SYSTEMIC LUPUS ERYTHEMATOSUS

• An autoimmune disorder, non-contagious, chronic, progressive inflammatory disease

of the connective tissue that can cause major body organ and system failure
• Cause is UNKNOWN

Characterized by spontaneous remission and exacerbation

● Remission: absence of disease activity in patient
● Exacerbation:an increased inseverity of the disease (flare-up)

➢ No treatment but there are available drugs to control the manifestations

especially exacerbations
➢ Course of the disease is unpredictable with periods of flares alternating with
remissions
➢ Occurs mostly in young women (15-40 y.o.)
➢ 9x more in women (child-bearing age)
➢ SLE has a ratio of 100 in every 100,000
➢ Affects 1 in 295 black American women

RISK FACTORS
• Genetic abnormality
- It has a genetic link. It does run in the family, multiple genes influence person’s
chance to developing lupus when triggered by environmental factors such as
exposure to sunlight
• Viral infection
 - Researches have sought to find a connection between certain infectious agent
like viruses and bacteria, but no pathogen can be consistently linked to the
disease
• Medications
- Drug-induced lupus erythematosus is a reversible condition
- Once the medication that trigger the episode is stopped, the symptoms will also
disappear
- 38 medications can cause this condition

SIGNS AND SYMPTOMS

● Arthritis (initial manifestation) to arthralgia
o Arthralgia – joint pain
● Weakness, fever, fatigue, weight loss
● Photosensitivity from the sun
● Butterfly rash/malar rash
● Skin lesions
Note:
Possible diagnostic tests if there is inflammation:
o ESR – purple tube
o CRP – red / yellow tube
⬆ ESR and CRP in SLE
For CBC (purple top), half amount of blood from the expected range would be
acceptable. However, for ESR, it should reach the expected amount of blood.
The laboratory will not accept insufficient blood sample. If it is not enough, you
have to explain to the patient and extract blood again.

Characteristics of Skin Lesions

• Margins are bright red
• May extend beyond the hairline
• May occur in the exposed part of the neck
• May spread to the mucous membranes and other tissues of the body
• Do not ulcerate, but cause degeneration and atrophy of tissues involved
o Size of affected tissue will decrease

SYSTEMIC INVOLVEMENT OF OTHER ORGANS

● Lupus nephritis
➢ Renal impairment, kidney problem
➢ Renal Function Tests: BUN andcreatinine
● Pleuritis
➢ Inflammation of the tissue layer thatseparates the lungs
➢ Causes sharp chest pain
➢ Pleuritic pain worsens during inhalation

● Pericarditis – inflammation of the pericardium (thin sac membrane surrounding

the heart)
● Peritonitis – inflammation of the abdomen
● Neuritis – inflammation of the nerve
● Anemia – decreased RBC; decreased iron
➢ Give iron supplements
➢ Diet: high iron diet
Oral medications: Liquid preparation use straw to prevent staining of the teeth.
CLINICAL SYMPTOMS OF SLE

Organ system Symptoms

Musculoskeletal Arthritis, arthralgia

Constitutional Fever (absence of infection), fatigue,

weight loss

Skin Malar (butterfly) rash, alopecia,

photosensitivity, purpura,
Raynaud’s phenomenon,
uritcaria, vasculitis

Gastrointestinal Nausea, vomiting, abdominal pain

Renal Proteinuria, hematuria, nephrotic

syndrome
 Hematologic Anemia, thrombocytopenia, leuokopenia

Cardiac Pericarditis, endocarditis, myocarditis

Neurologic Seizures, psychosis, peripheral

and cranial neuropathies

Pulmonary Pulmonary hypertension,

pleurisy, parenchymal disease

Note:
● Alopecia – hair loss
● Vasculitis – inflammation of the blood vessels
● Purpura – purple spot caused by internal bleeding of the small blood vessels
● Raynaud’s phenomenon – condition when cold temperature and strong emotions
can cause blood vessel spasm that blocks blood flow to the distal parts of the
body (fingers, toes, ears)
o Blockage in blood flow → pallor
o Lack of blood → lack of oxygen→ turns blue/violet (cyanosis)
• Remember: BUN and creatinine when checking for the renal system
• Thrombocytopenia – low platelet count

Note:
● The body is unable to recognize its own cell as part of itself leading to
auto-antibody formation.
● Connected tissue and fibrin deposits collect in blood vessels, collagen fibers, and
organs , which leads to inflammation and necrosis of blood vessels, lymph
nodes, GI (affected lahat)
● RBC - decreased RBC = anemia
● Kidneys
o Proteinuria - presence of protein in urine
o Hematuria – presence of blood in urine
● Platelets: the patient is prone to bleeding
● CNS: High risk to developing seizure, psychosis, cranial neuropathies or
dysfunction
DIAGNOSTIC CRITERIA
● Remember: SOAP BRAIN MD
● Serositis – pleuritis or pericarditis or peritonitis
● Oral ulcers
● Arthritis
● Photosensitivity
● Blood
o Hematological disorder
o Low RBC → anemia
o Low WBC → lymphopenia / lymphocytopenia
o Low platelet → thrombocytopenia
● Renal disorder
● Antinuclear antibody
o Test used to look for any antinuclear antibodies in the blood
o Positive antinuclear antibody = positive to autoimmune disorder
●
● Immunologic disorder
● Neurologic disorder
● Malar rash – butterfly-shaped
● Discoid rash – disc-shaped

