Sections

Sections Systemic Lupus Erythematosus (SLE)
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
Tables
References

DDx

Diagnostic Considerations

Before making a diagnosis of systemic lupus erythematosus (SLE), ruling out drugs as the cause of the condition is important. Many pharmacologic agents have been associated with a lupuslike syndrome (see Drug-Induced Lupus Erythematosus), but procainamide, hydralazine, and isoniazid have been studied the most extensively. Many patients who take these medications have positive antinuclear antibody test results and other serologic findings. Only a few have the clinical manifestations. Drug-induced lupus differs from SLE by the following features:

Sex ratios are nearly equal
Antibodies to histones are usually found in 80-90%
Nephritis and central nervous system features are not commonly present
There are no antibodies to native DNA or hypocomplementemia
Discontinuation of the drug leads to resolution of clinical manifestations and reversion of abnormal laboratory values to normal

A syndrome of drug-induced SLE has been observed with minocycline and propylthiouracil. Both drugs have a decreased frequency of antihistone antibodies and anti–double-stranded DNA antibodies, and results for antineutrophil cytoplasmic antibodies are sometimes positive. Anti-TNF drugs are reported to cause severe drug-induced lupus, including production of many SLE autoantibodies and, rarely, even nephritis.^[111]

Other problems to be considered in the differential diagnosis of SLE include the following:

Discoid skin lesions
Erythematous macules
Interstitial lung disease
Leukemia
Leukopenia
Parvovirus or other viral infections
Photodistributed rash
Pleuritic chest pain
Pneumonitis
Polyarthritis/polyarthralgia
Renal vasculitis
Seizures
Stroke
Thrombocytopenia
Vasculitis

Differential Diagnoses

Acute Pericarditis
Antiphospholipid Syndrome
Autoimmune Hepatobilliary Disease
B-Cell Lymphoma
Fibromyalgia
Hepatitis C
Epstein-Barr Virus (EBV) Infectious Mononucleosis (Mono)
Infective Endocarditis
Lyme Disease
Mixed Connective-Tissue Disease (MCTD)
Polymyositis
Rheumatoid Arthritis (RA)
Scleroderma
Sjogren Syndrome
Undifferentiated Connective-Tissue Disease

Workup

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Media Gallery

Systemic lupus erythematosus (SLE). 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 (nasolabial fold sparing is indicated by black arrows).
Dermatomyositis. Acute onset of confluent macular erythema in a periorbital and malar distribution (involving the cheeks and extending over the nasal bridge), with extension to the chin in a female with juvenile dermatomyositis. Note the perioral sparing. In some patients, there may be more extensive involvement of the face, including the perioral region, forehead, lateral face, and ears. In contrast to SLE , in dermatomyositis with malar erythema, the nasolabial folds are often not spared.
Discoid lupus erythematosus.
Photosensitive systemic lupus erythematosus (SLE) rashes typically occur on the face or extremities, which are sun-exposed regions. Although the interphalangeal spaces are affected, the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are spared. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic.
In systemic lupus erythematosus (SLE), many genetic-susceptibility factors, environmental triggers, antigen-antibody (Ab) responses, B-cell and T-cell interactions, and immune clearance processes interact to generate and perpetuate autoimmunity. HLA = human leukocyte antigen; UV = ultraviolet light.
This axial, T2-weighted brain magnetic resonance image (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.
Lupus band test. Microphotograph of a histologic section of human skin prepared for direct immunofluorescence using an anti-IgG antibody. The skin is from a patient with systemic lupus erythematosus and shows IgG deposit at 2 different places: the first is a band-like deposit along the epidermal basement membrane ("lupus band test" is positive); the second is within the nuclei of the epidermal cells (anti-nuclear antibodies).
Microphotograph of a fixed Hep-2 line cell prepared for indirect immunofluorescence. The preparation was exposed to a serum of a patient with systemic lupus erythematosus and labeled using a murine anti-human immunoglobulin G (IgG) antibody. It shows IgG deposit in the nucleus and nonspecific deposit in the cytoplasm.
Mesangial proliferative lupus nephritis with moderate mesangial hypercellularity. International Society of Nephrology/Renal Pathology Society 2003 class II (×200, hematoxylin-eosin).
Focal lupus nephritis. International Society of Nephrology/Renal Pathology Society 2003 class III (×200, immunofluorescence).
Membranous lupus nephritis showing thickened glomerular basement membrane. International Society of Nephrology/Renal Pathology Society 2003 class V (×200, silver stain).
The chest x-ray from a patient with lupus demonstrates a right-sided pleural effusion (yellow arrow) and atelectasis with scarring in the left lung base (blue arrow). In severe complications, a fibrothorax may develop.
Vasculitis, antiphospholipid antibodies, and renal failure are commonly found in patients with lupus; these conditions greatly increase the risk of developing pulmonary emboli. The diagnosis in a patient with shortness of breath, hemoptysis, and pleuritic chest pain is commonly made with ventilation-perfusion scans or computed tomography (CT) angiography. The CT angiogram demonstrates a filling defect in the left anterior segmental artery (arrow).
Libman-Sacks endocarditis is the most characteristic cardiac manifestation of lupus. It is characterized by clusters of verrucae on the ventricular surface of the mitral valve. These lesions consist of accumulation of immune complexes, platelets, and mononuclear cells. This can lead to heart failure, valvular dysfunction, emboli, and secondary infective endocarditis. Diagnosis is best made via echocardiography, which may reveal the characteristic valvular masses (arrows). IVS = interventricular septum; LA = left atrium; LV = left ventricle.
Histologic image of a normal renal cortex, including the glomerulus (1) and proximal (2) and distal (3) convoluted tubule. [Image from Wikipedia: http://en.wikipedia.org/wiki/File:Histology-kidney.jpg]
Discoid lupus erythematosus is a chronic scarring skin condition causing scaly plaques on the scalp, face, and ears.
Focal lupus nephritis. International Society of Nephrology/Renal Pathology Society 2003 class III (×100, hematoxylin-eosin).

