Systemic Lupus
Erythematous
(SLE)
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Lupus
clinical
case
Systemic
lupus
erythematosus
(SLE)
Lupus
clinical
case
Systemic
lupus
erythematosus
(SLE)

Introduction
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● Systemic Lupus Erythematosus (SLE), or lupus, is an autoimmune
disorder where the immune system produces antibodies that
attack the body’s own tissues, causing inflammation in many
different parts of the body such as the skin, joints, brain, lungs,
heart and kidneys.
● SLE predominantly affects women between 12 and 45 (frequently
starting at childbearing age)
INTRODUCTION

Epidemiology

● Female:Male = 9:1
● About 90% of SLE sufferers are women while about 10% are men and children.
● About 90% of women with SLE are in their childbearing years, within the range of 15 to
50 years old.
● In Malaysia, it is estimated that more than 10,000 people have been diagnosed with SLE
over the past 30 years. However, the Malaysian SLE Association believes that there are
many more SLE sufferers in Malaysia who have not been diagnosed.
● In Asians: 30–50/100,000 individuals
● A prevalence of 43/100,000 individuals in Malaysia (2012)
○ Chinese (57/100,000)
○ Malays (33/100,000)
○ Indians (14/100,000)
● Ratio of SLE sufferers : In the West, among Afro-Carribeans 1 in 250-500 people
○ USA – 1 in 2,000 people
○ China – 1 in 1,000 people
EPIDEMIOLOGY

Aetiology
Nuratun ‘Aufa Binti Bahrul Kamil
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AETIOLOGY
The exact etiology is unknown, but several predisposing factors have been
identified.
● Genetic predisposition
○ HLA-DR2 and HLA-DR3 are commonly present in individuals with SLE.
○ Genetic deficiency of classical pathway complement proteins (C1q, C2,
C4) in approx. 10% of affected individuals
● Hormonal factors: Hyperestrogenic states (e.g., due to oral contraceptive use,
postmenopausal hormonal therapy, endometriosis) are associated with an
increased risk of SLE.
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AETIOLOGY
● Environmental factors
○ Cigarette smoking and silica exposure increase the risk of developing
SLE.
○ UV light and EBV infection may trigger disease flares, but there is
insufficient evidence on whether they cause SLE.
○ Drugs such as procainamide or hydralazine
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Pathophysiology
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Pathophysiology
● Autoantibody development: deficiency of classical complement proteins
(C1q, C4, C2) → failure of macrophages to phagocytose immune complexes
and apoptotic cell material (i.e., plasma and nuclear antigens) →
dysregulated, intolerant lymphocytes targeting normally hidden intracellular
antigens → autoantibody production (e.g., ANA, anti-dsDNA)
● Autoimmune reactions
○ Type III hypersensitivity (most common in SLE) → antibody-antigen
complex formation in microvasculature → complement activation and
inflammation → damage to skin, kidneys, joints, small vessels
○ Type II hypersensitivity → IgG and IgM antibodies directed against
antigens on cells (e.g., red blood cells) → cytopenia
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Clinical Features
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Clinical Features
SLE is a systemic disease characterized by phases of remission and relapse.
Some individuals only experience mild symptoms, while others experience
severe symptoms and rapid disease progression. SLE can affect any organ.
Common
● Constitutional: fatigue, fever, weight loss
● Joints (> 90% of cases)
○ Arthritis and arthralgia
○ Distal symmetrical polyarthritis
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Clinical Features
● Skin (85% of cases)
○ Malar rash (butterfly rash)
○ Raynaud phenomenon
○ Photosensitivity → maculopapular rash
○ Discoid rash
○ Oral ulcers (usually painless)
○ Nonscarring alopecia
○ Periungual telangiectasia
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COMPLICATION
Inflammation caused by lupus can affect many areas of the body, including:
● Kidneys. Lupus can cause serious kidney damage, and kidney failure is one of the
leading causes of death among people with lupus.
● Brain and central nervous system. If the brain is affected by lupus, the patient may
experience headaches, dizziness, behavior changes, vision problems, and even strokes
or seizures. Many people with lupus experience memory problems and may have
difficulty expressing their thoughts.
● Blood and blood vessels. Lupus may lead to blood problems, including a reduced
number of healthy red blood cells (anemia) and an increased risk of bleeding or blood
clotting. It can also cause inflammation of the blood vessels.
● Lungs. Having lupus increases the chances of developing an inflammation of the chest
cavity lining, which can make breathing painful. Bleeding into lungs and pneumonia
also are possible.
● Heart. Lupus can cause inflammation of the heart muscle, the arteries or heart
membrane. The risk of cardiovascular disease and heart attacks will increases.

► Having lupus also increases the risk of:
► Infection. People with lupus are more vulnerable to infection because
both the disease and its treatments can weaken the immune system.
► Cancer. Having lupus appears to increase your risk of cancer
► Bone tissue death. This occurs when the blood supply to a bone declines,
often leading to tiny breaks in the bone and eventually to the bone's
collapse.
► Pregnancy complications. Women with lupus have an increased risk of
miscarriage. Lupus increases the risk of high blood pressure during
pregnancy and preterm birth.

