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American Journal of  Medical 
Science and Innovation (AJMSI) 

Complex Overlap Syndrome of  Rheumatoid Arthritis and Systemic Lupus
Erythematosus: A Therapeutic Breakthrough with Azathioprine

Rana Dwai1*

Volume 2 Issue 2, Year 2023
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v2i2.1970
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: August 07, 2023
Accepted: September 11, 2023
Published: September 21, 2023

This case study explores the complex nature of  coexisting autoimmune diseases, which is 
most effectively demonstrated by the coexistence of  rheumatoid Arthritis (RA) and systemic 
lupus erythematosus (SLE), also referred to as “rhupus syndrome.” A comprehensive 
evaluation of  a 28-year-old woman with joint discomfort, morning stiffness, and increased 
C-reactive protein (CRP) values was conducted. Anti-cyclic citrullinated peptide (CCP), 
antinuclear antibodies (ANA), and other pertinent serological indicators were examined 
in the laboratory. The patient’s medical background, prior therapies, and family history 
were considered to create an individual therapy strategy. The patient’s symptoms remained 
despite a long history of  disease-modifying anti-rheumatic medication (DMARD) use.  
Positive outcomes for anti-CCP, anti-ANA, and anti-double-stranded DNA (anti-dsDNA) 
antibodies provide light on the overlap of  multiple autoimmune diseases. The diagnostic 
difficulty was increased when autoimmune neutropenia was diagnosed with a bone 
marrow biopsy. Once azathioprine therapy was started, symptoms significantly and quickly 
improved within a month. Azathioprine was found to be successful in the remission of  
the disease. Azathioprine therapy’s critical role in treating overlapping autoimmune illnesses 
emphasizes the necessity for individualized and advanced testing and treatment. Targeted 
immunosuppressive medicines have the potential to make significant advances and enhance 
patient care and results.

Keywords
Rheumatoid Arthritis (RA), 
Systematic Lupus Erythematosus 
(SLE), C-Reactive Protein (CRP), 
Anti-Cyclic Citrullinated Peptide 
(CCP), Antinuclear Antibodies 
(ANA), Disease-Modifying 
Anti-Rheumatic Medication 
(DMARD), Azathioprine 
(AZA), Prednisone

1 Mediclinic hospital Al Jowhara, Al-Ain, United Arab Emirates
* Corresponding author’s e-mail: RanaDwai15@outlook.com

INTRODUCTION
Approximately 200 medical conditions come under the 
umbrella of  Rheumatic disease. Multisystem autoimmune 
diseases primarily affect the bones, muscles, and joints and 
are characterized by immunological instability (Susmita 
et al., 2022). Clinically, they are distinguished by varied 
degrees of  impairment, pain, stiffness, inflammation, 
and deformity (Susmita et al., 2022). Rheumatoid 
Arthritis (RA) and systemic lupus erythematosus (SLE) 
are both autoimmune diseases in which the immune 
system goes against the body’s immune system, attacking 
the healthy tissues. The attack causes inflammation in 
different affected areas of  the body. Causes joint pain, 
joint swelling, and joint tenderness. Several patients with 
autoimmune diseases like rheumatoid arthritis are said to 
have an overlapping condition of  another autoimmune 
disease called systemic lupus erythematosus. SLE and RA 
are together called Rhupus. Rhupus was first discovered 
about 50 years ago by peter schur. The overlapping 
syndrome of  Rheumatoid Arthritis and systemic 
lupus erythematosus represents a crucial clinical varied 
treatment. It is a rare disorder and prevails in only 1%-2% 
of  patients with RA (Kondo et al., 2020). 
Rheumatoid Arthritis is a chronic autoimmune 
inflammatory disease that causes inflammation in 
primary synovial joints leading to disrupted joint 
structure and function (Radu & Bungau, 2021). Several 
autoimmune rheumatic disorders include systemic 
lupus erythematosus (SLE), Sjögren’s syndrome, adult-

