Dramatic response to plasma exchange in systemic lupus erythematosus with acute complications: Report of two cases
A 24-year-old male, a known case of SLE (for 13 years) with End Stage Renal Disease (class IV lupus nephritis) presented with shortness of breath, chest pain, and cough for 7 days. Patient had two episodes of diffuse alveolar hemorrhage in the past, managed with pulse steroids. The patient also had pulmonary tuberculosis and was on Anti-tubercular treatment for last 6 months. He was also Hepatitis B surface antigen (HBsAg) positive. He had received five pulses of cyclophosphamide prior to this admission. On examination, patient was tachypnoeic, endotracheal bleeding was present. There was right hypochondriac tenderness and hepatomegaly. He was admitted to ICU for ventilator support and was started on pulse methylprednisolone. Chest X-ray and CT scan showed bilateral middle and lower alveolar opacities. The possibility of acute exacerbation of SLE in the form of diffuse alveolar hemorrhage was considered. As there was no improvement on pulse steroids, plasma exchange was planned. Patient was assessed by transfusion medicine team and taken up for the plasma exchange on day 2 of ICU admission. Six cycles of plasma exchange were administered on alternate days by exchanging one plasma volume, using 4% human Serum Albumin as replacement fluid. After the 1st procedure there was clearing of the endotracheal tube bleeding and after the 2nd procedure patient could be successfully weaned off the ventilator and was shifted to the ward. Patient was on dialysis simultaneously and his renal function tests improved after the 6th procedure. His total duration of hospital stay was 17 days including 4 days in the ICU.