Systemic lupus erythematosus physical examination: Difference between revisions

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==Overview==
==Overview==
In the earlier stages of the disease, the patients are more well-appearing while in the late stages of the disease, patients are ill with multi-organ involvement.  
In the earlier stages of the disease, patients appear well, while in the late stages of the disease, patients are clearly ill with multi-organ involvement. The patient may show a wide range of skin manifestations including [[urticaria]], [[Bullous|bullous lesions]], [[malar rash]], and scarring [[alopecia]]. The patient may develop nasal and [[oral ulcers]]. [[Arthritis]] may lead to a decreased [[range of motion]], joint effusion, and [[arthralgia]]. Neurological manifestations including [[psychosis]], [[cognitive impairment]], and [[hallucinations]], may also be present. 


==Physical Examination==
==Physical Examination==
===Appearance of the Patient===
===Appearance of the Patient===
*In the earlier stages of the disease, the patients are more well-appearing.
*Patient appears well in the earlier stages of the disease
*In the late stages of the disease, patients are ill with multi-organ involvement.
*Patient appears ill in the late stages of the disease due to multi-organ involvement
===Vital Signs===
===Vital Signs===
*Fever More than 38o C aft er the exclusion of infection
*[[Fever]] higher than 38 after the exclusion of [[infection]]
*[[Tachycardia]]/ [[Bradycardia]] depends on the accompanying complication
*[[Tachycardia]]/[[bradycardia]] depends on the accompanying complication
*Tachypnea / bradypnea depends on the accompanying complication
*[[Tachypnea]]/[[bradypnea]] depends on the accompanying complication
===Skin===
 
<ref name="pmid25077888">{{cite journal |vauthors=Parodi A, Cozzani E |title=Cutaneous manifestations of lupus erythematosus |journal=G Ital Dermatol Venereol |volume=149 |issue=5 |pages=549–54 |year=2014 |pmid=25077888 |doi= |url=}}</ref><ref name="pmid26985173">{{cite journal |vauthors=Szczęch J, Rutka M, Samotij D, Zalewska A, Reich A |title=Clinical characteristics of cutaneous lupus erythematosus |journal=Postepy Dermatol Alergol |volume=33 |issue=1 |pages=13–7 |year=2016 |pmid=26985173 |pmc=4793050 |doi=10.5114/pdia.2014.44031 |url=}}</ref><ref name="pmid19824738">{{cite journal |vauthors=Walling HW, Sontheimer RD |title=Cutaneous lupus erythematosus: issues in diagnosis and treatment |journal=Am J Clin Dermatol |volume=10 |issue=6 |pages=365–81 |year=2009 |pmid=19824738 |doi=10.2165/11310780-000000000-00000 |url=}}</ref>
=== Skin<ref name="pmid25077888">{{cite journal |vauthors=Parodi A, Cozzani E |title=Cutaneous manifestations of lupus erythematosus |journal=G Ital Dermatol Venereol |volume=149 |issue=5 |pages=549–54 |year=2014 |pmid=25077888 |doi= |url=}}</ref><ref name="pmid26985173">{{cite journal |vauthors=Szczęch J, Rutka M, Samotij D, Zalewska A, Reich A |title=Clinical characteristics of cutaneous lupus erythematosus |journal=Postepy Dermatol Alergol |volume=33 |issue=1 |pages=13–7 |year=2016 |pmid=26985173 |pmc=4793050 |doi=10.5114/pdia.2014.44031 |url=}}</ref><ref name="pmid19824738">{{cite journal |vauthors=Walling HW, Sontheimer RD |title=Cutaneous lupus erythematosus: issues in diagnosis and treatment |journal=Am J Clin Dermatol |volume=10 |issue=6 |pages=365–81 |year=2009 |pmid=19824738 |doi=10.2165/11310780-000000000-00000 |url=}}</ref> ===
*[[Cyanosis]]
*[[Cyanosis]]
