SLE

2. Lupus eritematosus sistemik (LES)
Penyakit autoimun yang melibatkan berbagai organ dengan
manifestasi klinis yang bervariasi dari yang ringan sampai berat .
Pada keadaan awal, sering sekali sukar dikenal sebagai LES,
karena manifestasinya sering tidak terjadi bersamaan.
Sampai saat ini penyebab LES belum diketahui ada dugaan faktor
genetik, infeksi dan lingkungan ikut berperan pada patofisiologi
LES

3. Lupus menyerang jaringan ikat pada seluruh tubuh, dengan penyebab
yang multifaktorial.
Biasanya terjadi pada seseorang yang memiliki predisposisi genetik dan
terekspos oleh beberapa faktor berikut ini :
 Pengaruh lingkungan
 Zat/agen infeksius
 Obat-obat pencetus lupus
 Sinar ultraviolet
 Trauma fisik
 Stress emosional atau faktor-faktor lainnya
 Predisposisi genetik
Workshop LES-16-Februari-2008;Hotel Horison Bandung
•Lupus Eritematosus Sistemik

5. Sel T
Sel T yang abnormal ( jumlah dan phenotipe)
 Limfopenia
 Penurunan subset supressor (CD4+CD45R+, 2H4+)
 Penurunan 'naive cells’ (CD4/8CD45RA+).
 Penurunan 'memory cells’ (CD4/8CD29). Berkorelasi
negatif dengan pembentukan anti DNA
 Penurunan aktivitas sel suppressor
 Peningkatan aktivitas sel helper (CD4+, DR+)
Respon proliperasi dan signal yang abnormal
 Defective anti-CD2 proliferation
 Circulating anti-CD45 antibodies

6. Sel B
 Fungsi sel B yang abnormal
 Aktifasi dari poliklonal sel B
 Sel B intrinsik yang abnormal
 Peningkatan respon terhadap stimulus sitokin

7. Mekanisme pengendapan imun kompleks

8. Gambaran klinis LES
LES
SSP
20%
Hepotomepali/
Splenomegali
20%
Sal cerna
18%
Paru
38%
Hematologi
50% Jantung
48%
Vaskulitis
Ginjal
50%
Limphadenopati
12-50%
Kelelahan
90%
Panas lama
80-82%
BB turun
60%
Artritis/Artralgia
90%
Kulit
50-58%

9. Faktor pencetus/eksaserbasi
LES
Obat :
Keguguran
Kehamilan
Tindakan
pembedahan
Infeksi
Sinar UV
(320-400 nm)
Procainamid
Hidralazin
Metildopa
CPZ

13. Positive
ANA
Nucleoli
Raynaud’s
phenomenon
Scleroderma
Diffuse (homogeneous)
Anti-nucleoprotein
SLE
RA
Drug LE
Histone
SLE
RA
Drug LE
Centromere
CREST
Sdleroderma
Peripheral (rim)
Anti-dsDNA
SLE
Negative
No disease
Lab error
Treatment
Remission
Antigen XS
Nephrotic syndrome
No specificity
UCTD
SLE
RA
Liver disease
Mono
Any chronic
inflammatory disease
RNP
SLE
MCTD
RA
Scleroderma
UCTD
Sm
SLE
RO (SS-A)
SLE
Sogren’s
syndrome
PcNA
SLE
Scl-70
Scleroderma
PM/Jo/Ku/Mi
PM/DM
La
SLE
Sogren’s
syndrome
Speckled

14. American College of Rheumatology (ACR) membuat kriteria LES yang
secara bertahap (revisi 3 kali)
Kriteria klasifikasi tersebut memiliki penekanan pada kelainan yang
berbeda-beda yaitu :
1. 1971, konsentrasi di kelainan kulit : fotosensitiviti pada kulit,
oral ulcer, butterfly rash dan lesi discoid
2. 1982, berkaitan dengan organ spesifik : pleuritis, kelainan ginjal,
kelainan neurologi dan persendian.
Workshop LES-16-Februari-2008;Hotel Horison Bandung
•Lupus Eritematosus Sistemik

