Systemic Lupus Erythematosus in Special Situations: Navigating Complex Clinical Dilemmas

Abstract

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with a wide spectrum of clinical manifestations. In certain “special situations,” clinicians are often faced with complex diagnostic and therapeutic dilemmas where timely decisions can significantly influence outcomes. This presentation highlights real-world, case-based scenarios to illustrate key challenges in the management of SLE.

The first case explores lupus nephritis diagnosed during an unrecognized pregnancy, emphasizing the importance of considering pregnancy in all women of reproductive age and adapting treatment strategies to ensure both maternal and fetal safety. A second scenario discusses SLE complicated by thrombotic thrombocytopenic purpura (TTP), a life-threatening condition that requires rapid recognition and urgent plasma exchange, underscoring the need to distinguish it from a lupus flare.

Another case focuses on digital gangrene in a young woman with autoimmune features, where overlapping mechanisms—vasculitis, vasculopathy, and thrombosis—must be carefully differentiated. This highlights the diagnostic complexity between lupus vasculitis, systemic sclerosis overlap, and antiphospholipid syndrome (APS). Finally, a challenging neuropsychiatric presentation illustrates the overlap between neuropsychiatric SLE (NPSLE) and APS-related cerebrovascular events, demonstrating the importance of integrating clinical, serological, and imaging findings to guide combined immunosuppressive and anticoagulant therapy.

Across these scenarios, key principles emerge: maintaining a high index of suspicion, recognizing overlapping pathophysiological mechanisms, and initiating early, targeted, and multidisciplinary management. These case-based discussions aim to provide practical insights for clinicians managing SLE in complex, high-risk situations, where individualized decision-making is crucial to improving patient outcomes.

Bangladesh J Medicine 2026; Vol. 37, No. 2(1) : pp. 190