A 15-year-old male presented with complaints of moderate grade fever for 4 months and generalized body swelling with facial puffiness for 2 months. There was no history of cough, weight loss, joint pain, oral ulcerations, skin rash, photosensitivity, loss of hair, pain abdomen, jaundice, or any significant illness in the past. There was no past history of tuberculosis in the patient or in any other family member. General examination revealed moderate pallor and bilateral cervical and axillary lymph nodes, with the largest being of size 1 cm x 1 cm mobile, nontender, and firm. Systemic examination was insignificant except for the presence of palpable spleen, 2 cm below the costal margin. Hemogram was suggestive of bicytopenia (Hb 6.9 g/dL (normal: 12-14 g/dL), TLC 2700/mm3 (normal: 4000-11000/mm3), and total platelet count 2,10,000/mm3 (normal: 150000-400000/mm3)). Serum amino transferases and alkaline phosphatase were raised (SGOT 316 U/L (normal: 20-40 U/L), SGPT 109 U/L (normal: 20-50 U/L), and S. ALP 2750 IU/L (normal: 44 to 147 IU/L)). Total serum protein (5.1 g/dL, normal: 6.0-8.3 g/dL) and albumin (2.3 g/dL, normal: 3.5-5.5 g/dL) were low. Renal function tests were normal. Mantoux test was negative and ESR was slightly raised. Urine routine and microscopy showed 4-5 RBCs and 8-10 pus cells per high power field and 4+ albuminuria. 24-hour urinary protein was 2.1 gm. Kidney biopsy was done. Chest roentgenogram was normal. Ultrasonography of abdomen revealed mild splenomegaly with a tiny hypoechoic mass in spleen suggestive of splenic granuloma, along with a few subcentimetric retroperitoneal lymph nodes. Bone marrow studies were suggestive of nutritional anemia. Cervical lymph node biopsy showed reactive lymphoid hyperplasia. Barium meal follow through showed jejunoileitis. IgM antibody for Epstein-Barr virus was negative. Serum angiotensin converting enzyme levels were also normal. Based on the clinical picture, the high prevalence of tuberculosis in this part of the world and the investigations, a provisional diagnosis of disseminated tuberculosis was kept. The patient was started on a trial of antituberculous treatment and was asked for review with renal biopsy report. He turned up early with high grade fever, swelling of upper lips, and oral ulceration. On further investigations, his antinuclear and antidouble stranded DNA titers were significantly raised (ANA 7.3 IU/mL, N < 1, and anti-dsDNA 680 IU/mL, N < 40).
Histopathological report of kidney biopsy was suggestive of membranoproliferative (Type) lupus nephritis. Contrast enhanced computerized tomography of the abdomen revealed hypodense lesions in both liver and spleen (without contrast enhancement), suggestive of granulomas along with few retroperitoneal and mesenteric lymph nodes. Consequently, a revised diagnosis of SLE with lupus nephritis and granulomatous hepatitis was now evident, and the child was put on pulse methylprednisolone 500 mg for 3 days. He showed dramatic improvement clinically.