Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease that can affect many different organs in the body. It is more common in women, especially African American women of childbearing age. The cause is largely unknown but genetic and environmental factors are believed to play a role. Diagnosis is based on clinical criteria including symptoms like arthritis, rashes, and involvement of organs like the kidneys or brain. Treatment involves managing symptoms with medications like NSAIDs, steroids, and immunosuppressants. Prognosis is generally good if major organ dysfunction can be prevented or treated, though risks like infection and lymphoma remain. Early diagnosis and management are important to optimize outcomes for patients with SLE.

1. SYSTEMIC LUPUS
ERYTHEMATOSUS
Yidana Daniel B.

2. OUTLINE
• Introduction and Definition
• Epidemiology
• Pathogenesis
• Aetiology
• Pathology
• Clinical features and Diagnosis
• Investigations
• Treatment
• Course and Prognosis
• Conclusion

3. Introduction
• ‘Lupus’ in Latin means wolf. This term was used in
the middle ages to describe erosive skin lesions
evocative of a wolf’s bite.
• In 1846, Viennese Physician, Ferdinand Von
Hebra introduced the term ‘butterfly rash’ and was
the first to use the name Lupus erythematosus.
• Many other physicians have since discovered and
named various conditions associated with the
disease.

4. Definition
• SLE is an inflammatory, multisystem disorder with
arthralgia and rashes as the commonest clinical
features and cerebral/renal disease as the most
serious problem.

5. Epidemiology
• Prevalence rates in the USA is about 10-400 per
100000.
• Common in African-American women
• Disease is 9 times more common in women than
in men
• Peak age is between 20 and 40 years (women in
their fertile years).

6. Pathogenesis
• 1. Ineffective Phagocytosis of apoptotic cells.
• 2. Breakdown in tolerance ( B cells and T cells
destroy self cells).
• There is therefore sustained production of auto
antibodies and immune complexes that bind
tissues.
• There is complement activation and release of
cytokines, vasoactive peptides, destructive
enzymes and development of chronic
inflammation, causing tissue damage.

7. Aetiology
• Cause is largely unknown. A number of
predisposing factors have however been
implicated;
1. Heredity: Higher concordance rates among
monozygotics (25%), than dizygotics (3%). First
degree relatives have a 3% chance of developing
disease.
2. Genetics: Associations with HLA genes-
HLADRB1, HLA A1, B8 and DR3.

8. 3. Homozygous deficiencies of complement genes-
c1q, c2 or c4.
4. Sex hormone status- commoner in pre-
menopausal women, women who use oestrogen
containing oral contraceptives or women on
hormone replacement therapies.
5. Klinefelter syndrome(XXY), TREX-1, STAT4
CTLA4.

9. • 6.UV light
• 7. EBV infection
• 8. Tobacco smoking
• 9. Drugs- Hydralazine, procainamide, isoniazid,
penicillamine; here, the CNS and Kidneys are
usually not affected.

10. Autoantibodies present in SLE:
1. ANA 6. Anti-phospholipid
2. Anti dsDNA 7. Anti-RNP
3. Anti sm 8. Anti-histone
4. Anti-Ro 9.Anti c1q
5. Anti-La 10. Anti-ribosomal P

11. Pathology
• Biopsies of skin and kidneys reveal igG antibodies
and complement deposition with influx of T
lymphocytes and neutrophils.

12. Clinical features
1. General features: Fever, severe fatigue, weight
loss.
2. Joints and Muscle symptoms: In more than
90% of patients.
-Symmetrical small joint arthralgia ( hands,
wrists) and Knees and sometimes arthritis.
-Myalgia

13. 3. Mucocutaneous Manifestations:
-Butterfly rash
-Photosensitivity
-Discoid rash
-Vasculitic lesions in finger tips,around the nailfolds,
purpura and urticaria.
Livedo reticularis

14. - Palmar and plantar rashes
- Scarring alopecia
- Oral and nasal ulcerations
4. Lungs: - Recurrent pleurisy
-Pleural effusions
-Pneumonitis
-Atelectasis
-Restrictive lung disease in few cases

15. 5. CVS: - Pericarditis
- Pericardial effusions
- Libman-sachs endocarditis
- Myocardial infarction
6. Renal: - Lupus nephritis
-Nephrotic syndrome
- ESRD

