Unmasking a malar rash during the COVID-19 pandemic- BMJ Cas
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A 70-year-old woman presenting with loin pain was found to have an acute kidney injury with a creatinine of 176 µmol/L. Urine dipstick was positive for blood and protein with a protein:creatinine ratio of 71 mg/mmol. Her medical history was significant for a recent episode of anterior uveitis for which she had received topical steroid treatment with ongoing ophthalmology follow-up. Other medical history included fibromyalgia, Raynaud’s phenomenon and intermittent right leg weakness with no cause identified on an MRI spine.

An abdominal CT scan did not show a cause for her pain. She had a strongly positive antinuclear antibody with dense fine speckle pattern, but normal complement levels and anti-dsDNA with a negative panel of extractable nuclear antigens. CRP was mildly elevated at 12 mg/L. Urine microscopy showed a small number of white blood cells (22/mm3) and red blood cells (5/mm3). Transfer to the renal unit was organized.

On transfer, the patient mentioned a tendency to a photosensitive facial eruption of longstanding duration. A malar rash was evident, previously unrecognized due to the wearing of a facemask. The main differential diagnosis was tubulointerstitial nephritis with uveitis (TINU). A malar rash is not a recognized feature of this syndrome, and therefore systemic lupus erythematosus was also considered.

A kidney biopsy showed a lymphocytic tubulointerstitial nephritis with negative immunohistochemistry, not supportive of lupus nephritis. The patient started treatment with 60 mg oral prednisolone for a diagnosis of TINU. Within 2 weeks, her creatinine had fallen to 88 µmol/L, though the facial rash persisted.

While the ‘butterfly’ rash seen in this case did not secure a diagnosis of systemic lupus, missing it in other cases could lead to diagnostic delay or misdiagnosis. Removing masks with the clinician at a safe distance may form part of a systematic clinical examination. A detailed history remains of paramount importance. The importance of video consultations have risen during the COVID-19 pandemic. Counterintuitively, these may be superior to face-to-face consultations with a mask because physical signs can be fully assessed.

Source: https://casereports.bmj.com/content/13/9/e239004?rss=1
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