Investigation

Lab studies
Finding
1) Complete blood count
- Leukopenia - thrombocytopenia
- Normochromic normocytic anemia - increase in ESR
- +/- autoimmune hemolytic anemia - normal CRP
- Rh factor positive (30-50%) - False positive syphilis serology
- Complement level low (C3 and C4)
2) Autoantibody test
- Antinuclear antibody (ANA) is positive
- Anti ds-DNA -> double stranded DNA is positive (50%)
- Antiphospholipid antibodies (APLs) is positive
- Anti-Sm is positive of people with lupus (30%)
- Anti Ro (SSA) and anti-La (SSB) -> more common in Sjogren syndrome patient.
- Raised igG and IgM
-

3) Urine test
Microalbuminuria
Creatinine clearance increase
Urine microscopic : >5RBCs, >5 WBCs, cellular casts, spot proteins or spot creatinine
(proteinuria +)
4) Liver function test
Mildly elevated in acute SLE in response to NSAIDs
Creatine kinase levels may be elevated

5) Radiologic studies
Joint radiography
-> radiographic anomalies in SLE are periarticular osteopenia and soft tissue swelling without erosions
Chest X-ray CT scan
-> Fluid or inflammation in the lung -> Vasculitis, antiphospholipid, renal failure
-> right sided pleural effusion (yellow) -> Risk of developing pulmonary emboli
-> atelectasis with scarring in the left -> CT angiogram demonstrates filling defect in lung base (blue)
left anterior segmental arrow
CXR: monitor interstitial lung disease & assess pneumonitis, PE, alveolar hemorrhage

5) Radiologic studies
• Brain MRI
-> used to evaluate for CNS lupus white matter changes, vasculitis,
stroke
-> Axial, T2-weighted brain MRI demonstrate area of ischemic in the
right periventricular white matter
6) Joint effusion & CSF studies
• Arthrocentesis
-> cell count range <25% PMNs in noninflammatory effusions to >50% in
inflammatory effusions
-> gross appearance : straw colored or clear, viscosity
(noninflammatory cases) of fluids : yellow, viscosity (inflammatory
cases)
• Lumbar puncture
-> Elevated in nonspecific cell count found in CSF fluid
-> Proteins level increase with CNS lupus
-> Glucose decrease

7) Kidney biopsies
• Help in distinguishing renal lupus from renal vein thrombosis
which may be a complication of antiphospholipid antibody
syndrome
-> serum creatinine increased (absence of sepsis, hypovolemia,
medication)
-> spot protein: proteinuria >1.0g/24 hour
-> proteinuria (0.5g/>24 hours) with;
1) hematuria (>5 RBC/hpf) 2) cellular casts

MANAGEMENT

● Maintaining an active lifestyle to keep joints flexible and may prevent cardiovascular
complications. .
● Patients with lupus should avoid excessive sun exposure because the ultraviolet rays in
sunlight can cause a skin rash to flare, and may even trigger a more serious flare in the
disease itself. Wearing protective clothing (long sleeves, a big-brimmed hat) and using
sunscreen liberally when outdoors on a sunny day should protect against such
complications.
● Develop strategies for maintaining wellness. Wellness involves close attention to the
body, mind, and spirit. One of the primary goals of wellness for people with SLE is
coping with the stress of having a chronic disorder. Effective stress management varies
from person to person. Some approaches that may help include exercise, relaxation
techniques, and setting priorities for spending time and energy.
● Develop and maintain a good support system.A support system may include family,
friends, medical professionals, and support groups such as Persatuan SLE Malaysia.
● Learning more about SLE also helps. Studies have shown that patients who are
well-informed and participate actively in their own care tend to experience less pain,
make fewer visits to the doctor, and remain more active.
Non pharmalogical

1) NSAIDs
- Naproxen sodium
- Ibuprofen
-> treat pain, swelling and fever associated with lupus
-> stomach bleeding, kidney disease and increased risk of heart disease
2) Antimalarial drugs
- Hydroxychloroquine
-> used to treat malaria
-> affect the immune system and help decrease the risk of lupus flares.
-> stomach upset
-> damage to retina eyes (rarely)

3) Corticosteroid
- Prednisone
- Methylprednisolone*
- Triamcinolone (IM)
-> can counter the inflammation of lupus
-> high dose steroids often used to control serious disease that involves
kidneys and brain*
-> weight gain -> HTN
-> easy bruising -> diabetes
-> thinning bones -> risk of infection
4) Immunosuppressants
- Azathioprine - Cyclosporine
- Leflunomide - Mycophenolate
- Methotrexate
-> Drugs that suppress the immune system
-> increased risk of infection
-> liver damage
-> decreased fertility
-> increased risk of cancer

5) Biologics
- Belimumab (IV)
- Rituximab
-> Reduces lupus symptoms in people
-> useful in other medications that haven’t helped
-> Nausea, diarrhea, infections, depression worsening
-> allergic reactions to the intravenous and infections

● https://lupusmalaysia.org/what-is-sle#
● https://www.studocu.com/my/document/universiti-putra-malaysia/medical-doctor/sysytemic-lupus-erythem
atous/5712406
● https://emedicine.medscape.com/article/332244-overview#showall
●
References

THANK
YOU
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Lupus clinical case
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