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Table 1. EULAR/ACR Clinical Domains and Criteria for SLE

Domain	Criteria	Points
Constitutional	Fever	2
Hematologic	Leukopenia Thrombocytopenia Autoimmune hemolysis	3 4 4
Neuropsychiatric	Delirium Psychosis Seizure	2 3 5
Mucocutaneous	Non-scarring alopecia Oral ulcers Subacute cutaneous or discoid lupus Acute cutaneous lupus	2 2 4 6
Serosal	Pleural or pericardial effusion Acute pericarditis	5 6
Musculoskeletal	Joint involvement	6
Renal	Proteinuria > 0.5 g/24 h Kidney biopsy class II or V lupus nephritis Kidney biopsy class III or IV lupus nephritis	4 8 10

Table 2. EULAR/ACR Immunologic Domains and Criteria for SLE

Domain	Criteria	Points
Antiphospholipid antibodies	Anti-cardiolipin antibodies or Anti-β2GP1 antibodies or Lupus anticoagulant	2
Complement proteins	Low C3 or low C4 Low C3 and low C4	3 4
SLE-specific antibodies	Anti-dsDNA antibody or Anti-Smith antibody	6

Table 3. Autoantibody Tests for SLE

Test	Description
ANA	Screening test; sensitivity 95%; not diagnostic without clinical features
Anti-dsDNA	High specificity; sensitivity only 70%; level is variable based on disease activity
Anti-Sm	Most specific antibody for SLE; only 30-40% sensitivity
Anti-SSA (Ro) or Anti-SSB (La)	Present in 15% of patients with SLE and other connective-tissue diseases such as Sjögren syndrome; associated with neonatal lupus
Anti-ribosomal P	Uncommon antibodies that may correlate with risk for CNS disease, including increased hazards of psychosis in a large inception cohort, although the exact role in clinical diagnosis is debated^[115]
Anti-RNP	Included with anti-Sm, SSA, and SSB in the ENA profile; may indicate mixed connective-tissue disease with overlap SLE, scleroderma, and myositis
Anticardiolipin	IgG/IgM variants measured with ELISA are among the antiphospholipid antibodies used to screen for antiphospholipid antibody syndrome and pertinent in SLE diagnosis
Lupus anticoagulant	Multiple tests (eg, direct Russell viper venom test) to screen for inhibitors in the clotting cascade in antiphospholipid antibody syndrome
Direct Coombs test	Coombs test–positive anemia to denote antibodies on RBCs
Anti-histone	Drug-induced lupus ANA antibodies are often of this type (eg, with procainamide or hydralazine; p-ANCA–positive in minocycline-induced drug-induced lupus)
ANA = antinuclear antibody; CNS = central nervous system; ds-DNA = double-stranded DNA; ELISA = enzyme-linked immunoassay; ENA = extractable nuclear antigen; Ig = immunoglobulin; p-ANCA = perinuclear antineutrophil cytoplasmic antibody; RBCs = red blood cells; RNP = ribonucleic protein; SLE = systemic lupus erythematosus; Sm = Smith; SSA = Sjögren syndrome A; SSB = Sjögren syndrome B.

