Role of medical nutrition therapy in improving nutritional status in systemic lupus erythematosus: A case report

Pragatheeswari C*, Sangeetha R, Selvamani N, Ishathri PV

Department of Clinical Nutrition and Dietetics, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

*Correspondence

Abstract

Systemic lupus erythematosus is an autoimmune inflammatory illness that affects multiple organs and has a wide range of clinical symptoms. The skin, joints, kidneys, hematologic system, lungs, heart, neurological system, and other organs can all be affected by immunological dysregulation, which also causes production of auto antibody, immune complex formation, complement consumption, and tissue inflammation. This case describes the Medical Nutrition therapy of a 17-year-old female with SLE associated with high grade fever, GI discomforts, weight loss and erythematous rash. The case demonstrates the nutrition intervention of the patient from the day of admission till discharge. By the eighth day of hospitalization, nutritional intake improved, with the patient achieving 83% of the estimated energy requirement and 78% of the estimated protein requirement. The nutrition intervention emphasized an anti-inflammatory dietary pattern and the inclusion of calorie- and protein-dense foods to address increased nutritional demands and enhance recovery. Early nutritional assessment, structured dietary intervention, and continuous monitoring should be incorporated into routine clinical management of patients with active SLE to optimize nutritional status and improve overall outcomes.

Key words: Systemic lupus erythematosus; Hematemesis

Introduction

Systemic Lupus Erythematosus (SLE) is a chronic multisystem autoimmune disorder characterized by impaired immune tolerance and the production of pathogenic autoantibodies. The disease predominantly affects females, with a female-to-male ratio of approximately 9:1.

The exact aetiology of Systemic Lupus Erythematosus (SLE) remains incompletely understood. Current evidence suggests that the disease results from a complex interaction between genetic susceptibility and environmental triggers, leading to abnormal immune activation. This immune dysregulation promotes excessive production of pathogenic autoantibodies by B lymphocytes and altered cytokine expression, resulting in inflammation and progressive tissue and organ damage. A hallmark of SLE is the presence of autoantibodies directed against nuclear and cytoplasmic antigens.

Patients with systemic lupus erythematosus (SLE) are at increased risk of malnutrition due to a combination of chronic inflammation, increased metabolic demands, and gastrointestinal complications. Persistent inflammatory activity accelerates catabolic processes, while gastrointestinal symptoms such as nausea, vomiting, and diarrhoea may compromise nutrient intake and absorption, leading to deficiencies in proteins, vitamins, and minerals.

This case demonstrates the role of comprehensive medical nutrition therapy in improving nutritional intake during hospitalization.

Case Presentation

Patient profile

A 17-year-old female was admitted to kauvery hospital, Vadapalani, on 7 September 2025 with a two-month history of intermittent high-grade fever, poor oral intake, and progressive weight loss, along with a one-week history of abdominal discomfort, oral ulcers, and an erythematous rash. She was diagnosed with Systemic Lupus Erythematosus (SLE) with autoimmune manifestations and hematemesis. The patient had been hospitalized twice previously (on 1 July 2025 and 1 August 2025) at another tertiary care centre for recurrent febrile episodes. Her family history was notable for sjögren syndrome in her mother. On admission, severe oral ulcers, swollen lips, and herpetic gingivostomatitis markedly impaired chewing and swallowing, resulting in significantly reduced oral intake and an increased risk of malnutrition.

Nutrition assessment

Table 1. Anthropometry data

ParameterValue
Height153cm
Weight48.9 kg
BMI20.8 kg/m2
IBW56 kg
Weight loss %20.4%

With detailed anthropometric measurements and nutrition assessment the subjective global assessment score was 25 with moderately malnourished.

Table 2. Biochemical parameters

Parameter 7/9/2025 9/9/2025 12/9/2025 15/9/2025
Hemoglobin (g/dL) 9.4 ↓ 10.8 ↓ 9.8 ↓ 9.3 ↓
WBC (10⁶/µL) 2.9 ↓ 4.09 5.34 -
Neutrophils (%) 58.3 80.0 81.1 ↑ 75.5
Lymphocytes (%) 37.3 17.1 ↓ 16.1 ↓ 16.8 ↓
Eosinophils (%) 1.1 0.0 ↓ 0.4 ↓ 0.0 ↓
Urea (mg/dL) 31 - - -
Creatinine (mg/dL) 0.79 - - -
Amylase (U/L) - - 115 ↑ -
Lipase (U/L) - - 45.5 -
Albumin (g/dL) 3.7 - - 3.4 ↓
Total Protein (g/dL) 7.0 - - 6.3 ↓
SGOT (U/L) 41 ↑ - 124 ↑ 49 ↑
SGPT (U/L) 14 - 87 ↑ 136 ↑
Alkaline Phosphatase (U/L) 48 - 108 ↑ 135 ↑
Calcium (mmol/L) 3.5 ↓ - - -
Ferritin (µg/L) 625.9 ↑ - - -

Haematological abnormalities result from autoimmune-mediated destruction of blood cells, circulating antigens, and bone marrow involvement.

