Thanks a lot for the opportunity and, more importantly, an impetus to keep moving.
Hope you all stayed engaged and entertained
See you in other
@ECNeph
discussions.
#ECNeph
#ECNeph @brammahin @Dilushiwijay @myadla
@acssjr @dra_miliflores
Diagnoses in nephrology at different junctures
Few at admission
Few in the history
Few in the sequence
Few in the investigations
Few in the biopsy
And a few in the recovery
#ECNeph @brammahin.@myadla. @Dilushiwijay
@dra_miliflore @acssjr
Similar presentation in Post Tx Pt
But ..why is it so rare ?
Why dont we see it often despite high use ?
Thoughts ?
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
pubmed.ncbi.nlm.nih....
pubmed.ncbi.nlm.nih....
☄️ More than few reported cases exist
When you suspect MMF-hyperinflammation
dont forget to exclude these
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores
@acssjr.bsky.social
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
⚠️ Few warnings exist already
Proposed mechanism of hyperinflammation due to MMF
#ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores
@acssjr.bsky.social
💥 Could this be MAS in SLE? We are seeing it more often,
🗝️ - Clues in clinical practice
Fever
Pancytopenia
Organomegaly
⬇️ ESR with disease activity
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
Differentiating fever from flare in lupus
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores @acssjr
NLR
CRP/ESR ratio <2/2-15/>15 : <2 s/o infection
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
💣. Predisposition - Yes
Not enough for diagnosis
❌ No organism identified
❌ No focus of infection
ℹ️Turns out patient has hypogammaglobulinemia
❓MMF related/disease related
Ig A - 134 mg/dl ( 70-400)
⬇️Ig G - 669 mg/dL (700-1600)
⬇️⬇️Ig M - 38 mg/dL (40-230)
😏Does it explain all?
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph
Do you agree ?
Post your final diagnosis ....
Is it to do with IST ?
#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph
see the time line of admissions for febrile episodes
Class switch
High inflammatory markers
Infection clues negative
3 episodes in 2-3 months
Where should this lead to ?
🦠 When do you think fever is of infection in origin?
⁉️ Can we rule out all infections all the times? Say some hidden TB or a very timid virus. We need more markers.
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr
@dra_miliflores
#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph
yet another admission ..in a weeks time
premature discharge vs recurrence of infection /appearance of flare
High inflammatory markers favour infection
or is it non infectious inflammation
⚓️ What features would suggest SLE activity for you?
⚖️ Do you weigh on global assessment?
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
#ECNeph @brammahin @myadla @Dilushiwijay
@acssjr @dra_miliflores
#ECNeph
Rx with antibiotics
Restarted on IST after fever subsidence
What next ?
Evaluation being negative for all infections : Bacteria /virus ..
How to go further ?
🔂 3 admissions with acute febrile illnesses within
2-month span
🩺 No focal signs/symptoms
☢️ Routine imaging -negative -No organ-specific
illness
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
#ECNeph @brammahin @myadla @ISNkidneycare
@Dilushiwijay @acssjr @dra_miliflores
ESR:CRP <2
S/O infection than flare
Lupus. 2018 Jun;27(7):1123-1129
How to differentiate between flare /Infection in SLE
#ECNeph @brammahin @myadla @Dilushiwijay
@dra_miliflores @acssjr.bsky.social
🗣️Fever in SLE - An enigma wrapped in mystery.
Interested in hearing your phrases of fever and also how do you define it in routine practice?
🧈 Just basics
#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores
#ECNeph @brammahin @myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores
Does the evaluation suggest flare ?
All atypical infections ruled out
Malignancy ??????
What else ?
PET-CT ?
#ECNeph
#ECNeph@brammahin@myadla @ISNkidneycare @Dilushiwijay
@acssjr @dra_miliflores
How to differentiate flare /infection in SLE
Infection versus disease activity in systemic lupus erythematosus patients with fever. BMC Rheumatol. 2024 Aug 14;8(1):34
#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr @dra_miliflores
Admitted in a weeks time with fever , polyarthralgia
Is it relapse /recurrence of infection
High inflammatory markers : is it SLE flare ?
#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr@dra_miliflores
Febrile admission in year time
Flare vs infection ?
Rx : Antibiotics ..Response +
Whats the time of reinitiation of IST after infection ?
How to differeentiate flare from infection ? Any novel markers #ECNeph
#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr@dra_miliflores
Admitted with Febrile illness - Pneumonia
Appropriate antibiotics given
#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr@dra_miliflores
Now Pt on triple IST with MMF /HCQ
CyC not initiated -Young woman
Proteinuria remission attained
#ECNeph @brammahin @myadla @ISNkidneycare
@Dilushiwijay @acssjr @dra_miliflores
Class switching in LN
Bomback AS. Nonproliferative Forms of Lupus Nephritis: An Overview. Rheum Dis Clin North Am. 2018 Nov;44(4):561-569