**Secondary to repiratory complications
**Secondary to [[respiratory]] complications
*[[Jaundice]]
*[[Jaundice]]
**Secondary to hepatitis complications
**Secondary to [[hepatitis]]
*[[Pallor]]
*[[Pallor]]
**Secondary to anemia
**Secondary to [[anemia]]
*Generalised erythema
*Generalised [[erythema]]
*Bruises
*[[Bruises]]
**Secondary to thrombocytopenia
**Secondary to [[thrombocytopenia]]
*Urticaria
*[[Urticaria]]
*Bullous lesions
*[[Bullous|Bullous lesions]]
*Sclerodactyly
*[[Sclerodactyly]]
*Skin ulceration
*Skin [[Ulcerations|ulceration]]
*Malar rash. The classic lupus ‘butterfly’ rash
*[[Malar rash]]: the classic lupus ‘butterfly’ rash
** Erythematous, elevated lesion, pruritic or painful, in a malar distribution, commonly precipitated by exposure to sunlight
** [[Erythema|Erythematous]], elevated [[Lesions|lesion]], [[Pruritis|pruritic]] or painful, in a [[malar]] distribution, commonly precipitated by exposure to sunlight
* Annular or psoriasiform skin lesions
* Annular or psoriasiform skin [[lesions]]
** Small, erythematous, slightly scaly papules that evolve into either a psoriasiform (papulosquamous) or annular form and tend to involve shoulders, forearms, neck, and upper torso
** Small, [[erythematous]], slightly scaly [[papules]] that evolve into either a psoriasiform (papulosquamous) or annular form and tend to involve shoulders, forearms, neck, and upper torso
* Scarring chronic alopecia
* [[Scarring]] [[chronic]] [[alopecia]]
** Mostly present on face, neck, and scalp
** Mostly present on face, neck, and scalp
* Telangiectasias
* [[Telangiectasias]]
* Dyspigmentation (hyper- or hypopigmentation) of skin in scar places
* Dyspigmentation ([[hyperpigmentation]] or [[hypopigmentation]]) of skin in [[scar]] places
* Follicular plugging
* Follicular plugging
** Discrete, erythematous, slightly infiltrated plaques covered by a well-formed adherent scale that extends into dilated hair follicles  
** Discrete, [[erythematous]], slightly infiltrated [[plaques]] covered by a well-formed adherent scale that extends into dilated [[hair follicles]]
* Nodules
* [[Nodules]]
** Can be firm (Lupus profundus) and often are painful
** Can be firm (Lupus profundus) and painful
* photodistributed lesions with chronic pink indurated plaques or broad lesions that are slow to heal (more seen in lupus tumidus)
* Photodistributed [[lesions]] with chronic pink indurated plaques or broad [[lesions]] that are slow to heal (more seen in lupus tumidus)
* Thin hair that easily fractures (lupus hair)
* Thin hair that easily fractures (lupus hair)
* Irregularly shaped raised white plaques, areas of erythema, silvery white scarred lesions, and ulcers with surrounding erythema on the soft or hard palate or buccal mucosa
* Irregularly shaped raised white plaques, areas of erythema, silvery white scarred [[lesions]], and [[ulcers]] with surrounding [[erythema]] on the soft or hard palate or buccal [[mucosa]]
* Periungual erythema
* Periungual [[erythema]]
** Dilated tortuous loops of capillaries and a prominent subcapillary venous plexus along  
** Dilated tortuous loops of [[capillaries]] and a prominent subcapillary venous plexus along  
** Involves the base of the nail and edges of the upper eyelid
** Involves the base of the nail and edges of the upper [[eyelid]]
[[File:Systemic lupus erythematosus 055.jpg|300px]]
'''For more pictures of the rash presentation in lupus, click [[Systemic lupus eryhthematosus physical examination:Gallery|here]].'''
 