Table 4. International Society of Nephrology 2003 Revised Classification of SLE Nephritis

Class	Classification	Features
Class I	Minimal mesangial	Normal light microscopy findings; abnormal electron microscopy findings
Class II	Mesangial proliferative	Hypercellular on light microscopy
Class III	Focal proliferative	< 50% of glomeruli involved Class III lupus nephritis is further subclassified as follows: Class III (A), focal proliferative: Active lesions Class III (A/C), focal proliferative and sclerosing: Active and chronic lesions Class III (C ) (focal sclerosing): Chronic lesions
Class IV	Diffuse proliferative	=50% of glomeruli involved; classified segmental or global; treated aggressively Class IV lupus nephritis is also further subclassified, as follows: Class IV-S: Diffuse segmental proliferative Class IV-G: Diffuse global proliferative Class IV-S or IV-G, active (A) or chronic (C) Note: It remains to be determined whether further subcategories have a prognostic difference.^[120]There are conflicting data from studies; some investigators report that class IV-G (A) has a better prognosis relative to class IV-S (A/C), which is less responsive to treatment.
Class V	Membranous	Predominantly nephrotic disease Note: Class V may occur with class III or IV (then, both cases would be diagnosed)^[113]
Class VI	Advanced sclerosing	≥90% of glomeruli involved without residual activity^[113] Chronic lesions and sclerosis
Source (except as noted otherwise) : Weening JJ, D'Agati VD, Schwartz MM, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol. Feb 2004;15(2):241-50.^[121] SLE = systemic lupus erythematosus.

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Author

Christie M Bartels, MD, MS Division Head, Associate Professor, Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health

Christie M Bartels, MD, MS is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American College of Rheumatology

Disclosure: Received research grant from: Independent Grants for Learning and Change (Pfizer).

Coauthor(s)

Shivani Garg, MD, MS Assistant Professor (CHS), Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health; Director, Lupus Clinic, Co-Director, Lupus Nephritis Clinic, UW Health

Shivani Garg, MD, MS is a member of the following medical societies: American College of Rheumatology, American Medical Association, American Society of Nephrology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Daniel Muller, MD, PhD Associate Professor of Medicine, Department of Medicine, Section of Rheumatology, University of Wisconsin School of Medicine and Public Health

Daniel Muller, MD, PhD is a member of the following medical societies: American Holistic Medical Association, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology

Disclosure: Nothing to disclose.

Acknowledgements

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.

Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine

Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology

Disclosure: Nothing to disclose.

Julie Hildebrand, MD Consulting Staff, Department of Internal Medicine, Associated Physicians of Madison, WI

Disclosure: Nothing to disclose.

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.

Viraj S Lakdawala, MD Clinical Instructor of Emergency Medicine, University of California, San Francisco, School of Medicine; Attending Physician, San Francisco General Hospital

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.

Mark J Leber, MD, MPH Assistant Professor of Emergency Medicine in Clinical Medicine, Weill Cornell Medical College; Attending Physician, Lincoln Medical and Mental Health Center

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

Disclosure: Nothing to disclose.

Carlos J Lozada, MD Director of Rheumatology Fellowship Program, Professor, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine

Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Pfizer Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Anuritha Tirumani, MD Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center

Disclosure: Nothing to disclose.

Acknowledgements

The authors would like to thank Joanna Wong for assistance in preparation of revisions to this topic.