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

This case report describes a 56-year-old man with extensive digital gangrene as a primary manifestation of late-onset systemic lupus erythematosus (SLE), which is rare. The patient had symptoms including joint pain, hair loss, photosensitivity, and dyspnea, with lab tests confirming SLE with lung involvement. 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 underscores the complexity of SLE with digital gangrene and suggests rituximab as an effective treatment when other therapies are unsuccessful.