Systemic Lupus Erythematous

Question 1

What is Systemic Lupus Erythematous?

Answer 1

An autoimmune disease in which antinuclear antibodies occur (often years before clinical symptoms).

Lupus erythematosus describes the typical rash of SLE and the term systemic emphasises the potential for multi-organ involvement. The cause of SLE is unknown.

Question 2

What will you find on history taking of Systemic Lupus Erythematous?

Answer 2

Symptoms:
SLE is a remitting and relapsing illness
At least 4 of the following
Malar rash
Discoid rash
Photosensitivity
Oral ulcers
Arthritis - non erosive, two or more joints
Serositis - pleuritis or pericarditis
Renal disorder - proteinuria or casts
Neurological disorder - fits or psychosis
Haematological disorder - anaemia, lymphopenia, leucopenia, thrombocytopenia
Immunological disorder - anti-dsDNA or anti-SM antibodies
Raised ANA

Risk Factors:
female sex
age 15 to 45 years

Specific Questions to ask?
SLE causes antiphospholipid syndrome so ask about miscarriages and DVT/PE

Differentials:
Rheumatoid arthritis - tends to be less symmetrical.
Antiphospholipid Syndrome - occurrence of venous or arterial thrombosis or recurrent fetal loss in the presence of antiphospholipid antibodies.
Systemic sclerosis - Systemic Scleoriss will have digital ulcers associated with the Raynauds Phenomenon , also will have otehr signs like sclerodactyly and calcinosis
HIV - History of exposure to risk factors for HIV.

Question 3

What will you find on examination of Systemic Lupus Erythematous?

Answer 3

End of the bed:
Discoid lupus erythematosus - In sun exposed areas

Hands:
Splinter Haemorhages

Neck:
Lymphadenopathy

Face:
Butterfly Rash - Erythematous and may be raised and pruritic. Spares the naso-labial folds
Chest:

Abdomen:
Splenomegaly

Legs:

Question 4

What investigations will you order in Systemic Lupus Erythematous?

Answer 4

Bedside:
Urinalysis - TO asses renal involvement (haematuria, casts (red cell, granular, tubular, or mixed) or proteinuria)
ECG if any chest pain - To exclude MI

Bloods:
FBC - May see anaemia/Leukopenia/Thrombytopenia that is caused by SLE
Clotting - PTT will be raised in antiphospholipid syndrome which can be due to SLE
UnE - Assess renal involvement
ESR - Will be raised
CRP less commonly raised - If ESR solely raised then consider SLE
Anti Nuclear Antibody (ANA) - Will be raised in 90% of SLE
Antiphospholipid Antibodies - Raised in Antiphospholipid syndrome
Anti DS Dna antibody - Positive if SLE
Complememt Protein levels - Low C4/C4 due to inflamtion provess using them up

Imaging:
CXR - If any cardiopulmonary symptoms - May see pleural effusion, infiltrates, cardiomegaly
X-Ray of any affected joints - To rule out osteoarthritis or RA

Special Tests:
organise any tests needed for he systems effected e.g. Echo for heart, Pulmonary function tests for Lungs, Renal Ultrasound for Kidneys

Question 5

What is the treatment of Systemic Lupus Erythematous?

Answer 5

Refer to specialist

Lifestyle:
Use of sunblock to protect photosensitive skin
Education on chronic nature of the disease

Medical:
Hydrocholroquinine given to slow disease
Topical steroids for skin flare ups
NSAIDS as pain relief for joint pain
Methotrexate/Mycofenalate Mofetil for flare ups with no organ involvement
Methotrexate/Mycofenalate Mofetil + High dose steroids + Rituximab + Hydrochlorquinine for flare ups involving organs