15. 3. 1996 : merupakan revisi terakhir, meliputi kriteria
berikut :
Kriteria untuk kelainan kulit
Butterfly rash (lupus/malar rash yang meliputi pipi dan hidung)
Discoid rash (kelainan kulit lebih tebal, biasanya disertai skar,
biasanya didaerah kulit yang terpapar sinar matahari)
Fotosensitivity/ sun sensitivity (rash/kulit kemerahan setelah
terpapar sinar ultraviolet A dan B)
Oral ulcer (ulkus di mulut, biasanya di langit-langit rongga
mulut atau hidung, dan tidak nyeri.
Workshop LES-16-Februari-2008;Hotel Horison Bandung
•Lupus Eritematosus Sistemik
Penegakkan diagnosis

16. Kriteria sistemik
 Artritis (peradangan pada sendi sendi jari tangan dan kaki disertai
pembengkakan, nyeri bahkan penumpukan cairan)
 Serositis (peradangan pada selaput pleura, selaput pericardial dan
peritoneum)
 Kelainan ginjal (proteinuri atau kelainan pada sediment urine secara
mikroskopis)
 Kelainan neurology (kejang atau psikosa tanpa sebab yang jelas)
Workshop LES-16-Februari-2008;Hotel Horison Bandung
Penegakkan diagnosis
•Lupus Eritematosus Sistemik

17. Kriteria laboratoris :
Kelainan darah (anemia hemolitik, leucopenia,
trombositopenia)
Kelainan imunologi (Anti-DsDNA [+],
antiphospholipid antibodi [+], lupus
anticoagulant [+], false positif test sifilis, atau
anti-Sm[+])
ANA test [+].
Workshop LES-16-Februari-2008;Hotel Horison Bandung
•Lupus Eritematosus Sistemik
Penegakkan diagnosis

18. Pemeriksaan SLE
 Diagnosis (ANA test, ds DNA, ANA panel)
 Defisiensi komplemen-berhubungan dengan
reaksi hipersensitivitas (CH50,C3,C4,C1q)

19. Complement activation plays a
critical role in the inflammatory
process and tissue damage in SLE,
but early complement deficiencies
cause SLE.
Complement prevents SLE through:
processing and clearing of
immune complexes

22. Clinical Laboratory Testing
 Serum complement hemolytic activity: CH50
(serum dilution at which 50% hemolysis occurs)
if low = complement deficiency

23. PEMERIKSAAN AKTIVITAS
KOMPLEMEN CH50
 CH50 is a measure of total complement (dilutions
until will not lyse 50% if antibody coated cells)
 If CH50 is low, then order C3 and C4 quantitative
levels
 C3 with normal C4: defect in alternate pathway
 C4 suggests defect in classic pathway

24. Lysis of cell
Sample with different dilution
37 °C incubated
CH50
0
10
20
30
40
50
60
70
80
90
0 100 200 300
Dilutions of serum
%
Hemolysis
CH50 =
98
+
50% hemolysis occurs

25. CH50
 CH50 assay a test of total complement activity as the
capacity of serum to lyse a standard preparation of
sheep red blood cells coated with antisheep
erythrocyte antibody. The reciprocal of the dilution of
serum that lyses 50 per cent of the erythrocytes is the
whole complement titer in CH50 units per milliliter of
serum.

27. Pemeriksaan C3 dan C4

28. PEMERIKSAAN CIRCULATING IMUN COMPLEX
C1q-CIC
•Mendeteksi CIC yang mengandung
fragmen komplemen C1q
•Prinsip pemeriksaan : ELISA
Nilai referensi : 40µ g/ml : negatif
Positif > 50µ g/ml
Equivocal 40-50 µg/ml

29. Prinsip test
 The assay wells are coated with a monoclonal
antibody specific for the C1q component of
complement. On adding diluted serum to the
wells, any C1q containing CICs present bind to
the antigen. After incubating and washing away
unbound material, horseradish peroxidase
conjugated anti-human IgG monoclonal
antibody is added which binds to C1q and IgG
containing CICs.

30.  Following incubation and washing, the
substrate (tetramethyl benzidine) is added
to each well. The presence of the {conjugate -
cic - antigen} complex turns the substrate to a
dark blue colour. Addition of stop solution
turns the colour to yellow.
 The colour intensity is proportional to the
amount of C1q containing CICs present in
the serum.