===HEENT===
===HEENT===
*Ophthalmology<ref name="pmid26367085">{{cite journal |vauthors=Preble JM, Silpa-archa S, Foster CS |title=Ocular involvement in systemic lupus erythematosus |journal=Curr Opin Ophthalmol |volume=26 |issue=6 |pages=540–5 |year=2015 |pmid=26367085 |doi=10.1097/ICU.0000000000000209 |url=}}</ref><ref name="pmid25904124">{{cite journal |vauthors=Silpa-archa S, Lee JJ, Foster CS |title=Ocular manifestations in systemic lupus erythematosus |journal=Br J Ophthalmol |volume=100 |issue=1 |pages=135–41 |year=2016 |pmid=25904124 |doi=10.1136/bjophthalmol-2015-306629 |url=}}</ref>
*[[Ophthalmology]]<ref name="pmid26367085">{{cite journal |vauthors=Preble JM, Silpa-archa S, Foster CS |title=Ocular involvement in systemic lupus erythematosus |journal=Curr Opin Ophthalmol |volume=26 |issue=6 |pages=540–5 |year=2015 |pmid=26367085 |doi=10.1097/ICU.0000000000000209 |url=}}</ref><ref name="pmid25904124">{{cite journal |vauthors=Silpa-archa S, Lee JJ, Foster CS |title=Ocular manifestations in systemic lupus erythematosus |journal=Br J Ophthalmol |volume=100 |issue=1 |pages=135–41 |year=2016 |pmid=25904124 |doi=10.1136/bjophthalmol-2015-306629 |url=}}</ref>
**[[Nystagmus]]
**[[Nystagmus]]
**Visual Retinal changes from systemic lupus erythematosus cytoid bodies, retinal haemorrhages, serous exudate or haemorrhage in the choroid, optic neuritis (not due to hypertension, drugs or infection)
**Visual [[Retinal|retinal changes]] from systemic lupus erythematosus cytoid bodies, [[Retina|retinal]] [[haemorrhages]], serous exudate or [[haemorrhage]] in the [[choroid]], [[optic neuritis]] (not due to [[hypertension]], drugs or [[infection]])
**Cataract
**[[Cataract]]
**Optic nerve atrophy
**[[Optic nerve atrophy]]
*Icteric sclera
**[[Icterus|Icteric sclera]]
*Cotton wool spots in the retina in ophthalmoscopic exam
**[[Cotton wool spots]] in the [[retina]] in [[Ophthalmoscopy|ophthalmoscopic exam]]
*Nasal ulcers<ref name="pmid1526055">{{cite journal |vauthors=Robson AK, Burge SM, Millard PR |title=Nasal mucosal involvement in lupus erythematosus |journal=Clin Otolaryngol Allied Sci |volume=17 |issue=4 |pages=341–3 |year=1992 |pmid=1526055 |doi= |url=}}</ref>
*Nasal [[ulcers]]<ref name="pmid1526055">{{cite journal |vauthors=Robson AK, Burge SM, Millard PR |title=Nasal mucosal involvement in lupus erythematosus |journal=Clin Otolaryngol Allied Sci |volume=17 |issue=4 |pages=341–3 |year=1992 |pmid=1526055 |doi= |url=}}</ref>
**Mostly painless
**Mostly painless
**Mostly in lower nasal septum and bilateral and parallel
**Mostly in lower [[nasal septum]] and [[bilateral]] and parallel
**Nasal perforation secondary to vasculitis may happen rarely
**Nasal perforation secondary to [[vasculitis]] may happen rarely
*Oral ulcers<ref name="pmid23780804">{{cite journal |vauthors=Anyanwu CO, Ang CC, Werth VP |title=Oral mucosal involvement in bullous lupus |journal=Arthritis Rheum. |volume=65 |issue=10 |pages=2622 |year=2013 |pmid=23780804 |pmc=4333153 |doi=10.1002/art.38051 |url=}}</ref><ref name="pmid23248469">{{cite journal |vauthors=Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM |title=Oral discoid lupus erythematosus: A study of twenty-one cases |journal=J Oral Maxillofac Pathol |volume=16 |issue=3 |pages=368–73 |year=2012 |pmid=23248469 |pmc=3519212 |doi=10.4103/0973-029X.102487 |url=}}</ref>
*Oral [[ulcers]]<ref name="pmid23780804">{{cite journal |vauthors=Anyanwu CO, Ang CC, Werth VP |title=Oral mucosal involvement in bullous lupus |journal=Arthritis Rheum. |volume=65 |issue=10 |pages=2622 |year=2013 |pmid=23780804 |pmc=4333153 |doi=10.1002/art.38051 |url=}}</ref><ref name="pmid23248469">{{cite journal |vauthors=Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM |title=Oral discoid lupus erythematosus: A study of twenty-one cases |journal=J Oral Maxillofac Pathol |volume=16 |issue=3 |pages=368–73 |year=2012 |pmid=23248469 |pmc=3519212 |doi=10.4103/0973-029X.102487 |url=}}</ref>
**Mostly painless
**Mostly painless
**White plaques with areas of erythema, or punched-out erosions or ulcers with surrounding erythema on the soft or hard palate or buccal mucosa
**White plaques with areas of [[erythema]], or punched-out erosions or ulcers with surrounding [[erythema]] on the soft or hard palate or [[buccal mucosa]]


