Retinal disease has a high morbidity and should be treated aggressively by an ophthalmologist. 16 , 17 Ophthalmic screening programs in SLE are controversial. Most physicians agree that patients on antimalarial or steroid regimens should receive a full dilated-eye examination on initiation of therapy then with routine examinations in low-risk patients and yearly for high-risk patients. High risk is defined by medication dosage (> mg per kg hydroxychloroquine or >3 mg per kg chloroquine), duration of use (more than five years), high body fat level, presence of renal or liver disease, presence of concomitant retinal disease, and age greater than 60 years. 16 , 18
Novel approaches to the treatment of lupus nephritis, such as using adenosine analogues, and combinations of existing medications, are being studied. Indeed, many of these approaches are on their way to being put to use in the near future. Some of these treatments, involving the blocking of various molecules that stimulate the cells of inflammation, are being studied at the National Institutes of Health in Bethesda, Maryland. Finally, attempts are being made to completely reconstitute the immune system in patients with lupus by using bone marrow transplantation and stem cell transplantation. All of these approaches are in the very preliminary stages of development and are not yet accepted as useful. What is clear is that the treatment of lupus nephritis in decades to come will not be the same as it is today.
METHODS: This case describes a 23-year-old woman who presented with pulmonary arterial hypertension diagnosed by right heart catheterization with mean pulmonary artery pressure of 74 mmHg, pulmonary capillary wedge pressure of 12 mmHg, and a pulmonary vascular resistance of 1908 dyne s cm(-5). Due to the aggressive nature of her disease, she declined despite management with epoprostenol and sildenafil. Because of coexisting systemic lupus erythematosus with hemolytic anemia and worsening pulmonary arterial hypertension, intensive immunosuppressive therapy with pulse dose steroids was initiated.