Elevated serum amylase levels may result from lupus-associated pancreatic inflammation, macroamylasemia, or autoimmune-mediated mechanisms involving amylase.

Hypoalbuminemia and hypoproteinemia in Systemic Lupus Erythematosus (SLE) are frequently observed in the presence of active disease and may result from systemic inflammation, renal protein loss secondary to lupus nephritis, or gastrointestinal protein loss due to lupus-associated protein-losing enteropathy.

Elevated SGOT, SGPT, and Alkaline Phosphatase (ALP) together typically indicate hepatobiliary injury.

Elevated serum ferritin (hyperferritinemia) is commonly associated with systemic inflammation, liver dysfunction, metabolic syndrome, and iron overload disorders.

Table 3. PES

ProblemEtiologySigns and Symptoms
AnemiaDue to inadequate nutrient intake secondary to poor dietary practices and systemic inflammation associated with systemic lupus erythematosus.As evidenced by reduced haemoglobin and other abnormal haematological parameters.
Weight lossDue to inadequate energy intake secondary to poor oral intake resulting from oral ulcers and gastrointestinal symptoms.As evidenced by 20.4% unintentional weight loss and anthropometric assessment.

Table 4. Drug – Nutrient Interaction

DrugInteraction
T. Wysolone (Corticosteroid)It adversely influences nutritional status by accelerating protein breakdown, reducing calcium absorption, promoting fluid retention, and increasing appetite. These catabolic effects highlight the importance of appropriate nutritional management to help prevent complications such as osteoporosis, loss of skeletal muscle mass, and glucocorticoid-induced hyperglycemia.
T.MMF-S (Immunosuppressant)It should be taken on an empty stomach because the food intake can slow its absorption and reduce its effectiveness. Antacids and supplements containing iron, calcium, or magnesium should be taken at least two hours apart from MMF, as they can reduce its absorption.
T.HCQS(mild Immunosuppressant)It is commonly associated with gastrointestinal adverse effects, including nausea, vomiting, and diarrhoea. These symptoms may reduce appetite and adversely affect overall dietary intake, potentially compromising the absorption of essential nutrients.

Diet history

Diet pattern – Non vegetarian.

Known food allergies – None reported.

Table 5. Nutrition Prescription

Energy 2240 kcal @ 40kcal / kg IBW
Protein 85 g @ 1.5g / kg IBW (15%)
Carbohydrate 308 g @ 55 % of T. kcal
Fat 62 g @ 25 % of T. kcal
Salt 5 g / day
Fluid Liberal

Nutrition Intervention Graph 1

A comprehensive dietary evaluation was carried out during the eight-day hospital stay. Upon admission, the patient had significantly decreased oral intake due to severe oral ulcers, swelling of the lips, and herpetic gingivostomatitis, which caused painful chewing and swallowing. In the first 1- 2 days of hospitalization, the patient consumed only limited amounts of liquids, such as oral nutritional supplements, tender coconut water, fruit juices, and semi solids, fulfilling 50% of the estimated energy and protein needs.

As the oral lesions started to heal with medical treatment, the diet was gradually upgraded from semi solids to a high-calorie, high-protein soft solid diet. To enhance nutritional consumption, frequent small meals, energy- and protein-rich foods, along with oral nutritional supplements, were added. Nutritional counselling focused on promoting an anti-inflammatory dietary pattern that included plenty of fruits, vegetables, and whole grains.

On the eighth day of the hospital stay, the patient met around 83% of the projected energy needs and 78% of the anticipated protein needs, indicating a steady enhancement in oral consumption and nutritional condition.

Conclusion

This case highlights the significant impact of active systemic lupus erythematosus on nutritional status and demonstrates the importance of early nutrition intervention in improving clinical outcomes. Severe oral ulcers, gastrointestinal symptoms, prolonged inflammation, and reduced dietary intake contributed to moderate malnutrition and inadequate energy and protein consumption despite a normal body mass index. Comprehensive nutrition assessment facilitated early identification of nutritional risk and guided the development of an individualized nutrition care plan.

A stepwise approach involving oral bland semisolid diets, gradual progression to soft and regular textured foods, oral nutritional supplementation, adequate protein provision, and anti-

DayDay 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8
Energy (%)0%52%87%70%75%80%82%83%
Protein (%)0%41%100%52%52%70%76%78%
ONS - Oral Nutritional Supplement HC - High Calorie HP- High Protein

inflammatory dietary counselling resulted in progressive improvement in dietary intake and nutritional adequacy during hospitalization. Continuous monitoring and individualized dietary modifications were essential in addressing evolving nutritional challenges and supporting recovery.