===Neck===
===Neck<ref name="pmid19107085">{{cite journal |vauthors=Melikoglu MA, Melikoglu M |title=The clinical importance of lymphadenopathy in systemic lupus erythematosus |journal=Acta Reumatol Port |volume=33 |issue=4 |pages=402–6 |year=2008 |pmid=19107085 |doi= |url=}}</ref><ref name="pmid24722263">{{cite journal |vauthors=Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T |title=Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study |journal=PLoS ONE |volume=9 |issue=4 |pages=e94511 |year=2014 |pmid=24722263 |pmc=3983200 |doi=10.1371/journal.pone.0094511 |url=}}</ref>===
*[[Jugular venous distension]]
*[[Jugular venous distension]]
**Secondary to hypertension and cardiac complications
**Secondary to [[hypertension]] and cardiac complications
*Lymphadenopathy  
*[[Lymphadenopathy]]
** Lymph nodes are soft, non-tender, discrete
** [[Lymph node|Lymph nodes]] are soft, non-tender, discrete
** Usually detected in the cervical, axillary, and inguinal
** Usually detected in the [[cervical]], [[axillary]], and [[inguinal]]
===Lungs===
 
*Fine and coarse [[crackles]] upon auscultation of the lung
===Lungs<ref name="pmid21194884">{{cite journal |vauthors=Torre O, Harari S |title=Pleural and pulmonary involvement in systemic lupus erythematosus |journal=Presse Med |volume=40 |issue=1 Pt 2 |pages=e19–29 |year=2011 |pmid=21194884 |doi=10.1016/j.lpm.2010.11.004 |url=}}</ref><ref name="pmid26550810">{{cite journal |vauthors=Salvati F |title=[The involvement of pulmonary interstitial tissue in multisystemic lupus erythematosus: interdisciplinarity and role of the pneumologists] |language=Italian |journal=Clin Ter |volume=166 |issue=5 |pages=205–7 |year=2015 |pmid=26550810 |doi= |url=}}</ref><ref name="pmid25639532">{{cite journal |vauthors=Alamoudi OS, Attar SM |title=Pulmonary manifestations in systemic lupus erythematosus: association with disease activity |journal=Respirology |volume=20 |issue=3 |pages=474–80 |year=2015 |pmid=25639532 |pmc=4418345 |doi=10.1111/resp.12473 |url=}}</ref>===
*In case of pleural effusion:
*Fine and coarse [[crackles]] upon auscultation of the [[lung]]
**Asymmetric tactile fremitus
**May be due to [[pneumonitis]]
**Asymmetric chest expansion
*In case of [[pleural effusion]]:
===Heart===
**Asymmetric [[tactile fremitus]]
*Chest tenderness upon palpation
**Asymmetric [[chest expansion]]
*Diastolic murmur, or systolic murmur >3/6 due to valvular disease
*Chest pain or discomfort secondary to costochondritis
*Loud second heart sound (due to pulmonary hypertension)


===Abdomen===
===Heart<ref name="pmid24790989">{{cite journal |vauthors=Mak A, Kow NY |title=Imbalance between endothelial damage and repair: a gateway to cardiovascular disease in systemic lupus erythematosus |journal=Biomed Res Int |volume=2014 |issue= |pages=178721 |year=2014 |pmid=24790989 |pmc=3984775 |doi=10.1155/2014/178721 |url=}}</ref><ref name="pmid24722263">{{cite journal |vauthors=Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T |title=Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study |journal=PLoS ONE |volume=9 |issue=4 |pages=e94511 |year=2014 |pmid=24722263 |pmc=3983200 |doi=10.1371/journal.pone.0094511 |url=}}</ref><ref name="pmid23052654">{{cite journal |vauthors=Canpolat N, Kasapcopur O, Caliskan S, Gokalp S, Bor M, Tasdemir M, Sever L, Arisoy N |title=Ambulatory blood pressure and subclinical cardiovascular disease in patients with juvenile-onset systemic lupus erythematosus |journal=Pediatr. Nephrol. |volume=28 |issue=2 |pages=305–13 |year=2013 |pmid=23052654 |doi=10.1007/s00467-012-2317-3 |url=}}</ref>===
*Chest [[tenderness]] or discomfort upon palpation
**May be due to [[costochondritis]]
*[[Diastolic murmurs|Diastolic murmur]], or [[Systolic murmurs|systolic murmur]] >3/6 due to [[valvular disease]]
*Loud second heart sound (due to [[pulmonary hypertension]])
*Loud S1-S2 due to [[cardiomegaly]]
*Decrease heart sounds if associated with [[pericardial effusion]]
 
===Abdomen<ref name="pmid20572299">{{cite journal |vauthors=Tian XP, Zhang X |title=Gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment |journal=World J. Gastroenterol. |volume=16 |issue=24 |pages=2971–7 |year=2010 |pmid=20572299 |pmc=2890936 |doi= |url=}}</ref><ref name="pmid27329649">{{cite journal |vauthors=Alves SC, Fasano S, Isenberg DA |title=Autoimmune gastrointestinal complications in patients with systemic lupus erythematosus: case series and literature review |journal=Lupus |volume=25 |issue=14 |pages=1509–1519 |year=2016 |pmid=27329649 |doi=10.1177/0961203316655210 |url=}}</ref><ref name="pmid27055518">{{cite journal |vauthors=Fawzy M, Edrees A, Okasha H, El Ashmaui A, Ragab G |title=Gastrointestinal manifestations in systemic lupus erythematosus |journal=Lupus |volume=25 |issue=13 |pages=1456–1462 |year=2016 |pmid=27055518 |doi=10.1177/0961203316642308 |url=}}</ref><ref name="pmid28523968">{{cite journal |vauthors=Li Z, Xu D, Wang Z, Wang Y, Zhang S, Li M, Zeng X |title=Gastrointestinal system involvement in systemic lupus erythematosus |journal=Lupus |volume= |issue= |pages=961203317707825 |year=2017 |pmid=28523968 |doi=10.1177/0961203317707825 |url=}}</ref>===
*[[Abdominal distention]]
*[[Abdominal distention]]
*Ascitis
*[[Ascites]]
**Due to nephrotic syndrome
**Due to [[nephrotic syndrome]]
*Abdominal pain
*[[Abdominal pain]]
**Due to mesentric vasculitis
**Due to [[Vasculitis|mesentric vasculitis]]
*[[Hepatomegaly]]
*[[Hepatomegaly]]
*[[splenomegaly]]
*[[Splenomegaly]]
===Extremities===
*Costo-vertebral angle tenderness
 
