to hypotensive treatments. Laboratory tests revealed hypernatremia (elevation of sodium) and hypokalemia (decrease in potassium). Upon objective examination, the general condition was satisfactory, but the apex beat was located $1\,cm$ to the left of the middle-clavicular line, with an intense $II$ tone at the aorta. The heart rate was $110\,b/\text{min}$ and blood pressure was significantly elevated at $210/130\,mm\,Hg$.

The leading syndromes in this case are hypertensive crisis syndrome, neurological syndrome, and the hypernatremia/hypokalemia syndrome. The diagnosis is a severe stage Hypertensive Crisis with a grade $3$ risk of stratification. Common differential diagnoses for this pathology include heart failure, hypertrophic cardiomyopathy, and myocardial infarction. The diagnostic plan involves a complete blood analysis, biochemical profile (including cholesterol), urinalysis for protein and blood, fasting glucose assessment, and renal imaging such as ultrasound or arteriography. Echocardiography is vital to assess end-organ damage like left ventricular ($LV$) hypertrophy. The treatment plan focuses on controlling modifying risk factors, implementing a salt-restricted diet, and lifestyle modifications. Conservative pharmacotherapy includes a combination of $ACE$ inhibitors, diuretics, angiotensin $II$ receptor blockers ($ARBs$), beta-blockers, calcium channel blockers ($CCBs$), alpha-adrenoreceptor blockers, or imidazole receptor blockers.

Clinical Case 3: Essential Hypertension and Retinopathy

A $45$-year-old patient presented with symptoms of occipital headache, dizziness, visual disturbances described as "flies," tinnitus, and general weakness. The patient had a $10$-year history of hypertension, which they correlated directly with their symptoms. While beta-blockers provided rapid relief, cessation caused the blood pressure to rebound to $160-170\,mm\,Hg$. The patient’s lifestyle was characterized by high physical activity, night shifts, and smoking $20$ cigarettes per day. Family history was positive for hypertension in the mother. Physical examination showed obesity and an accentuated second heart sound at the aorta. The heart rate was $110/\text{min}$ and the blood pressure was $175/110\,mm\,Hg$. Routine blood and urine tests were normal, but a fundus examination of the eye revealed narrowed arterioles and full-blooded veins.

The clinical presentation highlights arterial hypertension syndrome and retinopathy syndrome. The most probable diagnosis is Essential Hypertension, $2$nd degree (moderate stage), grade $II$ risk of stratification, complicated by retinopathy. Differential diagnoses include secondary causes such as thyrotoxicosis, Cushing's syndrome, coarctation of the aorta, and diabetes mellitus. Additional diagnostic steps mirror those of the previous hypertension case, emphasizing biochemical analysis for cholesterol, fasting glucose, and echocardiography for left ventricular hypertrophy. Treatment encompasses risk factor control, a low-salt diet, and the same comprehensive conservative therapeutic classes ($ACEIs$, diuretics, $ARBs$, beta-blockers, $CCBs$, etc.).

Clinical Case 4: Atherosclerotic Vascular Disease and Hemodynamic Encephalopathy

A $68$-year-old female reported persistent headaches, dizziness, tinnitus, and a decrease in memory over a $5$-year period. Specifically, during the last year, her blood pressure had reached as high as $175/80\,mm\,Hg$. She also experienced loss of consciousness when standing up or turning her head quickly. Physical examination showed a left heart border located $1\,cm$ left of the middle-clavicular line and a vascular fascicle width of $11\,cm$. Auscultation revealed a reduced first heart sound and an elevated second heart sound on the aorta with a metallic shade. A rough systolic murmur was present, which intensified when the patient was in a vertical position. The pulse and heart rate were $76/\text{min}$, and the blood pressure was $170/90\,mm\,Hg$. Abdominal findings were normal.

The main syndromes include arterial hypertension, cerebral vascular insufficiency, cardiomegaly, and probable valve pathology. The diagnosis is Atherosclerosis of the aorta and brain arteries, secondary arterial hypertension, hemodynamic encephalopathy, and atherosclerotic stenosis of the aortic valve. Differential diagnosis focuses on distinguishing between primary and secondary arterial hypertension. Additional examinations should assess plasma cholesterol ($> 5.3\,mmol/l$), $LDL$ ($> 4\,mmol/l$), creatinine, urea, and electrolytes. An $ECG$ would look for signs of left ventricular hypertrophy, while a $CXR$ might show an aortic configuration of the heart shadow. Consultations with a neurologist and ophthalmologist are recommended. Treatment involves a hypolipemic diet (diet no. $10$) restricted in saturated fat and salt, statins like lovastatin or pravastatin, hypotensive drugs ($ACEIs$, $CCBs$, $ARBs$), antiaggregants (aspirin, clopidogrel), and angioprotectors like cavinton.

