Necrotising Lymphadenitis with Bicytopenia as Prelude to Systemic Lupus Erythematosus

Abstract

A 32-year-old woman presented with a three-month history of intermittent fever, profound weight loss, anorexia, and inflammatory polyarthralgia, followed by acute painful cervical lymphadenopathy. She had a prior history of immune thrombocytopenia. Examination revealed pallor, malar rash, and tender cervical lymphadenopathy. Laboratory evaluation demonstrated normocytic anaemia, leukopenia, elevated inflammatory markers, hypoalbuminaemia, low complement C3, positive direct Coombs test, and subnephrotic proteinuria with preserved renal function. Immunological studies showed high-titre antinuclear antibodies with strongly positive anti-Sm, U1-RNP/Sm, and ribosomal P antibodies, while anti-double-stranded DNA was negative. Ferritin was markedly elevated. Fine-needle aspiration cytology of the lymph node revealed necrotising lymphadenitis without malignancy. Renal biopsy confirmed ISN/RPS class II lupus nephritis with membranous features. This case highlights necrotising lymphadenitis and bicytopenia as early manifestations of systemic lupus erythematosus and underscores the importance of renal biopsy despite minimal urinary abnormalities.