Systemic Lupus Erythematosus in Emergency Medicine Treatment & Management

  • Author: Mark J Leber, MD, MPH, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jan 4, 2011
 

Emergency Department Care

Emergent complications of systemic lupus erythematosus (SLE) are managed in the usual manner. These can include strokes, acute myocardial infarctions, hemoptysis, respiratory distress, and pulmonary emboli.

In patients who present with fever, treating for an infection empirically may be necessary until culture results have been received.

Individual treatment plans are beyond the scope of this article and are discussed in other articles (see Differentials and Complications).

Next

Consultations

Consultation with a rheumatologist indicated for patients who present with symptoms suggestive of SLE and for patients with known disease.

For complications such as pericardial tamponade, pulmonary hemorrhage, renal failure, or cerebritis, the appropriate subspecialist needs to be consulted.

For cases of pregnancy associated with antiphospholipid antibody, the patient should be followed up by a high-risk obstetrician due to the increased risk of preeclampsia and placental insufficiency.[24]

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Mark J Leber, MD, MPH, FACEP  Attending Physician and Faculty, Department of Emergency Medicine and Residency Program, Lincoln Medical and Mental Health Center

Mark J Leber, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Viraj S Lakdawala, MD  Chief Resident, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY

Viraj S Lakdawala, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Gino A Farina, MD, FACEP, FAAEM  Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References
  1. Munoz LE, Gaipl US, Franz S, Sheriff A, Voll RE, Kalden JR. SLE--a disease of clearance deficiency?. Rheumatology (Oxford). Sep 2005;44(9):1101-7. [Medline].

  2. Rahman A, Isenberg DA. Systemic lupus erythematosus. N Engl J Med. Feb 28 2008;358(9):929-39. [Medline].

  3. D'Cruz DP, Khamashta MA, Hughes GR. Systemic lupus erythematosus. Lancet. Feb 17 2007;369(9561):587-96. [Medline].

  4. Uramoto KM, Michet CJ Jr, Thumboo J, Sunku J, O'Fallon WM, Gabriel SE. Trends in the incidence and mortality of systemic lupus erythematosus, 1950-1992. Arthritis Rheum. Jan 1999;42(1):46-50. [Medline].

  5. Danchenko N, Satia JA, Anthony MS. Epidemiology of systemic lupus erythematosus: a comparison of worldwide disease burden. Lupus. 2006;15(5):308-18. [Medline].

  6. Abu-Shakra M, Urowitz MB, Gladman DD, Gough J. Mortality studies in systemic lupus erythematosus. Results from a single center. II. Predictor variables for mortality. J Rheumatol. Jul 1995;22(7):1265-70. [Medline].

  7. Gladman DD, Urowitz MB. Prognosis, mortality and morbidity in systemic lupus erythematosus. In: Wallace DJ, Hahn BH. Dubois' lupus erythematosus. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2007:1333-53.

  8. Cervera R, Khamashta MA, Font J, Sebastiani GD, Gil A, Lavilla P. Morbidity and mortality in systemic lupus erythematosus during a 5-year period. A multicenter prospective study of 1,000 patients. European Working Party on Systemic Lupus Erythematosus. Medicine (Baltimore). May 1999;78(3):167-75. [Medline].

  9. Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger TA Jr, Jansen-McWilliams L, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Am J Epidemiol. Mar 1 1997;145(5):408-15. [Medline].

  10. Murali R, Jeyaseelan L, Rajaratnam S, John L, Ganesh A. Systemic lupus erythematosus in Indian patients: prognosis, survival and life expectancy. Natl Med J India. Jul-Aug 1997;10(4):159-64. [Medline].

  11. Xie SK, Feng SF, Fu H. Long term follow-up of patients with systemic lupus erythematosus. J Dermatol. Jun 1998;25(6):367-73. [Medline].

  12. Wang F, Wang CL, Tan CT, Manivasagar M. Systemic lupus erythematosus in Malaysia: a study of 539 patients and comparison of prevalence and disease expression in different racial and gender groups. Lupus. 1997;6(3):248-53. [Medline].

  13. Manzi S. Epidemiology of systemic lupus erythematosus. Am J Manag Care. Oct 2001;7(16 Suppl):S474-9. [Medline].

  14. Klein-Gitelman M, Reiff A, Silverman ED. Systemic lupus erythematosus in childhood. Rheum Dis Clin North Am. Aug 2002;28(3):561-77, vi-vii. [Medline].

  15. Dubois EL, Tuffanelli DL. Clinical manifestations of systemic lupus erythematosus. Computer analysis of 250 cases. JAMA. Oct 12 1964;190:104-11. [Medline].

  16. Harvey AM, Shulman LE, Tumulty PA, Conley CL, Schoenrich EH. Systemic lupus erythematosus: review of the literature and clinical analysis of 138 cases. Medicine (Baltimore). Dec 1954;33(4):291-437. [Medline].

