Acute limb ischemia in a young female with systemic lupus erythematosus

Kasthuri R1, Lucy Grace T2

1Senior Patient Safety Nurse, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

Background

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease with diverse clinical manifestations. Vascular involvement, though uncommon in young patients, can lead to severe complications such as thrombosis and acute limb ischemia. This report presents a rare case of a young female who developed acute limb ischemia secondary to SLE.

Key words: SLE; Limb ischemia; ANA; Hormonal pills

Case Presentation

An 18-year-old female presented with complaints of pain and swelling in the left lower limb for two days. The pain was intermittent and associated with discomfort while walking for the past one week Initially, she was evaluated at a local hospital, where she was diagnosed with vitamin D deficiency and advised supplementation. She also reported a history of menorrhagia and dysmenorrhea, for which she had been prescribed hormonal pills. Subsequently, she developed fever, cold and worsening leg pain. Rheumatologist opinion was obtained and he had advised to take ANA (Antinuclear Antibody) test. Laboratory investigations revealed a strongly positive ANA (Antinuclear Antibody). Based on the findings, a provisional diagnosis of SLE was made and she was started on steroid therapy. Within two days of treatment, her pain subsided, however, on the third day, she developed numbness in the left lower limb. She was referred to vascular surgeon for further evaluation.

Clinical examination

  • No edema / swelling in Left lower limb
  • Decreased temperature below knee level and toes
  • Finger and toe movements (+), sensation decreased
  • Tenderness at ankle region (+)
  • Tenderness at calf region (+)
  • Right lower limb: No complaints, normal temperature

Investigations

A CT Peripheral Angiogram showed

  • Thrombosis involving the left proximal popliteal artery, complete occlusion with multiple thin collaterals
  • No demonstrable reformation of distal arteries
  • Additionally, findings suggested right lower lobe pneumonitis with minimal pleural effusion and basal atelectasis.

Based on clinical and imaging findings, she was diagnosed with Acute Limb Ischemia, Left Lower Limb (Intrahospital Occlusion, Rutherford Class 2A, provoked type).

Management

The patient was started on intravenous heparin therapy for three days.and switched over to low molecular weight Heparin. She was also treated with antiplatelets, analgesic, steroids, Proton Pump Inhibitor(PPI) and other supportive measures. General physician opinion was obtained, and she was started on steroids. Rheumatologist opinion was obtained for SLE and orders were followed. Cardiologist opinion was obtained – Normal LV function (EF-60%). Antiphospholipid Antibody (APLA) workup was triple positive. She was started on Inj. Prostaglandin for 5 days and continued Inj. Clexane 60mg – 0 – 40mg SC OD along with Tab. Acitrom 2.5 / 3 mg alternate days were given for 3 days after attaining therapeutic range of INR, Clexane was stopped and continued only Tab. Acitrom. She showed gradual symptomatic improvement with reduction in pain and restoration of warmth and sensation in the affected limb. Her condition stabilized, and she was discharged with advice for regular follow-up under rheumatology and vascular surgery care. She symptomatically became better; hence she is being discharged with the following advice.

Nursing Responsibilities

Assessment and Monitoring

  • The nurse assessed vital signs regularly, including temperature, pulse, blood pressure, and oxygen saturation.
  • Peripheral pulses and limb temperature were monitored to detect changes in circulation.
  • The pain level and sensory status of the affected limb were checked frequently.
  • The nurse observed for signs of bleeding during heparin therapy and reported any abnormalities.

Medication Administration

  • The nurse administered intravenous heparin as prescribed and ensured correct dosage and infusion rate.
  • Steroid medications were given as ordered, monitoring for side effects such as hyperglycaemia or infection.
  • The nurse maintained strict aseptic technique during medication preparation and administration.

Positioning and Limb Care

  • The affected limb was kept in a neutral position to promote circulation.
  • The nurse avoided applying tight bandages or pressure to the limb.
  • Skin integrity was maintained by gentle care and observation for colour or temperature changes.

Patient Education

  • The nurse educated the patient and family about SLE, its complications, and the importance of lifelong follow-up.
  • Instructions were given on medication adherence, avoidance of trauma, and early reporting of limb pain or colour change.
  • The patient was advised to maintain a balanced diet rich in calcium and vitamin D and to avoid smoking or prolonged immobility.

Psychological Support

  • The nurse provided emotional support and reassurance to relieve anxiety.
  • Counselling was offered regarding disease acceptance and lifestyle modification.

Discharge Planning

  • The nurse reinforced the importance of follow-up visits with the rheumatologist and vascular surgeon.
  • Written instructions regarding medication schedule and warning signs were provided.
  • The nurse ensured the patient understood the importance of continued steroid and anticoagulant therapy.

Advice on discharge

Vascular Surgeon advice

S. No Medications Dose Frequency A/B Food Durations
1 Tab. Acitrom 3mg OD 6:00 PM Sunday
Monday
Wednesday Friday
2 Tab. Acitrom 2.5mg OD 6:00 PM Tuesday
Thursday Saturday
3 Tab. Ecosprin 75mg OD After Food Till review
4 Tab. Calpol 650mg TDS After Food SOS
5 Tab. Pantocid 40mg OD Before Food Till review

General Medicine advice

S. NoDrug NameDoseFrequencyDuration
1.Tab. Omnacortil50 mgODTill Review
2.Tab. Folvite5 mgODTill Review
3.Tab. HCQ200 mgBDTill Review

Rheumatologist Advice

S. NoDrug NameDoseMorningDuration
1Tab. MMF500 mgODTill Review

General instructions

  • Avoid injuries and trauma
  • Avoid travelling in two-wheeler
  • Watch for severe headache, chest and abdominal discomfort, chest pain, abdominal pain, dark urine, black stools
  • Do not skip the Inj. Clexane, Acitrom
  • Avoid Indian toilet/squatting
  • Take the injection / tablet regularly at the same time every day
  • Diet: Acitrom diet (Avoid Vitamin K rich foods i.e. Spinach and Leafy Vegetables)

Outcome and Follow-up

At review, the patient showed marked improvement:

  • No pain or numbness
  • Able to walk comfortably
  • Resumed her studies
  • Steroid dosage reduced as per rheumatologist’s advice
  • She continues her treatment and remains clinically stable with good improvement.

Conclusion

This case highlights the importance of early recognition of vascular complications in SLE. Even in young females, autoimmune-induced thrombosis can lead to acute ischemic events. Prompt diagnosis, appropriate anticoagulant therapy, and multidisciplinary management are essential to prevent irreversible complications and ensure functional recovery.

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