onset scleroderma, spondylarthritis, psoriatic arthritis, 
and polymyositis (Radu & Bungau, 2021). The disease 
process involves the activation of  immune cells, including 
T cells and B cells, building up the production of  
antibodies such as rheumatoid factor (RF) and anti-cyclic 
citrullinated peptide (anti-CCP) antibodies (Rocha et al., 
2019). RF and Anti-CCP are also diagnostic serological 
markers for the disease.  The distinctive feature of  RA 
is synovial hyperplasia which contributes to cartilage 
and bone destruction. Leading to the characteristic 
destructive changes observed in affected joints (Xin et 
al., 2021). Rheumatoid Arthritis (RA) has an unidentified 
origin. However, genetic, environmental, and serological 
variables contribute to the development of  the condition. 
It is reported that 50–60% of  RA susceptibility is 
attributed to smoking, a well-known environmental cause 
(Rocha et al., 2019).
On the other hand, systemic lupus erythematosus is a 
complicated autoimmune condition with a wide range 
of  autoantibodies and diverse symptoms that affect 
several organ systems. The formation of  a wide range 
of  autoantibodies, including anti-nuclear antibodies 
(ANA) and anti-double-stranded DNA antibodies 
(anti-dsDNA), is the defining feature of  SLE. Skin 
rashes, joint discomfort, serositis, renal involvement, 
hematological abnormalities, and neurological signs are 
all possible clinical presentations of  SLE (Lou et al., 
2022). The variability of  the illness makes it difficult to 
diagnose and treat SLE since patients can present with 



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various symptoms that change over time. However, to 
treat systemic lupus erythematosus (SLE), it is advised to 
determine the severity of  the illness, organ damage, and 
implications. According to the Hahn treatment plan, a 
mixture of  immunosuppressive medications and steroids 
should be delivered via hydroxychloroquine. However, 
this method is advised in serious case instances(Tanaka, 
2020).  SLE occurrence varies worldwide, with North 
America having high rates, Africa low, and Australia 
lowest. The disease outcome and treatment depend 
on age, gender, and ethnicity. It is reported that more 
women are affected due to environmental and genetic 
factors, with severe impact on men, mainly found in 
females aged 15-44, affecting pregnancy and hormones 
(Ameer et al., 2022).
Joint inflammation and involvement of  several organs 
are features of  the complicated inflammatory disease 
rhupus syndrome. It necessitates a strategic strategy that 
blends RA and SLE properties. Therapeutic strategies 
include disease-modifying anti-rheumatic medications 
(DMARDs) to reduce joint inflammation and 
immunological dysregulation. The common DMARDs 
used conventionally are methotrexate, leflunomide, 
hydroxychloroquine and sulfasalazine(Benjamin et al., 
2018). The immune response is modulated significantly 
by immunosuppressive substances, both conventional and 
biological. Biological agents commonly used to treat RA are 
infliximab, adalimumab, etanercept, rituximab, abatacept, 
tocilizumab and tofacitinib(Benjamin et al., 2018). 
The key inflammatory pathways are disrupted by 
DMARDs using various mechanisms. For instance, 
methotrexate causes the release of  adenosine, inhibits 
neutrophil adherence, blocks the synthesis of  leukotriene 
B4, and lowers IL-1 production. Other substances, such 
as leflunomide, which inhibits TLR9, Sulfasalazine, and 
hydroxychloroquine (Aletaha & Smolen, 2018). Contrarily, 
biological drugs play particular roles, interfering with 
cytokine function, impeding T-cell activation, and 
removing or blocking substances that stimulate B-cell 
activity (Oo et al., 2018).

LITERATURE REVIEW
A study conducted on 105 rhupus patients contributes 
to understanding the disease. The prevalence, clinical 
traits, and serological profiles of  rhupus individuals 
with both SLE and RA were investigated in the study. 
10 (9.7%) of  the 103 consecutive SLE patients were 
diagnosed with rhupus. Patients with RA had decreased 
renal involvement, but there were no differences in 
neuropsychiatric, cutaneous, hematological, or serositis 
involvement. They did not differ from RA patients but had 
higher CRP positive and ESR levels. Pathological findings 
were seen during ultrasound exams, with hands scoring 
higher. Compared to SLE and RA patients, rhupus patients 
had a larger cumulative burden (Tani et al., 2013).  
In a cross-sectional study, Researchers examined the 
clinical and immunological features of  rhupus patients 
and contrasted them with those who had SLE and RA. 200 

individuals participated; 80 had SLE and RA, and 40 had 
rhupus. Skin concerns, blood-related disorders, and joint 
problems were the prominent complaints. Those with 
rhupus experienced joint symptoms resembling those of  
RA; however, renal involvement was less common (10%) 
than in those with SLE (25%). While 96.3% of  patients 
with SLE and 92.5% of  rhupus patients satisfied the 2019 
EULAR/ACR SLE criteria, there were no appreciable 
differences in the proportion of  patients in either group 
who did. The study recommends a novel classification 
strategy to pinpoint overlapping autoimmune disease 
groups (Frade-Sosa et al., 2020).
In another investigation, the treatment of  RA with 
etanercept (ETN) and methotrexate (MTX) was 
examined. They aimed to determine whether these drugs 
could function without corticosteroids. 20 rhupus patients 
who had never received corticosteroids or other similar 
medications were the subject of  their study. Together 
with receiving MTX and ETN, these patients underwent 
a 24-week observation period. After administering ETN 
and MTX for 24 weeks, the patient’s joint pain, disease 
activity, and other symptoms significantly improved. 
Although there were a few mild side effects, including 
infections and rashes, the medication was largely safe. 
This shows that treating rhupus with ETN and MTX 
may be a successful option (Yang et al., 2018). In a case 
study, three individuals with RA and SLE, a complex 
overlap of  RA and SLE, are examined for their clinical 
and serological traits. All patients had high titers, positive 
anti-CCP, positive rheumatoid factor, and positive anti-
nuclear and anti-dsDNA antibodies.
Additionally, several patients were found to have certain 
autoantibodies, such as anti-SSA and anti-Sm. Despite 
the difficulty of  rhupus syndrome, all three patients who 
received methotrexate, folic acid, and hydroxychloroquine 
treatment experienced clinical remission. In addition 
to highlighting the value of  awareness and watchful 
clinical practice, the paper underlines the significance 
of  early diagnosis and appropriate treatment (Devrimsel 
& Serdaroglu Beyazal, 2018). In another study, 
biologic disease-modifying antirheumatic medications 
(bDMARDs) were used to treat RA and SLE. There were 
16 cases found, with rheumatoid arthritis succeeding 
before rhupus and joint problems. Ten individuals needed 
bDMARDs, with abatacept occasionally being successful. 
With persistent responses in six patients, rituximab was 
frequently prescribed and extremely effective. The study 
emphasizes the possibility of  specialized biologic therapies 
to treat difficult rhupus cases (Rottenberg et al., 2022).
These investigations collectively advance the knowledge 
of  the complex SLE and RA comorbidity known as 
rhupus syndrome. They provided information on the 
prevalence, clinical characteristics, serological profiles, 
and available treatments for people with rhupus. The 
findings underline the unique immunological features 
of  rhupus, its peculiar clinical course, and the difficulties 
separating it from specific SLE or RA cases. The studies 
emphasize the value of  early detection, individualized 



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treatment plans, and the potential effectiveness of  
biological medicines for treating rhupus cases that are 
resistant to conventional treatments.

Case Presentation
In this case, a 28 years old woman was admitted to the 
hospital with a concern about pain in her hand joints and 
morning stiffness. It was advised to run a Laboratory 
analysis of  a full blood test. The laboratory test results 
depicted elevated C-Reactive Protein (CRP) levels, Anti-
cyclic citrullinated peptide (CCP) came to be positive, 
Rheumatoid Factor (RF) came to be negative, Antinuclear 
antibody (ANA) negative, low white blood cell count, and 
it was found that in family history her sister had lupus.  
Initially diagnosed with Rheumatoid arthritis, the patient’s 
disease course later revealed an overlapping condition of  
Rheumatoid arthritis with systemic lupus erythematosus. 
The patient was admitted immediately and advised to give 
hydroxychloroquine and prednisolone intermittently. The 
patient’s symptoms remained after intermittent therapy 
with hydroxychloroquine, prednisolone, and other 
disease-modifying anti-rheumatic drugs (DMARDs), 
along with a decline in white blood cell (WBC) counts.

Treatment History
The patient had an extensive history of  DMARD usage, 
including methotrexate, cimzia, sulfasalazine, humira, 
and enbrel. Several treatments were discontinued due 
to adverse effects such as ecchymosis, headache, and 
recurrent upper respiratory infections. The patient’s sister 
had a history of  lupus, further complicating the diagnosis.

Diagnostic Workup
Unlike previous tests that yielded negative results, 
investigations revealed positive ANA and anti-dsDNA 
antibodies. A bone marrow biopsy indicated autoimmune 
neutropenia secondary to rheumatic disease. The patient’s 
lupus-like symptoms, photosensitivity, malar rash, and 
persistent low WBC count posed a diagnostic challenge.

Treatment Breakthrough
With limited treatment options and considering the 
patient’s complex presentation, Azathioprine was initiated 
after confirming normal Thiopurine methyltransferase 
enzyme levels. Remarkably, the patient reported a 
significant improvement in joint pain, morning stiffness, 
and other symptoms within one month of  initiating 
azathioprine therapy.

Follow-Up and Outcome
After one month of  azathioprine therapy, the patient 
remained free from joint pain and exhibited no significant 
complaints. Notably, the patient tolerated Azathioprine 
well, with no observed adverse effects.

RESULTS
The results of  this case report demonstrate the challenging 
nature of  managing a patient with overlapping features of  
rheumatoid arthritis and systemic lupus erythematosus, 
also referred to as rhupus syndrome. A 28-year-old RA 
patient reported frequent upper respiratory infections, 
morning stiffness, and joint discomfort. Her symptoms 
remained, and her white blood cell counts declined despite 
therapies like DMARDs and biologics. Positive results 
from anti-CCP, anti-ANA, and anti-dsDNA antibody tests 
highlighted the complexity of  coexisting autoimmune 
diseases. Clinical information and a low WBC count in 
the patient led to suspicions of  autoimmune neutropenia 
owing to rheumatic illness. After starting azathioprine 
therapy within a month, the patient showed considerable 
improvement, suggesting the drug may effectively 
treat overlapping autoimmune disorders like “rhupus.” 
The laboratory analysis conducted during the initial 
diagnosis of  Rheumatoid arthritis, prior to the initiation 
of  treatment, is presented in Table 1. To navigate the 
diagnostic and therapeutic difficulties brought on by 
overlap syndromes, this case emphasizes the significance 
of  considering various treatment modalities and the need 
for individualized, special care.

Table 1: Initial Serological Marker Analysis for Rheumatoid Arthritis Diagnosis
Test Results Reference range
Anti-CCP > 195 U/ml 0-5 U/ml
Rheumatoid Factor (RF) < 21 Negative < 30
White blood cell count (WBC) 3.2 4-10 1000/μL
ANA screen 0.5 Negative < 1.5
P-ANCA (MPO) 0.6 U/ml Normal < 5
c-ANCA (PR3) 1.3 U/ml Normal < 5
DNA, Double-Stranded Antibodies 1.5 Negative < 20

The table displays laboratory findings from various 
diagnostic tests, giving important details on the patient’s 
autoimmune condition. The absence of  significant 
rheumatoid factor antibodies indicates that the patient’s 
Rheumatoid Arthritis (RA) might not be primarily 
triggered by this specific antibody. However, the 

presence of  elevated anti-CCP antibodies, coupled with 
the patient’s symptoms, suggests a consideration for 
diagnosing Rheumatoid Arthritis. (RA). A lower white 
blood cell count (WBC) and an ANA screen indicate a 
comparatively low number of  antinuclear antibodies. 
Results from P-ANCA and c-ANCA are within the usual 



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reference limits, showing that these antibodies are not 
present in excess amounts. Compared to the reference 
range of  20, DNA double-stranded antibodies, frequently 
linked to systemic lupus erythematosus (SLE), are higher.
The results for these serological markers, observed after 
the patient did not respond to treatment and indicating 
the presence of  an overlapping syndrome, are presented 
in Table 2 as provided above.
The patient’s autoimmune condition is complex and 
involves various physiological, immunological, and 
diagnostic aspects. The patient’s WBC count 3.3 indicates 
leukopenia, which could be associated with immune 
system dysregulation. Positive ANA results indicate 
an autoimmune process with elevated levels of  DNA, 
double-stranded antibodies, and ANA titers. Kidney 
function and inflammation markers are also investigated 
with normal creatinine levels and high CRP and ESR 
levels, Ferritin levels are also elevated, indicating increased 
iron stores and inflammation. Bone marrow biopsy 
results indicate autoimmune neutropenia, while chest 
X-rays show normal lung involvement. Urine analysis 
shows potential kidney involvement with elevated 
leukocytes and normal red blood cells, other than this, 
proteinuria and casts are favorable indicators, suggesting 
no significant structural kidney damage or protein loss 
through urine. Thiopurine Methyltransferase (TPMT) 
activity levels are within an expected range. Azathioprine 
treatment is an immunosuppressive medication used in 
autoimmune diseases to suppress the overactive immune 
response responsible for inflammation and tissue 
damage. It is often chosen when other treatment options 
have proven insufficient or caused adverse effects. The 
patient’s complex presentation and limited treatment 

options align with the choice of  Azathioprine, as it may 
provide a broader immunosuppressive effect targeting 
rheumatoid Arthritis (RA) and lupus-like components.

DISCUSSION
Test results align with the patient’s complex autoimmune 
presentation, including anti-dsDNA antibodies, elevated 
inflammation markers, autoimmune neutropenia, and 
lupus-like symptoms. Azathioprine’s immunosuppressive 
action could help modulate the autoimmune response, 
leading to an improvement in lupus-related symptoms. 
The patient reports significant improvement in joint 
pain, morning stiffness, and other symptoms within one 
month of  initiating azathioprine therapy, corroborating 
the connection between treatment and test results. 
The observed symptom improvement reflects the 
medication’s positive impact on immune dysregulation 
and inflammation. Overall, the choice to initiate 
Azathioprine aligns well with the patient’s complex 
autoimmune presentation, highlighting the personalized 
and targeted nature of  the therapeutic approach.
RA and SLE can significantly affect patients’ quality of  
life and health-related quality of  life. Patients with SLE 
have a better chance of  survival than in the past, but they 
still experience a low quality of  life (Elera-Fitzcarrald et al., 
2018). Patients with SLE often have ongoing symptoms 
that worsen their quality of  life. A study involving 104 
women with SLE found that factors such as tiredness, 
feeling down, body image, and disease activity significantly 
impact patients’ feelings about life quality. The study 
found that emotional well-being, especially when the 
disease is active, is crucial for improving life quality. It is 
essential to help patients with emotional well-being, body 

Table 2: Serological and Diagnostic Markers After Treatment for Overlapping Syndrome (Results and Reference Ranges)
Test Results Reference Range Limit
White Blood Cell Count (WBC) 3.3 4-10 1000/μL
ANA (Antinuclear Antibody) Positive Negative
Method IF
DNA, Double-Stranded Antibodies 33.8 Negative < 20
ANA Titer (Fluorescence) > 1:1280 Negative < 1:80
Creatinine 53.8 umol/L 44.2-88.4
CRP (C reactive protein) 18.4 mg/L 0-5
ESR (Erythrocyte Sedimentation Rate) 41 mm/hr 2-39
Ferritin 124 ng/ml 30-120
Bone Marrow Biopsy Autoimmune Neutropenia Secondary to 

Rheumatic Disease
Chest X-Ray Normal
Urine Analysis
Leukocytes 11-20 cells/HPF  Ref  Range 0-5
RBC (Red Blood Cells) 0-2 cells/HPF  Ref  Range 0-2
Cast NIL
Protein Negative
Thiopurine Methyltransferase Activity 123 Ref  100-200



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image, and emotional well-being to improve their well-
being (Pereira et al., 2020). In another study, researchers 
examined the impact of  belimumab and rituximab 
treatments on the quality of  life of  patients with SLE. 
Some patients initially experienced lower quality of  life, 
but after a year, they experienced better physical and 
mental health. After three months, they experienced 
better mental and physical health (Parodis et al., 2019). 
This study implied that quality of  life could improve once 
the patient is administered proper modified treatment. 
Much like SLE, RA can cause serious problems like 
joint pain and difficulty moving, renal dysfunctionality 
and stiffness which can affect a person’s life. A cross-
sectional study examined the impact of  RA on quality of  
life using questionnaires. Results showed that RA patients 
had similar quality of  life as healthy individuals in some 
areas. However, more pain was linked to worse social 
interactions, general health, and physical ability. Those 
with worse overall health also had more physical problems 
and pain. The study suggests better pain management 
and improved mobility and interaction are crucial for RA 
patients (Martinec et al., 2019). The chronic autoimmune 
disease RA mostly affects the joints and can be painful and 
disabling. Another study examined the impact of  RA on 
patients’ quality of  life. The study took 464 Thai patients 
with RA, mostly females aged 59 or older and found that 
disease activity and psychological health impacted patient 
feelings. Severe disease and emotional suffering led to 
lower quality of  life, making this knowledge crucial for 
improved treatment and management (Katchamart et 
al., 2019). It is also reported that people with RA cannot 
sleep properly due to severe joint pain and discomfort. 
Hence, sleep loss dysregulates bodily functions leading to 
decreased quality of  life (Grabovac et al., 2018).  
Considering all these factors that affect the quality of  
life of  SLE and RA patients, it is crucial to determine 
the management of  these factors.  Rhupus syndrome 
treatment addresses joint inflammation and autoimmune 
and systemic manifestations in RA and SLE (Frazzei et 
al., 2022). Common management techniques include 
medication, such as Disease-Modifying Antirheumatic 
Drugs (DMARDs), biologic DMARDs, corticosteroids, 
pain and symptom management, physical therapy, 
immunosuppressive therapy, and hydroxychloroquine 
(Srivastava et al., 2019). Medications include Disease-
Modifying Antirheumatic Drugs (DMARDs), which 
control joint inflammation and slow joint damage 
progression. Biologic DMARDs target immune system 
parts to reduce inflammation, while corticosteroids 
provide quick relief. Pain and symptom management 
involves NSAIDs, analgesics, physical therapy, 
immunosuppressive therapy, and hydroxychloroquine 
(Guo et al., 2018). Lifestyle modifications include a healthy 
diet, regular exercise, stress management, regular medical 
monitoring, and an individualized approach.  
The findings from our case reports align with these 
management techniques to improve the quality of  life 
and remission of  the disease. The case report highlights 

the complexity of  managing rhupus syndrome, with the 
patient experiencing overlapping features of  RA and SLE. 
This highlights the need for an individualized treatment 
approach. Laboratory analysis revealed antibodies 
associated with RA and SLE, highlighting the diagnostic 
challenges of  overlap syndromes and the need for 
comprehensive serological marker analysis. Autoimmune 
neutropenia was suspected, leading to the initiation of  
azathioprine therapy. This strategy addresses overlapping 
features and complications in autoimmune diseases like 
rhupus. Ongoing monitoring and follow-up are crucial, 
as are regular medical evaluations to adjust treatment 
based on disease activity and patient progress. Despite 
therapies like DMARDs and biologics, the challenges 
faced in managing the patient’s symptoms highlight the 
complexity of  rhupus syndrome. This complexity aligns 
with the need for a multifaceted treatment strategy 
that considers the diverse aspects of  the disease and 
the potential for overlapping manifestations. The case 
report provides a real-world example that reinforces the 
management techniques and considerations discussed in 
the context of  rhupus syndrome.

CONCLUSION
This case emphasizes the difficulty in diagnosing and 
treating overlapping autoimmune diseases like rhupus 
syndrome. Accurate diagnosis and treatment are made 
more difficult by the convergence of  RA and SLE 
symptoms. To solve the case of  overlapping autoimmune 
manifestations, an integrative strategy is required. The 
patient’s reaction to azathioprine therapy indicates a 
potential advancement in treating overlapping rheumatoid 
arthritis and lupus. This accomplishment emphasizes 
the significance of  modifying treatments to target the 
immunological causes of  these illnesses. This case can 
inspire medical professionals and academics to investigate 
advanced therapeutic approaches and recognize the 
complexity of  related autoimmune diseases.

Strengths and Implications
This research will significantly impact clinical practice. 
Re-evaluation is essential when RA patients don’t respond 
well to medication since they could risk acquiring lupus or 
other autoimmune illnesses. Achieving disease remission, 
improving patients’ quality of  life, and ensuring patient 
safety all depend on prompt action. The findings of  
this study may help other medical professionals identify 
autoimmune conditions that need special care. This study 
also emphasizes the importance of  ongoing monitoring 
in patients with autoimmune disorders, such as RA, to 
quickly detect the onset of  lupus or other autoimmune 
conditions. This research has the potential to significantly 
affect patient outcomes and general well-being by 
providing appropriate treatment methods for disease 
remission and enhanced quality of  life.

Informed Consent
Informed consent was taken from the patient in order to 



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carry on the study.

Funding 
The study is not funded by any organization.

Conflict of  Interest
The author declares no Conflict of  Interest.

Author’s Contribution
The author contributed in the design, experimentation, 
writing, data generation, editing, prrof  read and 
verification of  the study.
 
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