  17. Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. Nov 1982;25(11):1271-7. [Medline].

  18. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. Sep 1997;40(9):1725. [Medline].

  19. Ramos-Casals M, Cuadrado MJ, Alba P, Sanna G, Brito-Zerón P, Bertolaccini L. Acute viral infections in patients with systemic lupus erythematosus: description of 23 cases and review of the literature. Medicine (Baltimore). Nov 2008;87(6):311-8. [Medline].

  20. Fessler BJ. Infectious diseases in systemic lupus erythematosus: risk factors, management and prophylaxis. Best Pract Res Clin Rheumatol. Apr 2002;16(2):281-91. [Medline].

  21. Muscal E, Brey RL. Neurologic manifestations of systemic lupus erythematosus in children and adults. Neurol Clin. Feb 2010;28(1):61-73. [Medline]. [Full Text].

  22. Lin YC, Wang AG, Yen MY. Systemic lupus erythematosus-associated optic neuritis: clinical experience and literature review. Acta Ophthalmol. Mar 2009;87(2):204-10. [Medline].

  23. Tierney, et al. Current Medical Diagnosis and Treatment. 2001:841-844.

  24. Nodler J, Moolamalla SR, Ledger EM, Nuwayhid BS, Mulla ZD. Elevated antiphospholipid antibody titers and adverse pregnancy outcomes: analysis of a population-based hospital dataset. BMC Pregnancy Childbirth. Mar 16 2009;9:11. [Medline].

  25. Ruiz-Irastorza G, Khamashta MA, Castellino G, Hughes GR. Systemic lupus erythematosus. Lancet. Mar 31 2001;357(9261):1027-32. [Medline].

  26. Silverman E, Jaeggi E. Non-cardiac manifestations of neonatal lupus erythematosus. Scand J Immunol. Sep 2010;72(3):223-5. [Medline].

  27. Hornberger LK, Al Rajaa N. Spectrum of cardiac involvement in neonatal lupus. Scand J Immunol. Sep 2010;72(3):189-97. [Medline].

  28. Amit M, Molad Y, Levy O, Wysenbeek AJ. Headache in systemic lupus erythematosus and its relation to other disease manifestations. Clin Exp Rheumatol. Jul-Aug 1999;17(4):467-70. [Medline].

  29. Braunwald E, Fauci AS, Kasper DL. Systemic Lupus Erythematosus. In: Harrison's Principles of Internal Medicine. 16th ed. 2005:1960-1967.

  30. Goldsmith L, Lazarus G, Tharp M. Adult and Pediatric Dermatology: A Color Atlas of Disease and Treatment. 1997.

  31. Gourley MF, Austin HA 3rd, Scott D, Yarboro CH, Vaughan EM, Muir J, et al. Methylprednisolone and cyclophosphamide, alone or in combination, in patients with lupus nephritis. A randomized, controlled trial. Ann Intern Med. Oct 1 1996;125(7):549-57. [Medline].

  32. Hahn BH. Management of systemic lupus erythematosus. In: Textbook of Rheumatology. Vol 2. WB Saunders; 1997:1040-56.

  33. Hochberg MC, Silman AJ, Smolen JS, et al. Systemic lupus erythematosus. In: Practical Rheumatology. 3rd ed. 2004:417-437.

  34. Khoshbin S, Glanz BI, Schur PH. Neuropsychiatric syndromes in systemic lupus erythematosus: a new look. Clin Exp Rheumatol. Jul-Aug 1999;17(4):395-8. [Medline].

  35. Lahita RG. Clinical presentation of systemic lupus erythematosus. In: Textbook of Rheumatology. Vol 2. WB Saunders; 1997:1028-39.

  36. Marks R. Skin Diseases in Old People. 2nd ed. Martin Dunitz Ltd; 1999.

  37. Mills JA. Systemic lupus erythematosus. N Engl J Med. Jun 30 1994;330(26):1871-9. [Medline].

  38. Mochizuki T, Aotsuka S, Satoh T. Clinical and laboratory features of lupus patients with complicating pulmonary disease. Respir Med. Feb 1999;93(2):95-101. [Medline].

  39. Mok CC, Wong RW. Pregnancy in systemic lupus erythematosus. Postgrad Med J. Mar 2001;77(905):157-65. [Medline].

  40. Molokhia M, Hoggart C, Patrick AL, Shriver M, Parra E, Ye J, et al. Relation of risk of systemic lupus erythematosus to west African admixture in a Caribbean population. Hum Genet. Mar 2003;112(3):310-8. [Medline].

  41. Roman MJ, Shanker BA, Davis A, Lockshin MD, Sammaritano L, Simantov R, et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. N Engl J Med. Dec 18 2003;349(25):2399-406. [Medline].

