What is the diagnosis and treatment plan for a patient with a history of rashes, fever, lymphadenopathy, joint pain, and dark-colored urine, with a previous diagnosis of systemic lupus erythematosus (SLE) and lupus nephritis?

History of Present Illness: Systemic Lupus Erythematosus with Lupus Nephritis

This patient has systemic lupus erythematosus (SLE) with lupus nephritis that is currently experiencing a disease flare requiring immediate reinitiation of immunosuppressive therapy with cyclophosphamide as previously recommended.

Timeline of Disease Progression

• December 2023: Patient developed bilateral preauricular lymphadenopathy with body malaise, no medical consultation sought 1

• December 2024: Experienced fever for 2 weeks with joint pain, self-medicated with paracetamol and sought traditional healing ("hilot"), symptoms resolved without medical intervention 1

• April 2025: Developed fever persisting for 3 weeks with onset of malar rash (classic butterfly rash characteristic of SLE) 2

  • Consulted with a physician who prescribed paracetamol and oral prednisone
  • Rash and fever resolved after 3 days of prednisone therapy
  • Laboratory tests were performed (results not specified)
  • Patient was referred to a rheumatologist based on clinical presentation and laboratory findings 1

• May 1-5,2025: Hospitalized at SVGH

  • Diagnosed with SLE and lupus nephritis
  • Discharged on maintenance medications including:
    • Hydroxychloroquine (cornerstone of SLE therapy) 2, 3
    • Mycophenolate mofetil (MMF) (immunosuppressant for lupus nephritis) 1
    • Methylprednisolone (corticosteroid) 1
    • Vitamin D and calcium supplements (for bone health during steroid therapy) 2
  • Monthly follow-up with laboratory monitoring was advised 1

• July 2025: Last follow-up appointment

  • Medication regimen was revised
  • Cyclophosphamide therapy was recommended 1
  • Patient was referred to charity service at CHHM for financial assistance

• August 15-18,2025: Medication non-adherence

  • Unable to take prescribed medications due to financial constraints
  • Recurrence of malar rash (indicating SLE flare) 2

• August 19,2025: Resumed medications

  • Developed periorbital edema (suggesting worsening renal involvement) 1
  • Noted dark-colored urine (suggesting active nephritis) 1

• Interim period: Condition tolerated, maintenance medications continued

• September 1,2025: Developed low-grade fever (indicating possible disease flare) 1

Current Clinical Status

The patient is currently experiencing signs of active SLE with lupus nephritis as evidenced by:

1. Recurrent malar rash (classic SLE manifestation) 2
2. Periorbital edema (suggesting hypoalbuminemia from nephrotic syndrome) 1
3. Dark-colored urine (indicating active nephritis with possible hematuria) 1
4. Low-grade fever (systemic inflammatory response) 1
5. History of medication non-adherence due to financial constraints 1

Assessment

This patient has SLE with lupus nephritis that was previously controlled on immunosuppressive therapy but is now experiencing a disease flare due to medication non-adherence. The presence of periorbital edema and dark urine strongly suggests active lupus nephritis requiring prompt intervention 1.

The previous recommendation for cyclophosphamide therapy suggests that the patient likely has proliferative lupus nephritis (Class III or IV) which requires aggressive immunosuppression 1. Financial constraints have been a significant barrier to treatment adherence, necessitating social service intervention 2.

Recommendations

1. Immediate reinitiation of immunosuppressive therapy with cyclophosphamide as previously recommended 1
2. Continuation of hydroxychloroquine as the cornerstone of SLE therapy 2, 3
3. Corticosteroid therapy with initial high-dose regimen (prednisone 1 mg/kg/day or pulse methylprednisolone) 1
4. Urgent laboratory assessment including complete blood count, renal function tests, urinalysis, protein/creatinine ratio, complement levels, and anti-dsDNA antibodies 1
5. Social service consultation to address financial barriers to medication access 2
6. Close monitoring for treatment response with follow-up within 2-4 weeks 1