===Extremities<ref name="pmid15580980">{{cite journal |vauthors=Zoma A |title=Musculoskeletal involvement in systemic lupus erythematosus |journal=Lupus |volume=13 |issue=11 |pages=851–3 |year=2004 |pmid=15580980 |doi=10.1191/0961203303lu2021oa |url=}}</ref><ref name="pmid22956550">{{cite journal |vauthors=Gabba A, Piga M, Vacca A, Porru G, Garau P, Cauli A, Mathieu A |title=Joint and tendon involvement in systemic lupus erythematosus: an ultrasound study of hands and wrists in 108 patients |journal=Rheumatology (Oxford) |volume=51 |issue=12 |pages=2278–85 |year=2012 |pmid=22956550 |doi=10.1093/rheumatology/kes226 |url=}}</ref><ref name="pmid19591780">{{cite journal |vauthors=Grossman JM |title=Lupus arthritis |journal=Best Pract Res Clin Rheumatol |volume=23 |issue=4 |pages=495–506 |year=2009 |pmid=19591780 |doi=10.1016/j.berh.2009.04.003 |url=}}</ref><ref name="pmid24862229">{{cite journal |vauthors=Zhu KK, Xu WD, Pan HF, Zhang M, Ni J, Ge FY, Ye DQ |title=The risk factors of avascular necrosis in patients with systemic lupus erythematosus: a meta-analysis |journal=Inflammation |volume=37 |issue=5 |pages=1852–64 |year=2014 |pmid=24862229 |doi=10.1007/s10753-014-9917-y |url=}}</ref><ref name="pmid23731640">{{cite journal |vauthors=Voulgari PV, Kosta P, Argyropoulou MI, Drosos AA |title=Avascular necrosis in a patient with systemic lupus erythematosus |journal=Joint Bone Spine |volume=80 |issue=6 |pages=665 |year=2013 |pmid=23731640 |doi=10.1016/j.jbspin.2013.03.018 |url=}}</ref>===
*[[Clubbing]]
*[[Clubbing]]
*[[Cyanosis]]
*[[Cyanosis]]
*Muscle atrophy or weakness
*[[Muscle weakness|Muscle atrophy or weakness]]
*Livedo reticularis
*[[Livedo reticularis]]
**Reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
**Reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
*Arthritis
*[[Arthritis]]
**Symmetrical
**Symmetrical
**Polyarticular
**Polyarticular
**Mostly involve knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint
**Mostly involve knees, carpal joints, and joints of the fingers, especially the proximal [[interphalangeal]] (PIP) joint
*Decrease in affected joints range of motion
**Decrease range of motion in affected joints
*Joints erythema
*Joints [[erythema]]
**Due to synovitis
**Due to [[synovitis]]
*Joint effusion
*Joint effusion
*Muscle atrophy
*Muscle [[atrophy]]
*Fasciculations in the upper/lower extremity
*[[Fasciculations]] in the upper/lower extremity
*Claudication
*[[Claudication]]
*Loss of digit or limb
*Loss of digit or limb