  42. Stevenson FK, Natvig J. Autoantibodies revealed: the role of B cells in autoimmune disease. Immunol Today. Jul 1999;20(7):296-8. [Medline].

  43. Urowitz MB, Gladman DD. How to improve morbidity and mortality in systemic lupus erythematosus. Rheumatology (Oxford). Mar 2000;39(3):238-44. [Medline].

  44. Wang CR, Chou CC, Hsieh KH, Chuang CY, Chen CY. Lupus patients with peripheral vascular thrombosis: the significance of measuring anticardiolipin antibody. Am J Emerg Med. Sep 1993;11(5):468-70. [Medline].

Previous
Next
 
The classic malar rash, also known as a butterfly rash, with distribution over the cheeks and nasal bridge. Note that the fixed erythema, sometimes with mild induration as seen here, characteristically spares the nasolabial folds.
Photosensitive systemic lupus erythematosus (SLE) rashes typically occur on the face or extremities, which are sun-exposed regions. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic.
This axial, T2-weighted brain MRI demonstrates an area of ischemia in the right periventricular white matter of a 41-year-old woman with long-standing systemic lupus erythematosus (SLE). She presented with headache and subtle cognitive impairments but no motor deficits. Faintly increased signal intensity was also seen on T1-weighted images, with a trace of enhancement following gadolinium that is too subtle to show on reproduced images. Distribution of the abnormality is consistent with occlusion of deep penetrating branches, such as may result from local vasculopathy, with no clinical or laboratory evidence of lupus anticoagulant or anticardiolipin antibody. Cardiac embolus from covert Libman-Sacks endocarditis remains less likely due to distribution.
Table 1. American College of Rheumatology Diagnostic Criteria
CriterionDefinition
1. Malar rashFixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
2. Discoid rashErythematous raised patches with adherent keratotic scaling and follicular plugging (Atrophic scarring may occur in older lesions)
3. PhotosensitivitySkin rash as a result of unusual reaction to sunlight, by patient history or physician observation
4. Oral ulcersOral or nasopharyngeal ulceration, usually painless, observed by a physician
5. ArthritisNonerosive arthritis involving ≥2 peripheral joints, characterized by tenderness, swelling, or effusion
6. Serositis(A) Pleuritis: Convincing history of pleuritic pain or rub heard by a physician or evidence of pleural effusion



or



(B) Pericarditis: Documented by ECG or rub or evidence of pericardial effusion
7. Renal disorder(A) Persistent proteinuria >0.5 g/d or >3+ if quantitation not performed



or



(B) Cellular casts: May be red blood cell, hemoglobin, granular, tubular, or mixed
8. Neurologic disorder(A) Seizures: In the absence of offending drugs or known metabolic derangements (eg, uremia, ketoacidosis, electrolyte imbalance)



or



(B) Psychosis: In the absence of offending drugs or known metabolic derangements (eg, uremia, ketoacidosis, electrolyte imbalance)
9. Hematologic disorder(A) Hemolytic anemia: With reticulocytosis



or



(B) Leukopenia: < 4000/mm3 total on ≥2 occasions



or



(C) Lymphopenia: < 1500/mm3 on ≥2 occasions



or



(D) Thrombocytopenia: < 100,000/mm3 in the absence of offending drugs
10. Immunologic disorder(A) Anti-DNA: Antibody to native DNA in abnormal titer



or



(B) Anti-Sm: Presence of antibody to Sm nuclear antigen



or



(C) Positive finding of antiphospholipid antibodies based on (1) an abnormal serum level of IgG or IgM anticardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method, or (3) a false-positive serologic test for syphilis known to be positive for at least 6 months and confirmed by Treponema pallidum immobilization or fluorescent treponemal antibody absorption tests
11. Antinuclear antibodyAn abnormal titer of antinuclear antibody by immunofluorescence or an equivalent assay at any point in time and in the absence of drugs known to be associated with drug-induced lupus syndrome
A person can be diagnosed with SLE if any 4 or more of the 11 criteria are present, serially or simultaneously, during any interval of observation.
Table 2. Drugs Associated With Lupus Erythematosus
Definite Association
ChlorpromazineMethyldopa
HydralazineProcainamide
IsoniazidQuinidine
Possible Association
Beta-blockersMethimazole
CaptoprilNitrofurantoin
CarbamazepinePenicillamine
CimetidinePhenytoin
EthosuximidePropylthiouracil
HydrazinesSulfasalazine
LevodopaSulfonamides
LithiumTrimethadione
Unlikely Association
AllopurinolPenicillin
ChlorthalidonePhenylbutazone
Gold



salts



Reserpine
GriseofulvinStreptomycin
MethysergideTetracyclines
Oral contraceptives
*Data from Tierney et al.[23]
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.