Subacute skin-type lupus misdiagnosed as common psoriasis 1 case

1 Clinical data
patient woman, 53 years old, married, hubei countyRed plaques, scaly re-emergences of the whole body for 15 years, and then more than half a year15 years ago, patients without obvious causes of the neck size of pale red papules, covered with a little silvery scaly, the skin damage gradually increased, evolved into large and small red plaques, and tired of the whole body, in the local hospital was diagnosed as "eczema", after a hospital in Wuhan City diagnosed as "psoriasis", to use and oral drugs (specifically unknown), the effect is not good, skin damage when bad, no seasonalSix months ago the patient skin damage relapsed, and gradually aggravated, then came to the hospital, outpatient to "common psoriasis" incomeSince the onset of the disease, the patient's spirit, diet, poor sleep, two as usual, physical strength and weight no significant changeHaving suffered from "hypertension" for 10 years, has been oral nitrobenzene flat tablet treatment, the current blood pressure is more stable, suffering from "type 2 diabetes" 1 year, oral metformin treatment, currently more stable blood sugar control, denied "hepatitis" "tuberculosis" and other infectious diseases, no history of food drug allergy, denied the history of surgical trauma and blood transfusion historyThe patient is married and no similar cases have been seen in the familyAdmission check-up: T 363 degrees C, P 92 times/min, R 18 times/min, Bp 120/80 mmHg, cardiopulmonary hearing unheard and noticeable abnormal, abdominal softness, untouched under the liver and spleen ribs, the whole body shallow lymph nodes did not touch the swelling, limb activity can, weight 61 kgDermatology: the whole body scattered in the distribution of green beans to palm-sized red patches, covered with flaky silver-white scales, local skin mild atrophy, Austen negative, to the head face, chest V area, double forearm extension and hand back heavy; Oral mucous membranes did not see erosion, ulcers and other damage, lips can see skin damage, no damage to a nailDermalhec pathology shows: epidermis excessive keratization, fundamental cell lesions liquefaction denaturation, dermal whole layer of blood vessels and appendages around visible lymphocytes-based inflammatory cells immersion, collagen visible mucus-like substance deposition (Figure 2)Laboratory Examination: Blood Routine: White Blood Cells 27 x 109 /L, lymphocyte percentage 1973%; Blood 73 mm/h, self-resistant test: ANA (-) titer 1: 100 (particle type), anti-SSA antibody (-), anti-U1RNP antibody (-), anti-Sm antibody (- ), anti-double-chain DNA antibodies (-), urine routine, liver function, blood lipids, kidney function, electrolytes, blood sugar, immunoglobulin IgM, IgG, IgA, complement factors C3, C4, hepatitis B are all normalFinal diagnosis: subacute skin type lupus (severe pimple type)Treatment: The patient was diagnosed with "common psoriasis" when he was admitted to hospital, and given oleta 5 mg 2 times/d, run-and-run itch capsule 20 g 3 times/d orally, ginseng glucose injection 200 mL hydroid; Dexametison cream, compound pine distillate ointment external use, hot spring spa treatment 2 d, the efficacy is not good; 2 g 2 times/d, acetate pernisone tablets 10 mg 3 times/d, potassium chloride slow release tablets, aluminum magnesium carbonate tablets orally; After 1 week, the pathological results were reported as a clear diagnosis of "subacute skin-type lupus." At this time, the skin damage color has been reduced, scales reduced, two weeks later skin damage gradually began to soft flat, local subsidence, the patient in the hospital treatment for 3 weeks, discharged from the hospital when the face of the red patches mostly subsided, local left brown color, the torso skin loss basically subsided, local atrophyAfter discharge from the hospital, the patient is instructed to continue to take oral acetate pentisin tablets 10 mg 3 times/d, hydroxychlorpyrifos sulphate tablets 02 g 2 times/d and other drugs, regular WeChat, telephone follow-up, depending on the change of the condition gradually reduced treatment2 Discussionsubacute skin-type lupus (SCLE) is between systemic lupus (SLE) and disc-like lupus (DLE), mainly to skin damage symptoms, and systemic damage is mild, once known as symmetrical centrifugal lupus, autoimmune cyclopathic lupus, subacute diffuse lupus erythematosus, psyloshing lupus, etcFirst reported by Sontheimer and others in 1979, SCLE accounts for 10% to 15% of all lupus (LE) cases, with two main types