Biopsy proven lupus nephritis in a black male patient in West Africa with systemic lupus erythematosus: case report

Lupus nephritis (LN) is a complication of systematic lupus erythematosus (SLE) with significant impact on morbidity and mortality. It is known commonly to affect females but has worse prognosis when males or blacks are affected. In a setting with deficiency in health care delivery, the diagnosis and adequate management of SLE patients becomes difficult and hence less cases of lupus nephritis in black males have been reported. We present a case of a male black patient with SLE who presented with neurolupus, serositis, skin manifestations and Class IV/V lupus nephritis on histology. Our case highlights the challenges in the management of lupus nephritis and the complications with immunosuppression in an attempt to induce remission. There is the need for high index of suspicion for the diagnosis of lupus nephritis especially in black males for prompt management to get the best outcome.


Systemic lupus erythematosus (SLE)
is a multi-systemic autoimmune condition with significant morbidity and mortality especially when it affects the kidneys. Lupus nephritis (LN) is recognised as a serious complication in SLE patients. It is second only to infection as the most common cause of mortality in SLE patients. In Africa, the prevalence of LN among SLE patients is 49 -60% [1]. SLE tends to affect females predominantly but males tends to have more severe disease with poorer prognosis. Renal survival in SLE patients among blacks is poor especially with diffuse proliferative nephritis on biopsy and with impaired renal function [2]. We set out to report a case of lupus nephritis in a black male patient with class IV/V lupus nephritis on renal histology who presented with hypertension, renal impairment, nephrotic range proteinuria, high ANA and anti-SM titre. Patient is currently on immunosuppression in partial remission but has experienced complications related to the use of immunosuppression. There was moderate ascites and left pleural effusion on ultrasound.

Patient and observation
He was then worked up for a percutaneous renal biopsy which was

Discussion
To our knowledge this is the first ever case report of a case of SLE in a black male patient with biopsy-proven lupus nephritis in Ghana.
This report highlights the presentation and management in this rare demography as lupus has been shown to be more common in young females in their reproductive age. The patient responded well to He also had a positive ANA and a very high anti-Smith antibody (Anti-SM) titre making 6 out of the 11 required criteria. The sensitivity of anti-SM antibody is low (24% -30%) but has high specificity of 96 -98%. Anti-Smith antibodies are known to be more prevalent in black patients [5] as was found in our patient. Anti- Africa. LN is the second most common cause of mortality after infection in SLE patients [6].
Renal biopsy is essential for the diagnosis of LN, to classify the disease, assess severity, to prognosticate and exclude other causes of renal diseases in SLE patients [1]. The patient's presentation with nephrotic range proteinuria, hypertension, renal impairment, hypoalbuminuria and hypercholesterolemia were all clinically suggestive of lupus nephritis class IV or class V [7]. Histology however proved Class IV LN with thickened capillary walls suggestive of elements of Class V lupus nephritis but could not be confirmed on electron microscopy as the only stain available in our setting was the Hematoxylin and Eosin (H and E) stains as a low resourced center. Immunofluorescence and electron microscopy were not available in our setting. This is a challenge as light microscopy alone is inadequate for the proper diagnosis of lupus nephritis. There may also have been an element of interstitial nephritis as there was edema and chronic active inflammation with eosinophils on histology report as has been described in up to 50% of cases of class IV LN in a study. Class IV LN is the commonest presentation of lupus nephritis and very aggressive when not well managed. It tends to present with sub-nephrotic proteinuria but class V membranous glomerulonephritis tends to present with nephrotic range proteinuria as noted in our patient with a peak as high as 9.7g/day [7].
Cyclophosphamide (intravenous or oral) or mycophenolate mofetil (MMF) with high dose steroids have been used for the treatment of proliferative nephritis. MMF has been found to be comparable to intravenous cyclophosphamide but with less side effects [8]. MMF was used in our patient for induction with high dose oral steroids. Oropharyngeal candidiasis have also been described in systemic lupus erythematosus patients and the use of immunosuppression [9,10]. The development of oropharyngeal candidiasis complicates treatment and may impair intake of food and oral medications.
There was good response to oral fluconazole which is indicated in the treatment of candidiasis and found to be superior to nystatin in patients with immunosuppressive disease like SLE.
There is increased incidence of herpes zoster reactivation associated autoimmune conditions including SLE and the use of high dose MMF has been associated with herpes zoster infection. Herpes zoster has been shown to be the most common infection among SLE patients on immunosuppression [10]. Despite the challenges expected in a black male patient with lupus nephritis class IV/V LN and the numerous complications as a result of the disease process and or the immunosuppression treatment, our patient is in partial remission and doing very well clinically.

Conclusion
Lupus nephritis has been less described among black males though known to be aggressive. Its management is associated with fungal, viral and bacterial infections. Prognosis is associated with Class of lupus nephritis, renal functions and complications of SLE. In our setting with inadequate facilities and poor patients who cannot afford investigations and treatment, procedures and treatment of lupus and lupus nephritis is a nightmare for the physician, rheumatologist and nephrologist. A high index of suspicion is required for the diagnosis of lupus nephritis in black males and a percutaneous renal biopsy imperative in the management.