Late-Onset Systemic Lupus Erythematous in a Man with Antiphospholipid Antibody Syndrome and Lupus Nephritis

Introduction: Late onset systemic lupus erythematosis (SLE) is a subgroup of SLE, with age 50 considered minimum age of onset. As with early onset disease, the incidence here is also higher in females. There is little available data characterizing males with SLE and biopsy proven lupus nephritis. That which is available notes the late onset SLE patients have less renal involvement and historically receive less aggressive treatment. We present a case of a 72 year old male with newly diagnosed SLE with positive antiphospholipid antibodies and proteinuria/hematuria. Renal biopsy ultimately revealed a class III lupus nephritis. Case Description: 72 year old male with a history of hypertension, presented to ER with pleuritic chest pain. He was found to have left lower extremity DVT. Hypercoagulable testing showed high titer anti cardiolipin & anti beta2 glycoprotein IgG. Additionally, ANA 1:1280 (nuclear, homogeneous), double stranded (ds) DNA antibody 79 IU/mL, C3 89 mg/dL (low), C4 11 mg/dL. Urinanalysis with 3+ protein, large blood and >100 RBCs. Urine protein to creatinine ratio (UPCR) 2112 mg/g. Kidney biopsy revealed focal endocapillary proliferative & crescentic immune complex mediated glomerulonephritis, and endothelial cells containing tubuloreticular inclusions. Rare glomerulus with small active crescent. This was felt to represent focal proliferative lupus nephritis, class III. 3 days of pulse steroids given, transitioning to Prednisone 60 mg daily (tapering). Cellcept added and escalated to 3 g/day. After 3 months of therapy, PCR down to 260 mg/g with negative ANA, ds DNA antibody 4 IU/mL and normal C3. Serum creatinine remained stable at 1.1 - 1.3 mg/dL. Discussion: This case illustrates the importance of constructing a broad differential diagnosis in older patients presenting with non specific symptoms. Early recognition and diagnosis proved critical to our patient's management. Antiphospholipid antibodies were found on hypercoagulable workup, which in turn prompted consideration of SLE. The active UA was the key to determining the presence of renal involvement, despite the literature noting decreased incidence of nepritis in this population. More information is needed to better characterize this late onset subtype, especially in males. Clincians need maintain a high index of suspicion regardless of age and gender.