===Neuromuscular===
===Neuromuscular<ref name="pmid19366083">{{cite journal |vauthors=Cojocaru IM, Cojocaru M, Tănăsescu R, Burcin C, Atanasiu AN, Silosi I |title=Detection of autoantibodies to ribosome P in lupus patients with neurological involvement |journal=Rom J Intern Med |volume=46 |issue=3 |pages=239–42 |year=2008 |pmid=19366083 |doi= |url=}}</ref><ref name="pmid22594009">{{cite journal |vauthors=Madrane S, Ribi C |title=[Central neuropsychiatric involvement in systemic lupus erythematosus] |language=French |journal=Rev Med Suisse |volume=8 |issue=337 |pages=848–53 |year=2012 |pmid=22594009 |doi= |url=}}</ref><ref name="pmid7555923">{{cite journal |vauthors=Sivri A, Hasçelik Z, Celiker R, Başgöze O |title=Early detection of neurological involvement in systemic lupus erythematosus patients |journal=Electromyogr Clin Neurophysiol |volume=35 |issue=4 |pages=195–9 |year=1995 |pmid=7555923 |doi= |url=}}</ref><ref name="pmid19217587">{{cite journal |vauthors=Juncal Gallego L, Almuíña Simón C, Muíños Esparza LF, Díaz Soto R, Ramil Fraga C, Quiroga Ordóñez E |title=[Systemic lupus erythematosus with fulminant neurological involvement] |language=Spanish; Castilian |journal=An Pediatr (Barc) |volume=70 |issue=2 |pages=202–4 |year=2009 |pmid=19217587 |doi=10.1016/j.anpedi.2008.09.009 |url=}}</ref>===
*Patient is usually oriented to persons, place, and time based on the disease course
*Patient is usually oriented to persons, place, and time based on the disease course
*Cognitive impairment
*[[Cognitive impairment]]
*Hallucinations
*[[Hallucination|Hallucinations]]
**[[Visual hallucinations|Visual]]
**[[Auditory hallucinations|Auditory]]
*Memory deficit
*Memory deficit
**Loose associations
**Loose associations
Line 117: Line 129:
**Illogical thinking
**Illogical thinking
**Bizarre disorganised or catatonic behaviour
**Bizarre disorganised or catatonic behaviour
{| class="wikitable"
==Gallery==
!
!
!
!
|-
|Constitutional symptoms
|Fatigue
|the most common complaint 11085805
multidimensional phenomenon due to different factors 7779127
 
does not correlate with disease activity 9598886
|frequently associated with depression, sleep disturbances, and concomitant fibromyalgia
|-
|
|Fever
|a manifestation of active disease-lupus flare, especially within short-term evolution of the disease 14530779
Can be hard to differentiate the cause of fever from other inflammatory and infection diseases
 
Leukopenia or normal range of leukocytes in the setting of fever is more suggestive of lupus activity rather than infection
|
|-
|
|Myalgia
muscle tenderness
 
muscle weakness
|may be first complaint and initial reason for the patient to seeks medical attention
May happen as a result of treatment with glucocorticoids or glucocorticoid withdrawal
|perivascular and perifascicular mononuclear cell infiltrates in 25 percent of patients
muscle atrophy, microtubular inclusions, mononuclear infiltrate, fiber necrosis, and, occasionally, vacuolated muscle fibers  2319520
|-
|
|Weight change
|
* Weight loss due to:
** Decreased appetite
** Side effects of medications (particularly diuretics)
** Gastrointestinal symptoms related to lupus (e.g. gastroesophageal reflux, abdominal pain, peptic ulcer disease, or pancreatitis)
* Weight gain due to:
** Hypoalbuminemia:
*** Result in salt and water retention (e.g. due to nephrotic syndrome or protein losing enteropathy)
** Increased appetite associated with the use of glucocorticoids
|
|-
|Extremities
|Arthritis
|
* migratory arthritis means that the symptoms may be gone by 24 hours
* Usually symmetrical and polyarticular with a predilection for the knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint
* Morning stiffness with a really short duration (less than 1 hour)
* Painful arthritis and decrease range of motion
* The SLE arthritis is mostly nondeforming
* It has been noted that 15-50% of patients may develop flexion deformities, ulnar deviation, soft tissue laxity, and swan neck deformities 3041493  9849313 19591780 7841997
12528115
* Synovial effusions are infrequent in patients with SLE, usually small with slightly cloudy or clear fluid
* septic arthritis may occurs as a result of low immune response and medication. it can be secondary to infections with Salmonella, gonococci, meningococci, and other organisms
|
|-
|Skin and mucous membrane involvement 
|acute cutaneous lupus erythema (ACLE) (also known as “the butterfly rash”)
|
* Localized ACLE (ie, malar rash, butterfly rash)
* Generalized ACLE
* Toxic epidermal necrolysis-like ACLE
presents as erythema in a malar distribution over the cheeks and nose (but sparing the nasolabial folds), which appears after sun exposure
|
|-
|
|discoid lesions
|more inflammatory and which have a tendency to scar
|
|-
|
|Photosensitivity
|common theme for skin lesions associated with SLE
|
|-
|
|oral and/or nasal ulcers
|usually painless
|
|-
|
|Nonscarring alopecia
|may occur at some point during the course of their disease
|
|-
|
|Subacute cutaneous lupus erythematosus (SCLE)
 
|Annular SCLE
 
Papulosquamous SCLE
 
Drug-induced SCLE
 
Less common variants: erythrodermic, poikilodermatous, erythema multiforme-like (Rowell syndrome), and vesiculobullous annular SCLE
|
|-
|
|Chronic cutaneous lupus erythematosus (CCLE)
|Discoid lupus erythematosus (DLE)
 
