4: Systemic Lupus Erythematosus Flashcards

1
Q

Summarise the epidemiology of systemic Lupus erythematosus (SLE)

A
  • Rare disease
  • Females more commonl than males (9:1)
  • Normally onset between 15-40years
  • increased prevalence in afro-carribean and asian population
    • • Prevalence varies - 4 - 280/100,000
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2
Q

What is the role of genes in the development of systemic Lupus eryththematosus

A
  • Associated with a genetic predisposition, multiple genes involved but
    • rare can by monogenic origin:
      • C1q+C3 deletion
  • Other: Fc receptors, IRF5, CTLA4, MHC class II HLAgenes
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3
Q

What are the general presenting features of someone with SLE?

A

1: very general presentation

  • malaise, fecer, weight loss, fatigue –> patients are unwell!
  • Lymphadenopathy (swollen lymph nodes)
    • If this is chronic, not improving –> might suspect Lupus
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4
Q

What are specific signs and symptoms of Lupus?

What is their limitation in the digansis of the disease?

A

They are specific and make it easy to diagnose, but are not present in most people presenting with Lupus

  • Butterfly rash –> sparing of nasal area, around cheeks and chin
  • alopecia (hair loss)
  • Arthralgia (joint pain)
  • Raynaud’s phenomenon (spasm of arteries cause reduced blood flow to extremities)

Other features:

  • Inflammation kidney, CNS, heart, lungs
  • Accelerated atherosclerosis
  • Vasculitis
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5
Q

Explain the characteristics of the SLE associated Butterfly rash

A
  • no pus
  • Present at cheeks and chins
  • Sparing of nasal wings /area around nose

Can be

  • epidermal
  • or in severe cases: deep dermal with loss of pigmentation and peramnent scaring
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6
Q

Which facots play a role in the pathogenesis of systemic lupus erythematosus ?

A

It is a complicated disease caused by

  • genetic predisposition in combination with
  • several envirnmantal triggers –> activate the
    • inate immune system
    • adaptive immune system
    • Immune complexes (can repeat until:)
      • –> immune complex activation sets off dowonstream disease with permanent tissue damage
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7
Q

Explain the formation of auto-antibodies in SLE

A
  1. Abnormal clearance of apoptotic cell material (expsed foreign nuclear substances)
  2. Dendritic cell uptake of autoantigens and activation of B cells
  3. B cell Ig class switching and affinity mutation
  4. IgG autoantibodies
  5. immune complexes
  6. complement activation, cytokine generation etc
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8
Q

What are the diagnositic immune/antibody test that are done to diganose SLE?

A
  1. Antinuclear Antibodies (ANA)
    • non-specific but can be good indicator to do further:
  2. Anti-Double-Strand DNA (Anti-DsDNA) and Smith Antigen (SM)
    • highly specific but less sensitive (not everyone with Lupus has it
  3. Anti-Ro and/or La
    • more antigen tests
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9
Q

What is an ANA?

How would it look in SLE?

A

Anti-nuclear Antibody test, in systemic Lupus Erythematosus

  • would give homogenous pattern in SLE –> Antibodies to DNA are formed
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10
Q

Which other laboratory test (other than antibodies) cna be done to diagnose SLE?

A

Other general tests:

  1. Decreased complement levels (due to increased consumption)
  2. Lupus anti-coagulant (might be pro thrombotic)
  3. ß1-glycoprotien

Renal tests:

  1. Proteinuria, haematuria
  2. Active urinary sediment

Haematological

  1. Lymphopaenia, normochromic anaemia (due to haemolytic)
  2. Leukopaenia, AIHA, thrombocytopaenia
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11
Q

How could a blood film look like with someone with SLE?

A

Might have

  • thrombocytopaenia (??? antobodies???)
  • Leukopaenia/Lymphopaenia
  • Autoimmune-haemolytic anaemia (normocytic)
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12
Q

How would you establish the severity of someone with SLE?

A
  1. Identify pattern of organ involvement
  2. Monitor function of affected organs
    • Renal - BP, U & E, urine sediment + Prot:Crea ratio
    • Lungs/CVS - lung function, echocardiography
    • Skin, haematology, eyes
  3. Identify pattern of autoantibodies expressed
    1. Anti-dsDNA, anti-Sm (poorer prognosis if anti-SM+) - renal disease
    2. Anti-cardiolipin antibodies
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13
Q

What is the aim for the clinical management of SLE?

A

Aim: pre-empt an actue attackand prevent severe attach

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14
Q

How do you monitor someone with SLE?

A

Try to pick up an attach early via

Via the

  1. Clinical Features
    • weight loss, fatigue, malaise, hair loss
    • Alopecia (spot baldness)
    • Rash
  2. Labortatory features
    • ESR
    • Increased complement consumption
    • Increased anti-dsDNA
      • Other Abs e.g ANA and CRP poor indicators
        *
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15
Q

How would you classify a SLE as mild, moderate or severe?

A

Look at the involvement of different systems and how severe they are affected

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16
Q

What are the characteristics of a mild SLE?

A
  • joint

+/- skin involvement

17
Q

What are the characterisitcs of a moderate SLE?

A

Next to skin and joint invovement (mild) also

  • inflammation of other organs
  • pleuritis, pericarditis, mild nephritis
18
Q

What are the characteristics of severe SLE?

A

severe inflammation in vital organs

  • severe nephritis
  • CNS disease –> depression, psychosis
  • • pulmonary disease*
  • • cardiac involvement –> rarew but possible*

• AIHA (auto-immune haemolytic anaemia) , Thrombocytopaenia, TTP (coagulation disorder)

19
Q

How do you treat mild SLE?

A
  1. Paracetamol +/- NSAID
    • Monitor renal function
  2. Hydroxychloroquine
    1. arthropathy
    2. cutaneous manifestations
    3. mild disease activity
  3. Topical corticosteroids
20
Q

How would you treat moderate SLE?

A

If NSAIDs fail/ and or there is a life-threatening disesae

Corticosterioids

  • high initial dose to suppress disease activity (0.5-1.5mg/kg/day)
  • iv methylprednisolone 3 x 0.5-1g per 24h
  • initial oral dose for 4 weeks
  • reduce slowly over 2-3 mths to 10 mg/d
  • reduce slowly at 1mg per month
21
Q

Additional to cortocosteriords, how would you treat severe SLE?

A
  1. Azathioprine
    • effective, steroid sparing drug
    • 20% neutropenia (3/1000 severe BM suppression)
    • regular FBC & biochemistry monitoring
  2. Cyclophosphamide
    • severe organ involvement, iv pulsed or oral Rx
    • –> has severe side-effects but should still be used to prevent dangerous attack
  3. Mycophenolate mofetil
    • supresses lmyphocyte (by blocking de novo purine synthesis)
  4. Anitbodies (Retuximab)
    • Anti CD20 (B-cell)
22
Q

What is the prognosis and survival of someone with SLE?

A

Dependant on the severity

15 year survival is

  • 85% without renal involvement
  • 60% with nepritis

–> highly dependant on and worse when black, male, low socio-economic status

23
Q

Why and when do people die from SLE?

A

They can either die early from direct complcations or later due to bad atherosclerosis

  1. Early
    • Acitve lupus
      • Renal Failure
      • CNS disease
    • Infections (Immune supression)
  2. Late
    • MI/ Stroke –> because of bad atherosclerosis
24
Q

What are biomarkers of active disease in SLE?

A
  1. ESR (increased)
  2. Anti-DsDNA/Sm
  3. Decreased C3, C4 complement

No CRP