Discussion
Rhupus is one of the overlap syndromes in CTD( connective tissue
disease) in which patients present with criteria satisfying both RA and
SLE. The prevalence varies from 0.01% to 2%.(3,4). The coexistence of
RA and SLE, Rhupus syndrome, is very rare. The absence of specific
diagnostic criteria to make a diagnosis makes it very difficult to
identify such patients. reports showed the presentation first comes with
clinical features of RA followed by SLE, and it is more common in women.
5
RA is an autoimmune inflammatory illness involving joints and other
organ system. There is no known etiology but genetic and environmental
factors are contributory. Synovial inflammation orchestrated by
T-cells, and B-cells, along with the release of pro-inflammatory
cytokines by TH1 cells is the key pathophysiologic process.
The exact etiology and pathology of SLE remains unclear. But complicated
interaction of environmental, genetic, and immunologic factors is
probably involved. The loss of immune tolerance increases the antigenic
load, and shifting of Th1 to Th2 immune responses leads to B-cell
hyperactivity and the production of pathogenic autoantibodies. The
coexistence of these two diseases with different pathophysiologies makes
it unique. (6)Previous studies have shown that patients with rhupus were
found to have a lower incidence of malar rash, hemolytic anemia, and
renal and neurological involvement compared with the SLE.
The rhupus group also had a rare incidence of severe renal disorders
such as nephrotic syndrome and renal failure. (7)Previous studies have
also shown a lower incidence of visceral organ involvement compared with
SLE alone. (8)
For nearly 10 years our patient had erosive polyarthritis with episodes
of flare-ups. She was on treatment for RA, and after 10 years of
treatment, she presented with an erythematous non-itchy patch on both
cheeks, alopecia, and oral ulcers on the buccal mucosa bilaterally which
are evidence of SLE (systematic lupus erythematosus).
The rare coexistence of those two diseases and the co-occurrence of some
of the symptoms such as arthralgia makes it difficult to pick it early.
Management of rhupus is not yet established and is primarily an expert’s
recommendation. The majority of reports of rhupus had been managed based
on the predominating features. Recent preliminary findings showed the
promising effect of Bacitracin along with other DMARDs, regarding
reducing disease activity and improving quality of life. Further
investigation is needed with a larger sample size to confirm the
efficacy and safety of bacitracin in rhupus (9)