Clinical Case 5: Peripheral Artery Disease and Intermediate Hypertension

A $63$-year-old male presented with leg pain that occurred after walking $200-300\,m$ and disappeared within $3-5$ minutes of rest. He also suffered from numbness and paresthesia in the lower extremities and constant thirst. These symptoms had progressed over two years. Upon examination, his legs were cold, and the skin of the shins and feet was pale with a marmoreal (mottled) shade. Pulses in the tibial arteries were moderately diminished, while pulses in the feet arteries were severely reduced. There were no peripheral edemas. The heart was moderately dilated to the left, and heart sounds were rhythmic but diminished. The heart rate was $80/\text{min}$ and blood pressure was $150/90\,mm\,Hg$.

The primary syndromes identified are arterial hypertension syndrome and heart enlargement syndrome. The diagnosis is Peripheral Artery Disease ($PAD$) at stage $IIa$ according to the Fontaine classification, and stage $3$ Arterial Hypertension. Deep vein thrombosis is the main concern for differential diagnosis. The diagnostic plan includes local and systemic assessments: $CBC$, blood urea nitrogen ($BUN$), creatinine, electrolytes, lipid profile, coagulation tests, glucose levels, Doppler ultrasonography, digital subtraction angiography, $MRI$, $CT$ angiography, and the ankle-brachial index ($ABI$). Treatment requires immediate smoking cessation, antiplatelet therapy (Aspirin or Clopidogrel), statins, antihypertensive medications, and phosphodiesterase inhibitors like Cilostazol.

Clinical Case 8: Paroxysmal Supraventricular Tachycardia in a Young Patient

A $21$-year-old female complained of episodic heartbeats beginning with a single strong beat in the apex area, which lasted for two hours. Associated symptoms included general weakness, nausea, dizziness, and tinnitus. The episodes were sudden and lacked a distinct trigger, though her history included recent common colds. Her menstrual cycle was regular. On examination, her skin was pale and moist, and her jugular veins were enlarged and pulsating. While heart sounds were otherwise normal, her heart rate was extremely high at $180/\text{min}$, and her radial pulse was weak and difficult to count. Her blood pressure was $100/80\,mm\,Hg$.

The syndromes categorized here are arrhythmia syndrome, tachycardia syndrome, and neurological (vegetative) syndrome. The diagnosis is Paroxysmal Supraventricular Tachycardia ($PSVT$). Differential diagnoses include atrial fibrillation, atrial flutter, ventricular tachycardia, and $AV$ nodal reentry tachycardia. Mandatory additional examinations include blood counts to check for inflammation ($WBC/ESR$), cardiac markers ($CK, CK-MB$, troponin), lipid profiles, creatinine, $CRP$, and a hormone profile via gynecological consultation. Instrumental tests should include $24$-hour $ECG$ monitoring, stress $ECG$, echocardiography, and possibly a coronary angiogram or myocardial biopsy. Acute management involves vagotonic maneuvers, adenosine, or calcium channel blockers (verapamil/diltiazem) if the $QRS$ complex is narrow. For this patient, low-dose beta-blockers like metoprolol or esmolol are indicated. Electrical cardioversion or radiofrequency catheter ablation are considered for long-term or resistant cases.

Clinical Case 12: Acute Myocardial Infarction and Emergency Management

A $48$-year-old patient was brought in by paramedics with pressing chest pain that occurred without physical exertion. The pain irradiated to the left hand and shoulder, was associated with dyspnea, and lasted $35$ minutes. Nitroglycerine failed to alleviate the pain, requiring narcotic analgesics. History revealed a seven-year struggle with hypertension and dyslipidemia. Examination showed diminished heart sounds and a diminished first tone at the apex, with a pulse of $84/\text{min}$ and a blood pressure of $130/80\,mm\,Hg$.