In addition to meeting macronutrient requirements, nutrition counselling emphasized an anti-inflammatory dietary pattern. Foods rich in omega-3 fatty acids, antioxidants, vitamins A, C, D, and E, calcium, dietary fibre, and polyphenols were encouraged because these nutrients have been associated with modulation of inflammatory pathways, reduction of oxidative stress, preservation of bone health, and improvement of cardiovascular risk factors in patients with SLE. The patient and family were also educated regarding adequate hydration, healthy fat selection, sodium restriction, and long-term adherence to balanced dietary practices to reduce future disease-related complications.

Medication-related nutritional considerations formed an important component of nutrition care. Corticosteroids increase protein catabolism, appetite, weight gain, hyperglycaemia, and bone demineralization, thereby necessitating adequate protein, calcium, and vitamin D intake. Immunosuppressive agents and antibiotics may contribute to gastrointestinal disturbances, while hydroxychloroquine may also produce gastrointestinal adverse effects that reduce appetite and food intake. Therefore, individualized counselling regarding meal timing, management of gastrointestinal symptoms, and potential drug–nutrient interactions was incorporated into the patient’s discharge education.

This case underscores the importance of integrating evidence-based medical nutrition therapy into the multidisciplinary management of patients with SLE. Early dietitian involvement, regular nutritional reassessment, individualized oral nutrition support, and long-term nutrition education can enhance nutritional status, preserve lean body mass, improve quality of life, and potentially reduce disease-related complications. Further clinical studies are needed to strengthen the evidence supporting disease-specific nutrition strategies and standardized nutrition care protocols for patients with systemic lupus erythematosus.

References

  • Bowers W, Blum MA. Systemic Lupus Erythematosus. In: StatPearls [Internet]. StatPearls Publishing; 2026. Updated March 23, 2026. Accessed July 7, 2026. https://www.ncbi.nlm.nih.gov/books/NBK535405/
  • Ameer, M. A., Chaudhry, H., Mushtaq, J., Khan, O. S., Babar, M., Hashim, T., Zeb, S., Tariq, M. A., Patlolla, S. R., Ali, J., Hashim, S. N., & Hashim, S. (2022). An Overview of Systemic Lupus Erythematosus (SLE) Pathogenesis, Classification, and Management. Cureus, 14(10), e30330. https://doi.org/10.7759/cureus.30330
  • Alibegovic, E., Kurtcehajic, A., Hasukic, I., Hujdurovic, A., Fejzic, J. A., & Kurtcehajic, D. (2017). Silence pancreatitis in systemic lupus erythematosus. Intractable & rare diseases research, 6(2), 141–144. https://doi.org/10.5582/irdr.2017.01000
  • Ramesh, R., Suganthan, N., Selvaratnam, G., Anushanth, U., & Vijitharan, V. (2023). Protein-Losing Enteropathy as the First Presentation of Systemic Lupus Erythematosus in a Resource-Limited Setting in Sri Lanka: A Case Report. Cureus, 15(3), e36619. https://doi.org/10.7759/cureus.36619
  • Esteves, G. P., Mazzolani, B. C., Smaira, F. I., Mendes, E. S., de Oliveira, G. G., Roschel, H., Gualano, B., Pereira, R. M. R., & Dolan, E. (2022). Nutritional recommendations for patients undergoing prolonged glucocorticoid therapy. Rheumatology advances in practice, 6(2), rkac029. https://doi.org/10.1093/rap/rkac029
  • Trevisonno, M., Hall, A., Rosengarten, S., & Ginzler, E. M. (2023). Mycophenolate Mofetil for Systemic Lupus Erythematosus: Our 20-Year Experience. Cureus, 15(1), e34413. https://doi.org/10.7759/cureus.34413
  • Wallace DJ, Tse K, Hanrahan L, Davies R, Petri MA. Hydroxychloroquine usage in US patients, their experiences of tolerability and adherence, and implications for treatment: survey results from 3127 patients with systemic lupus erythematosus conducted by the Lupus Foundation of America. Lupus Science & Medicine. 2019;6(1):e000317. doi:10.1136/lupus-2019-000317.
  • Islam, M. A., Khandker, S. S., Kotyla, P. J., & Hassan, R. (2020). Immunomodulatory Effects of Diet and Nutrients in Systemic Lupus Erythematosus (SLE): A Systematic Review. Frontiers in immunology, 11, 1477. https://doi.org/10.3389/fimmu.2020.01477
  • Aparicio-Soto, M., Sánchez-Hidalgo, M., & Alarcón-de-la-Lastra, C. (2017). An update on diet and nutritional factors in systemic lupus erythematosus management. Nutrition research reviews, 30(1), 118–137. https://doi.org/10.1017/S0954422417000026
  • Systemic Lupus Erythematosus. (2025). In Barnard, N. D. (Ed.), Nutrition Guide for Clinicians(3rd ed.). Physicians Committee for Responsible Medicine. https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342078/all/Systemic_Lupus_Erythematosus

 

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment