Referee Report: Case Report on Extensive Digital Gangrene as a Primary Manifestation of Late-Onset Systemic Lupus Erythematosus

This case report described a 56-year-old man who experienced extensive digital gangrene as a primary symptom of late-onset systemic lupus erythematosus (SLE), which was unusual. The patient had symptoms including joint pain, hair loss, photosensitivity, and dyspnea, with SLE confirmed through laboratory tests. Initial treatments with hydroxychloroquine, methylprednisolone, and cyclophosphamide were ineffective, but significant improvement was observed after administering rituximab, particularly in vasculitis lesions and dyspnea. The report emphasized the rarity of digital gangrene as an initial symptom of late-onset SLE and proposed rituximab as a potential treatment when other therapies are unsuccessful.