The leading syndromes are pain syndrome, cardiomegaly syndrome, acute coronary syndrome, and acute respiratory insufficiency syndrome. The diagnosis reached is Acute Myocardial Infarction ($AMI$). Differential diagnosis includes stable or unstable angina, acute pericarditis, myocarditis, pulmonary embolism, and pneumothorax. Diagnostic investigations should urgently include an $ECG$ (looking for $ST$ elevation or inverted $T$ waves) and serum cardiac markers (creatine kinase-$MB$, Troponins $I$ and $T$, and myoglobin). A total blood count may show anemia or leukocytosis with a shift to the left. Emergency treatment involves oxygen, aspirin, nitrates, and immediate triage. Long-term pharmacology includes antiplatelets, anticoagulants (heparin), beta-blockers, $ACE$ inhibitors, and statins. Reperfusion therapy via fibrinolytics or percutaneous coronary intervention ($PCI$) is critical.

Clinical Case 14: Climacteric Cardiomyopathy

A $52$-year-old female presented with aching chest pain in the heart apex and retrosternal area, radiating to the left shoulder and arm. Attacks lasted from $30$ minutes to several hours and were accompanied by palpitations, headaches, and facial flushing. The pain was somewhat relieved by validole or valocordine. The patient had reached menopause three months prior. Physical examination revealed hyperhidrosis and a red dermographism-type skin reaction. An $ECG$ showed deep negative $T$ waves in leads $V_2-V_4$. The blood pressure was $130/80\,mm\,Hg$.

The syndromes involve cardialgia and autonomic nervous system disturbances (fever, hyperhidrosis, flushing). The most probable diagnosis is Climacteric Cardiomyopathy and stage $I$ Heart Failure. Differential diagnosis should rule out ischemic heart disease and unstable angina. Further testing includes a complete blood count (which might show neutrophilic leukocytosis and increased $ESR$), biochemical tests (elevated $AST/ALT$), and hormonal assays (elevated $TSH/T4$). Instrumental investigation should include repeated $ECG$ monitoring, stress tests, and cardiac catheterization to detect low output. Treatment includes sedatives, metabolites (mexicor), selective beta-blockers, salt restriction, and possibly diuretics. Severe cases may require surgical management for valvular issues or revascularization.

Clinical Case 21: Biventricular Heart Failure Post-Infarction

A $56$-year-old female complained of tachycardia, leg and foot edema that worsened in the evening, heaviness in the right subcostal area, weakness, and insomnia. She had a history of myocardial infarction two years prior. Her symptoms had progressively worsened over the last $18$ months. Examination revealed acrocyanosis, bilateral ankle edema, and crackles in the lower lungs. Heart sounds were arrhythmic and heart borders were dilated to the left. The liver was palpable $2\,cm$ below the rib arch and was tender. Her heart rate was $140\,bpm$ and blood pressure was $105/70\,mm\,Hg$.

The syndromes identified are right and left ventricular systolic failure (biventricular failure), arrhythmic syndrome, and low output syndrome. The diagnosis is Ischemic Heart Disease with post-infective cardiac sclerosis and chronic heart insufficiency (Vaselenko stage $2b$, $NYHA$ class $II-III$). Additional tests should assess brain natriuretic peptide ($BNP$), atrial natriuretic peptide, and lipid ratios. A chest $X$-ray is needed to evaluate pulmonary congestion and cardiomegaly. Treatment consists of aldosterone antagonists, $ACE$ inhibitors, diuretics, and digoxin. If conservative therapy fails, cardiac resynchronization therapy through a biventricular pacemaker or a heart transplant may be necessary.

Clinical Case 23: Acute Massive Pulmonary Embolism and Obstructive Shock

A $56$-year-old patient presented with acute pressing heart pain irradiating to the interscapular area, severe dyspnea, and a cough producing pink foamy sputum. The patient also had a history of varicose veins. On examination, the patient was in extremely severe condition, pale and covered in cold sweat. Lung auscultation revealed wet small-bubbled rales and diminished breath sounds. The heart rate was very low at $34/\text{min}$ and blood pressure was critical at $50/0\,mm\,Hg$.

The primary syndromes are pulmonary edema (pink sputum), left ventricular dysfunction, and low cardiac output. The diagnosis is Venous Thromboembolism resulting in Acute Massive Pulmonary Embolism and obstructive cardiogenic shock (Kilip class $d$, $NYHA$ class $III-IV$). Diagnostic plans focus on a coagulogram showing decreased clotting time, positive $D$-dimer, and the $S_1Q_3T_3$ pattern on an $ECG$. Sputum analysis may show red blood cells. Treatment is an emergency: fibrinolytic or thrombolytic therapy within $6$ hours (Streptokinase/Urokinase), heparin ($10,000\,IU$), warfarin, and potentially pulmonary thromboembolectomy surgery.

