Rehena Akhter, Shahidul Hassan Mollick, Muhammad Misqatus Saleheen
A 16-year-old girl presented with a three-month history of progressive, painless, bilateral periorbital edema without renal, hepatic, thyroid, or allergic etiology. Physical examination revealed bilateral periorbital puffiness without erythema, tenderness, malar rash, synovitis, or peripheral edema. Laboratory studies demonstrated a hemoglobin level of 8.3 g/dL, erythrocyte sedimentation rate of 115 mm/hr, serum albumin at 2.6 g/dL, antinuclear antibody greater than 400 AU/mL (normal: <40), and anti-double-stranded DNA antibody greater than 800 IU/mL. Urinalysis and 24-hour urinary protein excretion (120 mg/day) were normal. Abdominal ultrasonography revealed moderate ascites with normal liver parenchyma, portal vein caliber, and renal architecture. Chest radiography demonstrated no pleural effusion or other cardiopulmonary abnormality. A clinical diagnosis of probable systemic lupus erythematosus was made based on strongly positive autoantibodies, active systemic inflammation, unexplained anemia, and moderate ascites with hypoalbuminemia in the absence of alternative etiologies. The combination of hypoalbuminemia, ascites, and absent proteinuria raised suspicion for protein-losing enteropathy or lupus serositis; however, confirmatory testing was unavailable. The patient received oral prednisolone at 1 mg/kg/day based on a documented body weight of 50 kg. Within seven days, periorbital edema markedly improved. Serum albumin normalized to 3.8 g/dL by three months. This case illustrates that isolated periorbital edema may be an initial manifestation of systemic lupus erythematosus in adolescents, and the presence of hypoalbuminemia with ascites in the absence of proteinuria should prompt consideration of protein-losing enteropathy or serositis in the differential diagnosis. Early immunological evaluation and corticosteroid therapy were associated with favorable clinical and biochemical outcomes.