Little Red Riding Hood

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If you ever wanted to feel like Dr. House, this is your case.


Case Number: 2026--SLE

Subject: Female, 21 years old

The patient was found in the house near to body of her grandmother, The red hood was teared and some breads were in the floor, the door and windows were fully closed.

External examination: The body shows a distinct malar rash — symmetrical, erythematous, and sharply bordered across the cheeks and nasal bridge, sparing the nasolabial folds. Skin pallor is evident (anemia?). No external trauma identified.


Musculoskeletal: The small joints of the hands and wrists demonstrate mild swelling without deformity. On section, the synovial membranes are thickened and dull, covered by a thin fibrinous exudate. Microscopic sections reveal chronic lymphocytic infiltration and fibrinoid necrosis of synovial tissue. The cartilage remains intact, with no erosions.

Hematologic: Peripheral blood analysis reveals normocytic, normochromic anemia (yes, it was anemia), leukopenia, and thrombocytopenia. The bone marrow is hypercellular with increased erythroid precursors, suggesting compensatory response.


Renal: Both kidneys are symmetrically reduced in size with fine granular cortical surfaces. On section, the cortico-medullary junction is indistinct. Microscopically, glomeruli are enlarged with diffuse endocapillary proliferation, wire-loop thickening of the capillary walls, and subendothelial immune complex deposits visible on immunofluorescence as a granular pattern of IgG and complement. Fibrinoid necrosis and hyaline thrombi are present in several glomeruli.
The interstitium shows mononuclear infiltration with tubular atrophy and scattered protein casts.
These features are diagnostic of diffuse proliferative lupus nephritis (Class IV, ISN/RPS).

Heart: The pericardium displays a fibrinous exudate with a coarse. The mitral and aortic valves exhibit small, sterile, verrucous vegetations along the line of closure.

Lungs: The lungs are heavy and firm, with patchy interstitial opacities. Histologic examination shows thickened alveolar septa, type II pneumocyte hyperplasia, and chronic inflammatory infiltrates rich in lymphocytes and plasma cells. Foci of intra-alveolar fibrin and hemosiderin-laden macrophages indicate previous hemorrhage.

Brain: The brain shows multiple small ischemic infarcts scattered within the subcortical white matter and basal ganglia. Vessels in these regions display fibrinoid necrosis and perivascular lymphocytic cuffing, consistent with small-vessel vasculopathy.

Gastrointestinal: Inflammation of the small bowel due to immune complex vasculitis and signs of small bowel ischemia.


Serologic studies confirm high-titer antinuclear antibodies (ANA) in a homogeneous pattern, strongly positive anti–double-stranded DNA, and anti-Smith antibodies. Complement levels (C3 and C4) are low.

The wolf did it,
THE END.

🐺Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD. Manifestations of systemic lupus erythematosus. Maedica (Bucur). 2011 Oct;6(4):330-6. PMID: 22879850; PMCID: PMC3391953.

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