7 - Lupus Flashcards
MC pt for Lupus?
Black women
What is lupus?
Inflammatory autoimmune disorder affecting multiple organ systems
Lupus pts need to worry about?
Sever renal disease early in life
Lupus is multifactorial, what are some of the factors suspected to be involved?
Genetic - monozygotic twins, HLA DR2 and DR3
Abnormal immune system - autoantibodies (ANA)
Endocrine - Menarche, HRT, OCPs
Environmental - tobacco, UV light, EBV
Drugs - procainamide, hydralazine, INH
Classification for lupus?
4/11 of the following:
- Malar rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Arthritis
- Serositis
- Renal (>0.5 proteinuria or cell casts)
- Neurologic (seizure, psychosis)
- Hematologic disorders
- Immunological abnormalities
- POS ANA
95-100% of lupus pts have?
Positive ANA
Immunological abnormalaties seen with Lupus?
Anti-dsDNA
Anti-Sm
Antiphospholipid antibodies
Hematologic disorders with lupus?
Hemolytic anemia
Leukopenia
Lymphopenia
Thrombocytopenia
Important Labs for lupus
Depressed serum complement (C3, C4, CH50)
Anti-phospholipid antibody
Labs for lupus
C3, C4, CH50 ANA Anti-smith Ds-DNA Anti-phospholipid antibody
UA = hematuria
CBC = anemia, leukopenia, thrombocytopenia
Chemistry = hyperkalemia, renal
LFT - multiple cases of test abnormalitis
CK elevated in associated mytosis
Skin biopsy
CT Imaging studies for lupus?
CT chest:
- lupus pneumonitis
- alveolar hemorrhage
- fibrosis
Endocardiogram for lupus?
Pericardial effusions
Valvular lesions
Screening for pulm HTN
CXR for lupus?
Initial eval of pleuritic chest pain
Lupus non-pharmacologic tx?
PT education Photoprotection Tobacco cessation Exercise Healthy diet Vaccine (flu, pneumococcal)
Pharmacologic cutaneous tx for lupus
Initially: low potency topical steroids
Truncal lesions: medium potency topical steroids
Severe hypertrophic regions: high potency topical steroid
Tacrolomus/pricrolimus: 2nd line agent
Retinoids: 2nd line
Systemic pharmacological agents for lupus
Hydroxychloroquine (plaquenil) - 1st line
Cloroquine - 2nd line
Corticosteroids - short term only
ACE/ARB - control B/P and Renal manifestations
If youre treating with hydroxychloroquine (plaquenil) you cannot give?
Chloroquine
You can but should never give lupus pts?
Corticosteroids
Systems effected by lupus
Constitutional Ocular Arthritis Osteonecrosis (avascular necrosis) Cardiovascular Pulmonary Hematologic Neurologic Renal Gastrointestinal
Occular lupus symptoms?
Keratoconjunctiva sicca
SLE retinopathy
Arthritic symptoms of lupus
Transient symmetric arthritis of:
- hands
- writsts
- knees
Seldom
- Deforming
- Non-erosive
Less severe than RA
MC presenting of SLE?
Arthritis
Lupus pts can have ___ w or w/o hx of steroid therapy?
Osteonecrosis (avascular necrosis)
Cardiovascular symptoms of lupus?
Raynauds Pericarditis Valvular heart dz Libman-sacks endocarditis CAD
Pulmonary features of lupus?
Serositis Plueral effusions Pleuritis Intersititial lung disease (restrictive) Pulmonary HTN Shrinking lung syndrome PE
PFT’s: restrictive, low diffusion
Hematologic presentation of lupus?
Anemia of chronic disease
- MOST COMMON
Lymphadenopathy (common) Leukopenia Thrombocytopenia Hemolytic anemia Coombs test +
Neurologic presentation of lupus?
HA Seiures Mood changes CVD Cognitive dysfunction
Renal presentation of lupus?
Lupus nephritis
- w/in 1st 36 mo
Hallmark of lupus nephritis?
Proteinuria
Hematuria
GI lupus presntation?
Mesenteric vasculitis (abdominal pain)
Malar rash is aka?
Acute cutaneous lupus
Butterfly rash
Describe malar rash
Fixed erythema
flat or raised
over the malar eminences
tending to spare the nasolabial folds
Acne rosacea, seborrheic dermatitis and flushing syndromes are differentiated from malar rash by:
Rosacea:
- telangiectasias and pustules may sting/burn
- heat and etoh make it worse
Seborrheic derm:
- scaly erythematous plaques on eyebrows, sclap, ears
- nasolabial folds common
If the rash dx is unclear?
Biopsy to differentiate SLE from other derm
Discoid rash is aka?
Chronic cutaneous lupus
Discouid rash is MC found:
Face
Scalp
Neck
S/s of discoid rash
Raised erythematous patches w adherent keratotic scaling and follicular plugging
Discoid lupus lesions:
- Typically expand w peripheral erythema and hyperpigmentation
Discoid rash can occur?
In the oral cavity
PAINFUL
Discoid lupus lesions hallmark?
Atrophic central scarring
Telangiectasia
Hypopigmentation
What causes subacute cutaneous lupus?
Most often induced by meds
- hydrochlorothiazide
- terbinafine
Where does subacute cutaneous lupus present?
Located on torso, limbs
Spares the face
Subacute cutaneous lupus is the most ___ of the lupus rashes?
Most photosensitive
Describe subacute cutaneous lupus rash
Papulosquamous or annular
Scaly erythematous papules
The most photosensitive rash
Diagnostic labs for subacute cutaneous lupus?
Anti-Ro
SSA antibodies
Neonatal lupus can present as?
Cardiac
Cutaneous
Or both
With neonatal lupus you need to worry about?
Heart block
Rash s/s of neonatal lupus?
Annular, Polycyclic skin plaques on face and scalp
After UV exposure for the 1st 3-5 months of life
Suspect neonatal lupus if mom had?
SSA
SSB labs
With neonatal lupus you can tell the parents?
It will typically resolves by 6-8 months of age
Patient population for drug induced lupus?
Men = women
Drugs associated w drug induced lupus?
Hydralazine INH Procainamide Minocycline Interferon alpha Anti-TNF agents Methyldopa Chloropromazine Quinidine
Hydrochlorthiazide is associated with?
Subacute cutaneous lupus
S/s of drug induced lupus?
Polyarthritis Myalgia Fever Serositis Nephritis CNS abnormalities rare
Diagnosis of drug induced lupus?
Anti-histone antibodies frequently present
Tx for drug induced lupus
Stop the drug!!!
It gets better once you do that
If systemic tx is needed in the interim than do that too
What is APS?
Antiphospholipid antibody syndrome
Hypercoagulability with recurrent thrombosis of either venous or arterial circulation
APS causes?
DVT
PE
Stroke
Renal injury
Clinical criteria for APS?
Vascular thrombosis Or 1+ pregnancy loss > 10 wks 1+ premature birth < 34 wks 3+ spontaneous abortion <10 wks
What antiphospholipid antibodies are included in APS?
False pos RPR (neg FTA)
Lupus anticoagulant (increased PTT)
Anticardiolipin antibodies (IgG/IgM)
Anti-beta-2 glycoprotein 1 antibodies
Tx for APS?
Warfarin or heparin
Lifelong anticuagulation w coumadin or heparin
Smoking cessation
If woman has hx of preg-associated complication (APS) the tx is?
aspirin (preeclampsia)
and
heparin/LMWH