Clinical Case 25: NSTEMI and Hypertensive Syndrome

A $49$-year-old patient experienced pressing precordial pain irradiating to the interscapular region and left hand following weight lifting. The pain gradually increased over $5$ hours and was not relieved by analgesics. The patient's blood pressure was recorded at $160/95\,mm\,Hg$.

The leading syndromes are anginal pain syndrome and hypertensive syndrome. The diagnosis is Ischemic Heart Disease ($IHD$) with a subacute Non-ST Elevation Myocardial Infarction ($NSTEMI$) of the inferior-lateral wall. Differential diagnoses include pericarditis and costochondritis. Diagnostic plans should include biochemical markers (troponin, myoglobin, $CK, AST, ALT$) and an $ECG$ showing $ST$ segment depression and inverted $T$ waves in leads $III, aVF, V_5, V_6$. Treatment requires morphine, oxygen, aspirin, and nitroglycerine in the emergency department, followed by stabilization with fondaparinux, perindopril, bisoprolol, and double antiplatelet therapy ($Aspirin + Clopidogrel$).

Clinical Case 33: Perforated Peptic Ulcer and Local Peritonitis

A $22$-year-old patient was admitted with sudden, acute "knife-like" stabbing pain in the right hypochondrium and umbilical region. The intensity lasted for $25$ minutes before slightly decreasing. The patient had a known history of duodenal ulcers. Examination revealed pale skin, tenderness and muscle tension in the abdomen, and a tympanic sound in the right hypochondrium. Blood pressure was $100/60\,mm\,Hg$.

The syndromes present are pain syndrome, shock syndrome, and local peritonitis syndrome. The diagnosis is a Primary Peptic Ulcer of the duodenum in the exacerbation stage, complicated by perforation, peritonitis, and shock. The tympanic sound is a pathognomonic sign. Diagnostic steps include a $CXR$ to look for free air under the diaphragm and an abdominal ultrasound to locate the ulcer. Immediate surgical intervention (laparoscopy or laparotomy) is the primary treatment. Pre-surgical medical care includes crystalloid therapy, analgesics (diamorphine), and antibiotics (cefotaxime and metronidazole). Post-surgical recovery involves a strict diet (Diet No. $1$) and eradication therapy with omeprazole, bismuth, tetracycline, and metronidazole.

Clinical Case 36: Chronic Viral Hepatitis B and Liver Cirrhosis

A $38$-year-old male complained of weakness, anorexia, nausea, and dull pain in the right hypochondrium. He has a history of viral hepatitis $B$ from three years ago. Over the last month, he noticed abdominal enlargement and extremity edema. Examination showed jaundice, spider nevi on the face and chest, palmar hyperemia, and a liver palpable $5\,cm$ below the costal arch. Hemorrhagic signs include bleeding from the gums.

The diagnosis is Chronic Viral Hepatitis $B$ transformed into Liver Cirrhosis, in the decompensation and active stage, with portal hypertension and liver insufficiency. Syndromes include hepatomegaly, dyspeptic, and hemorrhagic. Laboratory investigations should look for $Hbs$ antigens, prolonged prothrombin time, and elevated conjugated bilirubin. Treatment includes interferon ($5\,\text{million IU}$), tenofovir ($300\,mg$), and hepatoprotectors. Diuretics and vitamins ($A, D, E, K$) are necessary. Management includes Diet No. $5$ (high protein, restricted fat) and possibly a liver transplant.

Clinical Case 42: Bronchial Asthma and Status Asthmaticus

A $36$-year-old patient presented with a nine-hour asthma attack, dry cough, and palpitations. She has a $5$-year history of asthma triggered by pets. Repeated use of Salbutamol (over $10$ times) failed to resolve the attack. Examination noted a forced sitting posture, cyanosis of the nasolabial triangle, a barrel-shaped chest, and distant wheezing. Auscultation showed a "silent chest" sign where wheezing is no longer heard due to severe obstruction. Her heart rate was $104/\text{min}$.

The diagnosis is Bronchial Asthma complicated with Status Asthmaticus. Differential diagnosis includes $COPD$ and $GERD$. Diagnostic measures include spirometry and peak expiratory flow ($PEF$) measurement. Management requires hospitalization in the intensive care unit, parenteral corticosteroids ($IV$ hydrocortisone $100\,mg$ every $6$ hours), inhaled ipratropium bromide, and methylxanthines via $IV$ injection. Continuous oxygen saturation monitoring is mandatory.