16. 7. CNS:- Cognitive dysfunction
- Headaches
- Seizures
- Psychosis
- Stroke
- Aseptic meningitis

17. 8. GIT: -Nausea
- Diarrhoea - Hepatomegaly
- Vomiting - Uncommonly Pancreatitis
- Abdominal pain
9. Haematologic: - Anaemia
- Lymphocytopaenia
- Thrombocytopaenia

18. 11. Ocular: - Sicca
- Episcleritis
- Conjuctivitis
- Retinal vasculitis
- Optic neuritis
* Keep in mind the effects of glucocorticoid treatment

19. 12. Lupus and Pregnancy: Recurrent abortions in
those with the antiphospholipid antibody.
-Congenital heart block esp. with anti Ro.
-Teratogenic potential of warfarin and
cyclophosphamide.
- Preterm birth risk associated with high dose
steroids.

20. Malar Rash

21. Discoid rash

22. Recovery after discoid Lupus

23. Livedo reticularis

24. Diagnosis
• ACR diagnostic criteria (SOAP BRAIN MD)
Serositis Antinuclear antibodies
Oral and nasal ulcers Immunological disorder
Arthritis Neurologic disorder
Photosensitivity Malar rash
Blood disorder Discoid rash
Renal disorders

25. • 4 or more of the above, well documented, and
present at any time in a patient’s history is
required to make a diagnosis.
• The diagnosis is based on characteristic clinical
findings and the presence of autoantibodies.
• When a diagnosis is made, it is important to
establish the severity and potential reversibility of
symptoms and to establish the possible
consequences of various therapeutic
interventions.

26. Investigations
1. FBC, ESR and CRP
2. Urinalysis
3. BUE+Cr
4. Autoantibodies
5. C3, C4
6. Renal biopsy
7. ***CT scan head if need be to rule out other CNS
causes.

27. LUPUS NEPHRITIS
ISN classification of Lupus nephritis
I- Minimal mesangial lupus nephritis
II- Mesangial proliferative lupus nephritis
III- Focal lupus nephritis (3A, 3A/C, 3C)
IV- Diffuse lupus nephritis ( S(A), G(A), S(A/C), G(A/C),
S(C) and G(C) )
V- Membranous lupus nephritis
VI- Advanced sclerotic lupus nephritis ( ESRD)

28. Severity Assessment
1. SLEDAI score: Asseses the presence of a mild or
moderate and Severe flares.
2. SLICC/ACR Damage Index for SLE.

29. Management
• There is no cure.
1. General measures: -Discuss with patient the
disfiguring effects of cutaneous and the debility
associated with fatigue.
- Avoid UV/sunlight exposure
- Reduce cardiovascular risk factors

30. Symptomatic treatment
1. Athralgia, arthritis fever – NSAIDs bearing in mind
renal function.
If severe, low dose steroids by mouth and
hydroxychloroquine.
2. Cutaneous lesions- mild potency steroids for face,
mid to high potency for other areas, consider sunscreens;
Low dose oral steroids, hydroxychloroquine can be used.

31. 3. Serositis- Moderate dose steroids, Azathioprine or
mycophenolate.
4. Renal problems-
Class I, II- Low dose steroids
Class III,IV- these are the active stages and require
aggressive management to allow remission.
-Induction with high dose steroids and cyclophosphamide
-Maintenance with Azathioprine or Mycophenolate

32. Class V- ACEI, Steroids, consider other DMARDs
Class VI- Dialysis or Transplantation
5. CNS problems- Require induction and
maintenance medications as in Renal problems.

33. 6. Haematological problems-
Severe haemolytic anaemia is treated initially with
high dose IV Methylprednisolone 1g/day for 3 days.
Severe thrombocytopaenia may also require IV
methylprednisolone.

34. Course and Prognosis
• Prognosis is good in the absence of major organ
dysfunction.
• There is a long term risk of Lymphoma.

35. Conclusion
• SLE diagnosis at an early stage is crucial to
ensuring favourable prognosis.
• There is no exact cure, symptoms can however be
managed.
• Refer early for rheumatological consult.
• Educate patients on the various possible
complications of the disease and its treatment,
and especially pregnant women on the possible
effects on pregnancy.

36. THANKYOU