Case report: SLE in Monozygotic twins with same serology and same presentation
Nihal Ali, Darragh Foley Nolan, Claire Sheehy
Department of Rheumatology,University Hospital Waterford (UHW)
Monozygotic (MZ) twins share nearly all of their genetic variants including the same MHC sets, and many similar environments before and after birth. However, they can also show phenotypic discordance for a wide range of traits. Differences at the epigenetic level may account for such discordances in disease course.
This is a case report on 38 year old monozygotic female twins whom presented with clinical features of SLE. T.L presented to Rheumatology OPD in 2014 with axillary lymphadenopathy, pancytopenia with marked lymphopenia, fatigue, weight loss, and a history of hair thinning with no rash. Serology was strongly positive for ANA, high DsDNA titres positive anti Ro, and anti LA. She was initially treated with hydroxy-chloroquine (HCQ) 200mg OD to which she was intolerant , she developed alopecia related to severe scalp psoriasis, her skin disease was treated initially with Ustekinamab , then switched to secukinumab and now Guselkumab, with successful hair regrowth.
N.L presented to the emergency department of UHW in 2017 with symptomatic anaemia following referral from dermatology OPD which she is been attending for rash and alopecia, workup show severe megaloblastic anaemia with low folate level, hyperactive bone marrow that represent autoimmune anaemia pattern, Serology was identical to her twin sister except for negative DsDNA .Furthermore , skin biopsy from the scalp and rash on the arm showed acute folliculitis and perivascular inflammatory infiltrate respectively. Following Dermatology MDT meeting she was diagnosed with subacute lupus .She had been treated initially with hydroxy-chloroquine to which she is also developed allergic reaction and stopped .
Both twins presented within 3 years with haematological and systemic features of SLE. Both developed reaction to HCQ . Of interest T.L was been diagnosed with cervical cancer in 2017 for which she underwent hysterectomy , while her identical twin is under investigation for cervical pathology , histology report pending.
The twins presented with similar clinical picture and same serological pattern and had similar reaction to HCQ , they are both experiencing the same genito-urinary symptoms related to cervical pathology . There have been case reports of Lupus and cervical atypia,although none on monozygotic twins !