1
60
Discussion
ascites (peritoneal serositis) seen in our patient are com-
mon gastro-intestinal manifestations in the disease. Gas-
trointestinal involvement occurs in one-third of patients
manifesting as serositis, vasculitis, pancreatitis or enteri-
Systemic Lupus Erythematosus is uncommon in chil-
dren and rarer in African black children with only few
case reports . Less than 10% of SLE cases worldwide
are diagnosed in the first decade . Our patient presented
at the age of 7 years which is comparable to the median
4
1
tis and abdominal pain . Most patients respond to diuret-
1
ics and steroids and a few may require chloroquine to
achieve complete resolution of the ascites. Our patient
improved without the need for chloroquine. Similarly,
our patient had a stroke which is seen in 8-22% of all
2
age (9.2years) at diagnosis among Indian children .
However, Olowu in Ile-Ife (Southwest Nigeria) studied
5
9
1
1 children and found the median age to be 11.2 years.
cases of SLE . Cerebrovascular event in SLE is due to
The youngest among his patients was 6 years at diagno-
sis. The median age at diagnos1,i6s in Ile-Ife was similar to
the global average of 12years.
one or combination of accelerated atherosclerosis, vas-
culitis, coagulopathy in those that are positive anti-
phospholipid,3a,9ntibodies and or thromboembolism from
1
endocarditis . The most likely mechanisms in our
Recognised trigger factors in SLE include infections,
medications (antihypertensives and anticonvulsants) and
patient is vasculitis in view of her vasculitic rash, nor-
mal coagulation profile (Tab. 1) and the brain CT that
showed an extensive area of ischemic infarct on the left
cerebral hemisphere. However,the inability to do lupus
anticoagulant was a limitation in our evaluation of this
patient. Other neuropsychiatric symptoms seen in SLE
include seizures, headache and behavioural abnormali1--
ties and may be seen in as many as 90% of SLE cases
1
-3
hormonal changes . Our patient had culture-positive
urinary tract infection which was a possible trigger. Fur-
thermore, it was possible that sun exposure contributed
as a trigger in this instance considering the time of the
year in the northern part of the country. Generally, the
disease is thought to result from a combination of hu-
moral and environmental factors in genetically predis-
posed individuals. Human Leucocyte Antigen (HLA)
class II alleles DR2 and DR3 contribute to disease sus-
ceptibility in some patients as inherited complement
3
,9
.
SLE may presents with pancytopenia or isolated cell
1
line depletion, erythrocyte sedimentation rate (ESR) is
usually elevated depending on disease activity but
1
deficiencies .
C-reactive protein (CRP) is usually normal except in the
1
,3
presence of infection . Our patient had a slightly ele-
vated ESR but her blood count parameter appeared nor-
mal even during the febrile episode. The presence of
fever or absence of white cell abnormalities, as in our
patient, does not confirm or exclude respectively the
presence of infection.
The most frequent presenting symptoms of SLE are pro-
1
longed fever, malaise weight loss and lymphadenopathy
-3
.
This was not the case with our patient who first pre-
sented with features of nephritis. Renal disease is the
greatest contributor to morbidity and mortality in paedi-
atric SLE occurring in 60-80% within the first year of
Th1e0 American College of Rheumatology (ACR) crite-
ria for the diagnosis of SLE revised in 1992 require
that at least 4 out of the 11 criteria should be present
1
7
disease onset . According to Odetunde et al , nephritis
with skin rashes was the first manifestation in a 9- year-
old boy reported to have SLE in Enugu. Likewise in Ile-
2
either serially or simultaneously . Our patient fulfilled
5
Ife , the mean time of onset of renal disease was 1.22 ±
the following five of the ACR criteria; serositis, nephri-
tis, skin rash, positive ANA and neurologic disorder.
0
.93 years after onset of systemic illness.
Our patient had skin rash which was more of vasculitic
lesions that are not as common as the malar (butterfly)
rash. The use of cefixime around the time of appearance
of the rash suggested the possibility of a drug reaction
but these rash got worse after the withdrawal of the
drug. Moreso, cephalosporins are not recognized trigger
Conclusion
SLE is a rare disease of the black race with very diverse
manifestations. Nephritis is the most important manifes-
tation that often leads to its diagnosis in most Nigerian
series. However, stroke of an unidentified aetiology
should also make a paediatrician consider SLE like our
patient clearly demonstrated.
5
factor. Olowu had noted that only 3 out of the 11 cases
had the typical malar rash but none of them had the vas-
culitic rash. It may be that rash (regardless of morphol-
ogy) is not common manifestations in Nigerian children
with SLE.
Virtually all (10/11) of Olowu’s patients presented with
arthritis involving one or more site(s), which was not the
case with our patient who had no evidence of joint in-
volvement. Our patient had echocardiography-confirmed
moderate pericardial effusion. Pericarditis was the first
presentation in an 11-year-old girl reported by Elusiyan
Limitations
Our patient would have benefitted from renal biopsy,
ophthalmologic examination and some more specific
serologic tests which were not done due to logistic chal-
lenges that are peculiar to our setting.
8
and Olowu in Ile-Ife . Pericardial effusion is the com-
monest cardiac presentation and is often a cause of
recurrent chest pain .
Acknowledgement
1
,6
We sincerely appreciate the efforts of Dr R. Hashim and
Dr A. Yahaya in the evaluation of this patient.
The recurrent vomiting and abdominal pain as well as