A 23-year-old Hispanic female at 19 weeks of gestation, with medical history significant for preeclampsia and mild intermittent asthma, presented to the Emergency Room complaining of fever, dry cough, and shortness of breath for a week. The patient also reported painful swelling in her hands and feet associated with morning stiffness. She had tried acetaminophen at home which did not relieve her symptoms. Initial examination was remarkable for tachycardia (103 beats/min), tachypnea (20 breaths/min), and fever (101.8 F). Her lung examination was clear with equal air entry bilaterally. Joint exam showed swelling, tenderness, and warmth of bilateral ankles, knees, proximal interphalangeal joints, and metacarpal phalangeal joints. Laboratory studies were significant for lymphopenia (white blood cell count of 2.6 x 10/microL) and anemia (hemoglobin of 10.5 g/dL). Chest X-ray on admission did not show abnormalities.
Bilateral lower-extremity venous duplex studies did not show evidence of deep vein thromboses. Additionally, left knee arthrocentesis ruled out septic arthritis.
She was started empirically on ceftriaxone and azithromycin for possible community-acquired pneumonia. Her symptoms did not improve. C-reactive protein (CRP) and erythrocyte sedimentation rate were elevated (13 mg/L and 59 mm/h, respectively). Low complement levels were noted (C3 of 36 mg/dL and C4 of <8 mg/dL). The ANA test was positive. On day 5 of admission, she became tachypneic and hypoxic, saturating 84% on room air despite noninvasive ventilation. She was upgraded to the Intensive Care Unit where she required a high-flow nasal cannula.
Repeat chest X-ray showed new multifocal bilateral airspace opacities but no pleural effusions or pneumothorax (Figure 1).
Extensive infectious workup for viral, bacterial, and parasitic causes was negative. Notably, sputum cultures, blood cultures, and cultures for SARS-CoV-2, HIV, CMV, EBV, parvovirus B-19, hepatitis, and West Nile virus were negative. Legionella and Streptococcus urine antigens, Mycoplasma pneumoniae, QuantiFERON for tuberculosis, Lyme, Ehrlichia, Anaplasma, PCR for influenza A (subtypes H1 and H3), adenovirus, parainfluenza, and rhinovirus were also negative.
The patient was started empirically on IV methylprednisolone 60 mg daily for probable pneumonitis. This led to significant improvement of symptoms as her fever, tachypnea, hypoxia, cough, and arthralgias had resolved within 24 hours.
On further investigation, she was found to have positive anti-dsDNA (1 : 160 titers) and anti-SSA antibodies. CT chest was not pursued, given the risk of radiation exposure in pregnancy.
She never developed hemoptysis or significant drop in hemoglobin to favor of alveolar hemorrhage. The patient was diagnosed with new-onset SLE as per the EULAR/ACR 2019 criteria as she presented with fever, leukopenia, arthritis, pneumonitis, low complements, and positive serological lupus studies (ANA and anti-dsDNA). She was started on hydroxychloroquine 200 mg twice daily, and intravenous corticosteroids were switched to oral prednisone on the fourth day of IV methylprednisolone. This achieved adequate clinical and serological response as her CRP, hypocomplementemia, and pancytopenia significantly improved within 5 days.