Localized DLE
 
Generalized DLE
 
Hypertrophic DLE
 
Lupus erythematosus tumidus (LE tumidus)
 
Lupus profundus (also known as lupus panniculitis)
 
Chilblain lupus erythematosus (chilblain LE)
 
Lichenoid cutaneous lupus erythematosus-lichen planus overlap syndrome (LE-LP overlap syndrome)
|
|-
|nephritis
|Minimal mesangial lupus nephritis (class I)
|the earliest and mildest form of glomerular involvement
normal urinalysis, no or minimal proteinuria, and a normal serum creatinine
 
mesangial immune deposits that are identified by immunofluorescence alone or by both immunofluorescence and electron microscopy, but such patients do not have light microscopic abnormalities
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|-
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|Mesangial proliferative lupus nephritis (class II) 
|microscopic hematuria and/or proteinuria
 
Light microscope:
 
mesangial hypercellularity (of any degree) or mesangial matrix expansion
 
A few isolated subepithelial or subendothelial deposits may be seen on immunofluorescence or electron microscopy
 
|
|-
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|Focal lupus nephritis (class III) 
|hematuria and proteinuria
 
may also have hypertension, a decreased glomerular filtration rate, and/or nephrotic syndrome
 
Light microscopy: Active or inactive endocapillary or extracapillary segmental glomerulonephritis (Less than 50 percent of glomeruli are affected)
 
Electron microscopy: immune deposits in the subendothelial space of the glomerular capillary and mesangium
 
Glomeruli affected by fibrinoid necrosis and crescents
 
Presence of tubulointerstitial or vascular abnormalities
|Class III (A)=focal proliferative lupus nephritis
 
class III disease with active lesions
 
Class III (C)=focal sclerosing lupus nephritis
 
chronic inactive lesions with scarring
 
|-
|
|Diffuse lupus nephritis (class IV)
|most common and most severe form 
 
Hematuria and proteinuria
 
nephrotic syndrome, hypertension, and reduced glomerular filtration rate
 
hypocomplementemia (especially C3) and elevated anti-DNA levels, especially during active disease 
7231154
 
Light microscopy: more than 50 percent of glomeruli are affected that display endocapillary with or without extracapillary glomerulonephritis and Mesangial abnormalities
 
Electron microscopy: subendothelial deposits, at least during the active phase and diffuse wire loop deposits, but with little or no glomerular proliferation
 
|This class is classified based on the tissue involvement to segmentally (S) or globally (G), and based on the inflammatory activity (or chronicity) of the lesions into 6 subclasses include:
 
Class IV-S (A)
 
Class IV-G (A)
 
Class IV-S (A/C)
 
Class IV-G (A/C)
 
Class IV-S (C)
 
Class IV-G (C)
 
|-
|Vascular abnormalities
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|Livedo reticularis
|a reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
 
induced by vasospasm of the dermal ascending arterioles
 
Vasospasm in these cutaneous vessels 
 
Pathologic examination of involved blood vessels reveals thickening of the walls of the dermal vessels with subsequent narrowing of the lumens and, in some cases, intravascular thrombi
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|-
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|Raynaud phenomenon
|vasospastic process
blanching of the nail beds, fingers, and toes (and occasionally ears, nose, tongue, and nipples) with accompanying pain
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|Vasculitis
|urticarial vasculitis: lesions may remain for more than 24 hours and frequently evolve into painful petechiae or purpura that may heal with hyperpigmentation
small arteries involvement: microinfarcts of the tips of the fingers, the toes, the cuticles of the nail folds (splinter hemorrhages), and the extensor surface of the forearm and shin
 
Periarteritis nodosa-like lesions may occur
|
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|Nail abnormalities
|
|pitting, ridging, and onycholysis
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|Mucosal manifestations
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|painless oral ulcers 
 
|Treatment: topical corticosteroids, tacrolimus 0.1% ointment, intralesional corticosteroids, and systemic antimalarial drugs
|-
|Bullous cutaneous lupus erythematosus
|rare and distinct complication of SLE 
|
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====Skin====


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Latest revision as of 19:03, 4 August 2017

Systemic lupus erythematosus Microchapters

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Case #1

Systemic lupus erythematosus physical examination On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

In the earlier stages of the disease, patients appear well, while in the late stages of the disease, patients are clearly ill with multi-organ involvement. The patient may show a wide range of skin manifestations including urticaria, bullous lesions, malar rash, and scarring alopecia. The patient may develop nasal and oral ulcers. Arthritis may lead to a decreased range of motion, joint effusion, and arthralgia. Neurological manifestations including psychosis, cognitive impairment, and hallucinations, may also be present. 