31. Grossly haemolysed, lipaemic or
microbiologically contaminated samples should
not be used.
• A negative result should not be used as a sole
criterion to rule out SLE, RA or other
autoimmune disease but must be taken in
relation to other clinical observations and
diagnostic tests.
• It should be noted that C1q containing CICs do
occur in other autoimmune or non-
autoimmune conditions..

32. C4 C3 Fc.B Jalur cth
↓  N klasik SLE
↓   Alternatif
inf.bakteri
   sintesis komponen
inf.akut

33. ANA TEST

34. IFA
 Tahap 1 : serum pasien direaksikan dengan
substrat ag pada well sehingga terbentuk
komplek ag-ab
 Tahap 2: fluorescen yang dilabel ab antihuman
akan terikat dengan kompleks dan hasilnya
adalah fluorescen hijau cerah
 Jika tidak terbentuk kompleks maka fluorescen
negatif

36. interpretasi
 Pola utama :
1.Periferal
2.Homogenous
3.Speckled
4.nucleolar

37. ANA PATTERN, AUTOANTIGENS AND DISEASE ASSOCIATION
PATTERN/POLA ANTIGEN TARGET DISEASE ASSOCIATIONS
PERIPHERAL Histones; ds DNA; Lamin A,B,C
Membrane pore protein
SLE
Chronic autoimmune hepatitis
Primary biliary cirrhosis
Polymyositis
HOMOGENOUS Histones;dsDNA SLE
Drug induced lupus
Rheumatoid arthritis
SPECKLED SSA+SSB; RNA polymerase; Scl-70
Sm; snRNP,hnRNP
Nuclear matrix protein; hnRNA
SLE
Sjogren
Scleroderma
Polymyositis
Dermatomyositis
SLE
MCTD
SLE
Chronic rheumatic disease
NUCLEOLAR PM-Scl; multiprotein complex
Ku
RNA polymerase; Rnase
Fibrillarin protein (U3)
Polymyositis-Scleroderma overlap
syndrome
Polymyositis-Scleroderma
SLE
Scleroderma
Systemic sclerosis
NUCLEAR DOTS P80collin +sn RNA Primary biliary cirrhosis
Sjogren
Rarely SLE
RIBOSOMAL Actin; cytokeratin;tropomyosin; Vimentin,
Vinculin
Autoimmune hepatitis
Rheumatoid arthritis
Non-specific inflammatory dis.

39. ELISA
 Anti-Nuclear Antibodies (ANA) ELISA kit is based on
binding of ANA from serum samples to extracted nuclear
antigen immobilized on microtiter wells. After a washing
step, goat anti-human IgG-HRP conjugate is added. After
another washing step, to remove all the unbound enzyme
conjugate, chromogenic substrate (TMB) is added and
color developed. The enzymatic reaction (color) is directly
proportional to the amount of ANA present in the sample.
Adding stopping solution terminates the reaction.
Absorbance is then measured on a microtiter well ELISA
reader at 450 nm and the concentration of ANA in samples
is calculated as ANA index (AI) which is defined as the ratio
of net absorbance of the test sample and net absorbance of
the negative or endpoint-cutoff control.

40.  Negative samples <0..90
 Equivocal (borderline) >0.91-0.99
 >1.00 is interpreted as positive for IgG ANA.

41. ELISA

42. ANA PROFILE
Immunoblotting
Uses enzyme labeled antibodies
against human immunoglobulin to
detect antinuclear antibodies
which bind to nuclear antigen
displayed in characteristic position
on the agarose gel after they have
been electrophoretically
separated. The antibodies
detected by reaction of the
enzyme labeled antibodies with a
colour producing enzyme
substrate. The positive colour
changes in the band are read
visually.

43. 43

44. Coombs test?
Pemeriksaan immunohematology yang
menggunakan reagensia coombs serum atau
AHG (Anti Human Globulin)
 Direct Coombs Test : Sel darah merah  Ab
coated invivo
 Indirect Coombs Test : Serum / Plasma  Ab
invitro
44

45. 45

46. 46