Clinical Case 47: Post-Hepatitic Macronodular Liver Cirrhosis

A $42$-year-old patient presented with weakness, daytime drowsiness, jaundice, heaviness in the right hypochondrium, and ascites. History included viral hepatitis $6$ years prior. Examination showed a tremor of the hands, spider veins on the chest, gynecomastia, and dilated abdominal veins. The liver size was recorded as $15-15-13\,cm$ and the spleen as $15-12\,cm$. Laboratory results showed thrombocytopenia ($68 \times 10^{9}/l$) and hyperbilirubinemia ($130\,\mu mol/l$).

This case demonstrates asthenic syndrome, portal hypertension syndrome, and hepatosplenomegaly. The diagnosis is Post-Hepatitic Macronodular Liver Cirrhosis, Stage $4$. Diagnostic plans include a coagulation profile, $PCR$ for viral load, and a liver biopsy. Treatment involves Diet No. $5$, antiviral drugs (interferon alpha, ribavirin), and diuretics (spironolactone with furosemide). If the functional status worsens or ascites becomes refractory, a Transjugular Intrahepatic Portosystemic Shunt ($TIPS$) or liver transplant is required.

Clinical Case 72: Severe COPD and Chronic Cor Pulmonale

A $62$-year-old pensioner with a $40$-year smoking history presented with severe expiratory dyspnea, wheezing, and a paroxysmal cough producing yellow-green sputum ($20\,ml/\text{day}$). He also reported leg edema, insomnia, and headaches. Physical examination showed a barrel-shaped chest, diffuse cyanosis, and a "boxed" percussion sound. Auscultation revealed scattered dry wheezing. Heart sounds were muffled with a systolic murmur at the tricuspid valve. The liver was enlarged ($12 \times 11 \times 10\,cm$). Spirometry showed an $FEV_1$ of $27\%$ and a $VC$ of $48\%$.

The syndromes are broncho-obstructive, emphysematous, and Cor Pulmonale (right heart failure). The diagnosis is $COPD$ Stage $3$ (Severe), complicated by stage $II$ respiratory failure, Chronic Cor Pulmonale, and chronic heart failure stage $IIb$. Differential diagnosis includes bronchiectasis and bronchiolitis obliterans. Treatment focuses on long-term low-flow oxygen ($1-2\,L$), combinations of $SABA/LABA$ (albuterol/salmeterol), inhaled anticholinergics (tiotropium), and inhaled corticosteroids. Cor pulmonale requires diuretics, vasodilators, and anticoagulation therapy.

Clinical Case 93: Acute Myeloid Leukemia in a Student

An $18$-year-old student was admitted in serious condition with a fever of $39-40^{\circ}C$, a severe sore throat, and progressive weakness. Cervical and axillary lymph nodes were enlarged and painful. The patient displayed hemorrhagic spots on the skin and bleeding gums. Tonsils were covered with purulent plaques and necrotic ulcers. Laboratory tests were critical: $RBC 2.5 \times 10^{12}/l$, hemoglobin $83\,g/l$, platelets $5.0 \times 10^{9}/l$, and a white blood cell count of $0.8 \times 10^{9}/l$ with $90\%$ blasts. A sternal puncture showed $80\%$ blast cells.

The leading syndromes are intoxication, hemorrhagic, hyperplastic (nodes), and anemic. The most likely diagnosis is Acute Myeloid Leukemia ($AML$), first stage. Treatment involves immediate remission induction with the "$7+3$" regimen (cytarabine and daunorubicin), supportive care with blood transfusions and antibiotics, and potential bone marrow transplantation.

Clinical Case 100: Acute Systemic Lupus Erythematosus and Lupus Nephritis

A $21$-year-old female fell ill following hypothermia, presenting with a fever of $39^{\circ}C$, swelling of the knee/elbow joints, and enlarged submandibular lymph nodes. She reported sharp pain in the lower lungs during deep breaths and a "bright blush" on her cheeks. Examination noted a gallop rhythm in the heart and peripheral edema. Laboratory results showed pancytopenia (anemia, thrombocytopenia, leukopenia) and severe proteinuria ($4\,g/\text{day}$ loss) with waxy cylinders in the urine.

The primary syndromes are joint syndrome, lymphadenopathy, nephrotic syndrome, pancytopenia, and cardiomegaly. The diagnosis is Acute Systemic Lupus Erythematosus ($SLE$) with Lupus Nephritis. Management requires high-dose glucocorticoids, hydroxychloroquine, and immunosuppressive agents such as azathioprine or cyclophosphamide. Kidney biopsy is necessary to grade the nephritis for long-term prognosis.