of skin manifestations: ringery and papules scaly type (psoriasis type)Both types are sensitive to light, rash is good in the light exposure site, such as: face, ears, neck, front chest, upper limb extension and other areas, can affect the lips and cheeks mucous membranes, skin damage can be relapsed in the original and elsewhere, after retreating without scarringAbout 20% of cases are associated with DLE damageGenerally only one type of skin damage, there are very few cases of two types coexistingAccording to domestic and foreign literature reports, it is currently believed that skin damage for ring or multi-ring patients prone to the symptoms of dry syndrome, more tend to be benign, not easy to develop into SLE, while skin damage for papules scaly type of kidney damage and central nervous system is more likely to sufferBecause the clinical manifestations of papules scaly SCLE are similar to common psoriasis, it is easier to misdiagnose psoriasis, and domestic scholars have reported that they have been diagnosed with other diseasesRing/multi-ring SCLE is easily misdiagnosed as a body of erythema, drug rash, allergic dermatitis, frostbite and other common skin diseases, clinicians should be vigilantThe main reasons for misdiagnosis of patients in this case are: (1) skin damage distribution throughout the body, with the head face, torso and double upper limb extension side as heavy, skin damage is shown as bright red plaques, covered with silver white scales, and common psoriasis clinically similar; (2) repeated seizures, have been diagnosed in the hospital "psoriasis" or "eczema", to the doctor wrong information; (3) The medical examination of the attending doctor is not detailed, inexperienced, lack of sCLE disease conceptA closer look at the skin damage will find that its silver-white scales slightly thin, and have a certain degree of viscosity, red spot local visible depression pigment decline, and the general psoriasis of the clinical performance of slightly different The latter red spots are mostly bulging plaques, and the scales are thicker, scraping the scales visible film phenomenon, dot-like bleeding and other Ao's signs The patient's scales scraped off, did not see obvious film phenomenon, spot-shaped bleeding and other typical symptoms, coupled with the patient's face visible butterfly-shaped red spots, head-free hair, hair sparse phenomenon, which is enough to cause doubts about the diagnosis of psoriasis In summary, although the patient is easily misdiagnosed as psoriasis, it is not inevitable First of all, to be good at listening, the medical history of the analysis, can not superstitious authority, carefully distinguish the past diagnosis; Third, the grass-roots doctors should strengthen the study of hard-working basic skills, diligent reading of the literature to broaden their horizons, good at summing up experience, in order to achieve false existence, clear diagnosis purposes This case of patients for elderly women, chronic recurrent course, skin damage performance of scaly erythema, early has been misdiagnosed as "eczema" and "psoriasis", because psoriasis and LE in the genetic mechanism overlap, so LE and psoriasis can be concurrent, there are also Scholars reported concurrent cases of the disease, but this case of immunological examination can be seen anti-Ro/SSA impotence, coupled with blood routine test results can be seen white blood cell decline, tissue pathology test results are in line with sCLE diagnosis, can be clearly diagnosed as SCLE's papille scale type Patients according to the "psoriasis" treatment effect is not good, and the use of sulphate chloroquine tablets and small doses of hormone treatment, the patient white blood cells rose to the normal range, blood depression significantly decreased, skin damage subsided, clinical efficacy satisfaction, can also support the diagnosis Some scholars believe that in SCLE patients, SSA, SSB positive people are more light than those who are simply SSA positive, so it is considered that SSB positive is a sign of a mild clinical symptom, while the simple SSA positive is relatively serious, and kidney damage is possible In this case, the patient was only SSA positive, and the skin damage was shown as papules scaly type, and in terms of prognosis, the relatively ring/multi-ring type tended to develop into SLE However, in addition to the patient in this case did not enter the kidney tissue biopsy, the current test indicators, have not yet seen signs of visceral damage, should be closely followed up to observe references