DIAGNOSTIC EXAMS
● Medical history
● Complete physical exam
● Laboratory tests
o CBC
o ESR – for inflammation (including CRP)
● ESR - erythrocyte sedimentation rate
● CRP - c-reactive protein
 o U/A
o Blood chemistries
o Complement levels
▪ To measure the amount of activity of complement proteins in the blood
▪ Role of complement system: helps remove foreign pathogens like bacteria,
viruses, damaged cells
● Antinuclear antibodies/ ANA or ANF
o The ANA test measures the pattern and amount of autoantibody which can
attack the body’s tissues as if they were foreign material
o To screen autoimmune disorders
o A blood test to find if there is presence of antinuclear antibodies
● Anti-extractable nuclear antigen (anti-ena)
● Extractable nuclear antigens
● Anti-smith and anti-double stranded DNA (dsdna) - Confirmatory test for SLE
● Skin biopsy
o Tube with contrast medium and a cotton applicator
o Get a sample and put it on the contrast medium
o Can also be done thru surgery, small portion only
● Kidney biopsy

TWO DIAGNOSTIC CLASSIFICATION

1. Simplest classification tree: SLE is diagnosed if a person has an immunologic
disorder (anti-DNA antibody anti-Smith antibody, false positive syphilis test, or LE
cells) or malar rash

2. Full classification tree: Uses 6 criteria

o Serositis
o Oral ulcers
o Arthritis
o Photosensitivity
TREATMENT
● NSAIDS – pain, arthralgia, arthritis
● Anti-microbials
● Corticosteroids – for inflammation
o Taking corticosteroids will make one susceptible to infections because it is an
immunosuppressant
o Can also cause moon face appearance when used long-term because of the
fats that build up around the face
● Alternative therapies
o Special diet
o Nutritional supplement
o Fish oils
o Ointments and creams
o Chiropractics
● Arthritis may be present or possible malformations, so the goal is to correct the
alignment and support body’s structural ability
● What will be our management?
➢ Supportive care
➢ Rest when disease is active
➢ Exercise to maintain mobility
➢ Avoid sun
o Sunscreen
o Exercise and rest
o Stress reduction
o Family planning
o Yearly influenza and pneumococcal vaccination
Note:
• Encourage compliance to medication because of the increased risk of systemic
involvement. It would be detrimental if renal and cardiovascular are also
affected.
• Possible Nursing Diagnosis
o Fatigue
o Impaired skin integrity
o Body image disturbance
o Anxiety
o Possible knowledge deficit

WHAT TO AVOID
• Aromatic amines present in cleaning agents and hair dyes (can trigger or worsen
symptoms of lupus)
• Silicone and silica dust
• Alfalfa sprouts due to their high L- canavanine content
• Hydrazines found in some mushrooms andin tobacco smoke
• Tartrazines found as preservatives in food dyes
• Ultraviolet light
• Excess alcohol

MEDICATIONS
• Anti-inflammatory analgesics - NSAIDs and Aspirin
o Effective in managing cutaneous, musculoskeletal and mild systemic feature of
SLE
• Antimalarial drug: Hydroxychloroquine (Planequil)
o For constitutional, cutaneous, and articular manifestations
• Corticosteroids (Prednisone) in high doses
o Has anti-inflammatory response
 o It will decrease immune system and become susceptible to infection
(immunosuppressant)
• Topical Corticosteroids
• Cytotoxic Agents or Antineoplastic
o Chemotherapeutic drugs
o For severe glomerulonephritis and other organ damaging complications

Note:
• When a person is taking corticosteroids for a long time, para silang merong Cushing
syndrome
• In Cushing syndrome, there is HIGH 3S (sodium, sugar, sex drive/libido)
• Addison’s disease – opposite ng Cushing syndrome kasi LOW ang sodium, sugar, and
sex drive (SSS)

OTHER MANAGEMENT
• Kidney dialysis – during worst case scenario
• Total hip replacement – due to the arthritis
o Surgical procedure in which deceased parts of the hip joint are removed and replaced
with a new prosthesis

o The goal is to improve the mobility of the patient

o What is the first symptom of lupus?
ARTHRALGIA or JOINT PAIN
o In SLE, there is a bilateral joint pain
Plasmapheresis
o Plasma – liquid part of the blood; it is separated from the blood cells
o The plasma is typically replaced by other solution such as saline or
albumin, OR the plasma will be treated then returned to the body
o Sometimes, when plasma is treated, it will be frozen and eventually be used to
manufacture medication