Hepatitis Lupus in Systemic Lupus Erythematosus in Male Patients

Systemic Lupus Erythematosus (SLE) is a complex autoimmune disease characterized by autoantibodies against the cell nucleus and involves many organ systems in the body with unknown etiologies and various clinical manifestations, disease course and prognosis. SLE can be found at all ages, generally appearing at age 9-58 years with a peak at age 28 years. It is more common in women with a ratio of women to men 15: 1 to 22: 1. The highest incidence and prevalence of SLE was found in North America 23.2 / 100.000 population / year and 241 / 100.0000 population. In Indonesia, there has been an increase in visits to SLE patients from 17.9-27.2% in 2015 to 30.3-58% in 2017. One of the manifestations of SLE is hepatitis lupus, which is inflammation of the liver tissue. Lupus hepatitis can occur in 20-50% of patients with SLE. It was reported that a 20-year-old man presented with complaints of pain in the joints of the right and left hands which increased since 1 week. The patient also complained of reddish patches on the face, hair loss and mouth sores. Physical examination revealed anemic eye conjunctiva, malar rash, oral ulcer. During the joint examination, there was tenderness in bilateral MCP and PIP. The abdominal examination revealed hepatomegaly. Investigations revealed anemia, thrombocytopenia, increased liver function. Abdominal ultrasound revealed hepatomegaly. ANA profile examination was positive for anti RNP, anti -sm, and antiribosomal protein antibodies. The patient was diagnosed with Systemic Lupus Erythematosus with lupus hepatitis according to the ACR (American College of Rheumatology) criteria in which the patient had 6 criteria. The patient was given therapy with 2x125 mg of intravenous methyl prednisolone for 3 days and hydroxychloroquine 1x200 mg orally and other symptomatic drugs.


Systemic Lupus Erythematosus
The incidence of LES was also found to be higher among African, Asian and Hispanic races than for Caucasians, Canadians and Spanish. 2,5 Systemic lupus erythematosus is a complex autoimmune disease characterized by autoantibodies against the cell nucleus and involves many organ systems in the body. One of the manifestations is lupus hepatitis, which occurs in 20-50% of LES patients. 3 Liver dysfunction is common in LES patients. This may reflect liver disease as a component of LES, liver disorders associated with other autoimmune diseases such as primary biliary cirrhosis, drug poisoning, or Biomedical Journal of Indonesia https://www.jurnalkedokteranunsri.id/index.php/BJI/index other unrelated diagnoses, such as viral infection. 13 The anti-ribosomal P antibody is a useful serological marker for lupus hepatitis and was positive in 44% of lupus hepatitis patients. Anti-Smith antibodies are another useful marker for lupus hepatitis.
Approximately 99% of patients who are anti-SM positive meet the diagnostic criteria for LES. 13

Clinical Findings
A male patient 20 year old was treated with complaints of pain in the joints of the right and left hands which increased since 1 week before admission to the hospital. Pain has been felt since 2 months ago and was felt in the wrists and feet, elbows, knees and shoulders. Pain is felt intermittently. There was no history of joint stiffness.
The patient also complained of reddish patches on the face since 2 months before being admitted to the hospital, reddish spots increased when exposed to sunlight, no pain, no itching. Hair loss experienced since 2 months before entering the hospital, canker sores since 3 weeks before entering the hospital.
Weakness and fatigue that have increased since 1 week, decreased appetite since 1 week before admission to hospital. There is no fever.
The patient came with a moderate general condition and awareness composmentis cooperative, blood pressure 120/80 mmHg, pulse 87 x/minute, breath 18 x/minute, temperature 36.

Discussion
It has been reported that a 20- The principle of treating lupus nephritis is to suppress the inflammatory reaction of lupus, improve kidney function, or at least maintain kidney function so that it does not decrease. In patients with highly active lupus, a methyl pulse dose of 500-1000mg / iv / day may be given to induce rapid anti-inflammatory action. After 3 days of administration continued with the administration of oral methylprednisolone 0.5-1 mg / day. In this patient the indication for being given a methyl pulse dose of 250 mg / iv / day was because based on the criteria for assessing SLE activity, namely the MEX-SLEDAI criteria, a score of 10 was obtained so that the patient was treated with a methyl pulse dose.
According to Saleem et al, after the use of immunosuppressive therapy for 6-8 months, 20-50% of kidney histological examination will provide a picture of the active inflammatory process with positive proteinuria. In fact, after several years of immunosuppressive treatment, the inflammatory activity of the kidneys is still ongoing even though remission has been achieved. 7,8,12 The patient also had hepatomegaly with HBsAg and Costicosteroids should be tapered off carefully. In addition, it is also necessary to carry out routine blood checks and blood chemistry every 3 months and anti-dsDNA tests every 3-6 months as well as monitoring the side effects of the treatment given due to the relatively long time of therapy.

Conclusion
Systemic lupus erythematosus is an autoimmune Another thing that needs to be considered in managing LES-related lesions is reducing risk factors.
Sun protection is important because LES-related lesions are very easily triggered and exacerbate due to UV rays. Patients are required to use sunscreen when outside the house and wear clothes that protect themselves from the sun.