capita98

[capita98 @capita982]

@JustinVinomon @RosenelliEM

[capita98 @capita982]

1- Systemic lupus erythematosus is known as "the great impostor" of diseases. Many clinicians are familiar with fever, joint pains, and malar rash as a relatively frequent presentation of this autoimmune disease but how deep does the rabbit hole go?

[capita98 @capita982]

13- References:

https://t.co/D6kKhqmG1g

https://t.co/E3HlnI8sGq

https://t.co/i35uDHZlYv.

https://t.co/w7aruOOVAa

https://t.co/4Ijhu8S6vC

[capita98 @capita982]

12- Lots of monocolonal antibodies and other drugs in trials for SLE

Belimumab - Inhibits soluble B-cell survival factors theorized involved in SLE pathogenesis

Cyclosporine - Steroid sparing agent favored in Europe. Inhibits T-cell activation

[capita98 @capita982]

11- Choices in pharmacological therapy

Plaquenil/chloroquine - positive survival benefit and high symptom mitigation

Steroids - Prednisone often used to treat flares

MTX or other DMARDs - immunosupressive drugs for severe or life-threatening flares

[capita98 @capita982]

10- How can a patient manage this?

-UV protection
-Dietary mods
- - Often low Vit D (less sun)
- - Reduced salt to mitigate HTN
- -May need more calories in an inflammatory state
-Exercise
-Smoking cessation
-Immz
- -Live immz may cause complications while immunosuppresed

[capita98 @capita982]

9- What do all of these lab findings mean for the patient? How does it affect them?

Poor prognostic factors include:
-Renal dz
-HTN
-Male gender
-Age has a biphasic role (young or old at presentation)
-Presence of antiphospholipid Ab
-High overall dz activity

[capita98 @capita982]

8- Anti-dsDNA is a great test for SLE (97% specific), and anti-Smith Is 98% specific when used as a co-test. A clinician could gather more information with C3/C4 complement levels, ESR/CRP, and a urine protein/creatinine ratio as well.

[capita98 @capita982]

7- More often than not you will get a patient with fatigue and arthralgias with few other exam findings. So what can we do?

An ANA is a good place to start. It has great sensitivity/specificity for SLE (100/86) but lots of overlap with other rheumatoid dz (42/85)

[capita98 @capita982]

6- This patient may also be a slam dunk for SLE with lab findings that include +ANA, anti-double stranded DNA (dsDNA) and anti-Smith (Sm) antibodies, anemia, leukopenia, proteinuria, hypoalbuminemia, and urinary sediment.

Unfortunately most patients don't follow the textbook 🤷‍♂️

[capita98 @capita982]

5- 🤯 so where do we even start? Thankfully some symptoms are more common that others. A young female with development of fatigue, arthralgia, and pleuritic chest pain with malar rash, pleural rub, several joints that are TTP, and mild edema will be somewhat straightforward.

[capita98 @capita982]

4- Pulm: ILD, PAH, pleuritis (+/- effusion)
Neuropsych: very broad - seizures, HA, peripheral neuropathy, delirium, even psychosis
Heme: Anemia of chronic dz, leukopenia (50% of pts), poss. thrombocytopenia
Ophtho: 2ndry Sjögren's, retinal vasculopathy, uveitis, iritis

[capita98 @capita982]

3- Cards: pericarditis (affects 25% of SLE patients), endocarditis, myocarditis, Raynaud's phenomenon, vasculitis, thromboembolic status

Renal: glomerulonephritis, hematuria, nephrotic syndrome

GI: pancreatitis, hepatitis, peritonitis, many others

[capita98 @capita982]

2- Symptoms vary widely and can present in just about every system, making it a challenge to recognize:

Const: fatigue, fever, weight loss, myalgias
MSK: arthritis, arthralgias
Derm: cutaneous lupus erythema (malar or 🦋 rash), discoid lesions, photosensitivity