title: Lupus erythematosus cell phenomenon in synovial and peritoneal fluids in systemic lupus erythematosus: smoking guns, crime scenes and a twist.
abstract: The presence of the lupus erythematosus (LE) phenomenon has been generally conceptualized as an in vitro occurrence where numerous damaged cells are present and substantial nucleo-phagocytosis has occurred. In systemic lupus erythematosus (SLE), the positive LE cell phenomenon has been shown to indicate active disease with major organ involvement which potentially warrants prompt and heavy immunosuppressive therapy. We report a 36-year-old woman with a known history of SLE who presented with fever, left knee effusion, polyserositis, pancytopenia, low complement and high anti-dsDNA antibody levels whose immunosuppressive treatment was escalated in view of the clinically and serologically active SLE, accompanied by the presence of LE cells in her inflammatory yet sterile left knee synovial fluid. Within 3 days of immunosuppressant escalation, her ascites worsened. While microscopic examination of the ascitic fluid also revealed LE cells, culture of the ascitic fluid later grew Candida parapsilosis. The patient subsequently responded to the addition of anti-fungal therapy into her augmented immunosuppressive regime. Coexistence of the LE cell phenomenon and infection in SLE patients has hitherto not been described. This case illustrates that infection remains to be meticulously excluded despite the presence of the LE phenomenon in the context of clinically and serologically active SLE.
authors.affiliation: Division of Rheumatology, Department of Medicine, University Medicine Cluster, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Sen Hee
authors.initials: SH
authors.lastname: Tay
authors.forename: Min En
authors.initials: ME
authors.lastname: Nga
authors.forename: Dow-Rhoon
authors.initials: DR
authors.lastname: Koh
authors.forename: Anselm
authors.initials: A
authors.lastname: Mak
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use; D001202:Ascitic Fluid / Q000166:cytology* / Q000276:immunology; D002177:Candidiasis / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology / Q000382:microbiology; D004359:Drug Therapy, Combination; D065206:Extracellular Traps; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008180:Lupus Erythematosus, Systemic / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology; D010538:Peritonitis / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology / Q000382:microbiology; D011237:Predictive Value of Tests; D013582:Synovial Fluid / Q000166:cytology* / Q000276:immunology; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D007166:Immunosuppressive Agents
keywords: infection; neutrophils; systemic lupus erythematosus