Physical Examination

Appearance of the Patient

  • Patient appears well in the earlier stages of the disease
  • Patient appears ill in the late stages of the disease due to multi-organ involvement

Vital Signs

Skin[1][2][3]

For more pictures of the rash presentation in lupus, click here.

HEENT

Neck[9][10]

Lungs[11][12][13]

Heart[14][10][15]

Abdomen[16][17][18][19]

Extremities[20][21][22][23][24]

Neuromuscular[25][26][27][28]

  • Patient is usually oriented to persons, place, and time based on the disease course
  • Cognitive impairment
  • Hallucinations
  • Memory deficit
    • Loose associations
    • Impoverished thought content
    • Illogical thinking
    • Bizarre disorganised or catatonic behaviour

Gallery

Discoid Lupus Erythematosus
Head
Face
Lupus Erythematosus-Systemic
Face
Extremity
Trunk

Lupus Erythematosus Chronicus Disseminatus Superficialis

Lupus Erythematosus Chronicus Verrucous

Lupus Erythematosus Profundus

Lupus Erythematosus-Subacute Cutaneous Lupus Erythematosus

Lupus Vulgaris

References

  1. ↑ Parodi A, Cozzani E (2014). "Cutaneous manifestations of lupus erythematosus". G Ital Dermatol Venereol. 149 (5): 549–54. PMID 25077888.
  2. ↑ Szczęch J, Rutka M, Samotij D, Zalewska A, Reich A (2016). "Clinical characteristics of cutaneous lupus erythematosus". Postepy Dermatol Alergol. 33 (1): 13–7. doi:10.5114/pdia.2014.44031. PMC 4793050. PMID 26985173.
  3. ↑ Walling HW, Sontheimer RD (2009). "Cutaneous lupus erythematosus: issues in diagnosis and treatment". Am J Clin Dermatol. 10 (6): 365–81. doi:10.2165/11310780-000000000-00000. PMID 19824738.
  4. ↑ Preble JM, Silpa-archa S, Foster CS (2015). "Ocular involvement in systemic lupus erythematosus". Curr Opin Ophthalmol. 26 (6): 540–5. doi:10.1097/ICU.0000000000000209. PMID 26367085.
  5. ↑ Silpa-archa S, Lee JJ, Foster CS (2016). "Ocular manifestations in systemic lupus erythematosus". Br J Ophthalmol. 100 (1): 135–41. doi:10.1136/bjophthalmol-2015-306629. PMID 25904124.
  6. ↑ Robson AK, Burge SM, Millard PR (1992). "Nasal mucosal involvement in lupus erythematosus". Clin Otolaryngol Allied Sci. 17 (4): 341–3. PMID 1526055.
  7. ↑ Anyanwu CO, Ang CC, Werth VP (2013). "Oral mucosal involvement in bullous lupus". Arthritis Rheum. 65 (10): 2622. doi:10.1002/art.38051. PMC 4333153. PMID 23780804.
  8. ↑ Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM (2012). "Oral discoid lupus erythematosus: A study of twenty-one cases". J Oral Maxillofac Pathol. 16 (3): 368–73. doi:10.4103/0973-029X.102487. PMC 3519212. PMID 23248469.
  9. ↑ Melikoglu MA, Melikoglu M (2008). "The clinical importance of lymphadenopathy in systemic lupus erythematosus". Acta Reumatol Port. 33 (4): 402–6. PMID 19107085.
  10. ↑ 10.0 10.1 Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T (2014). "Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study". PLoS ONE. 9 (4): e94511. doi:10.1371/journal.pone.0094511. PMC 3983200. PMID 24722263.
  11. ↑ Torre O, Harari S (2011). "Pleural and pulmonary involvement in systemic lupus erythematosus". Presse Med. 40 (1 Pt 2): e19–29. doi:10.1016/j.lpm.2010.11.004. PMID 21194884.
  12. ↑ Salvati F (2015). "[The involvement of pulmonary interstitial tissue in multisystemic lupus erythematosus: interdisciplinarity and role of the pneumologists]". Clin Ter (in Italian). 166 (5): 205–7. PMID 26550810.
  13. ↑ Alamoudi OS, Attar SM (2015). "Pulmonary manifestations in systemic lupus erythematosus: association with disease activity". Respirology. 20 (3): 474–80. doi:10.1111/resp.12473. PMC 4418345. PMID 25639532.
  14. ↑ Mak A, Kow NY (2014). "Imbalance between endothelial damage and repair: a gateway to cardiovascular disease in systemic lupus erythematosus". Biomed Res Int. 2014: 178721. doi:10.1155/2014/178721. PMC 3984775. PMID 24790989.
  15. ↑ Canpolat N, Kasapcopur O, Caliskan S, Gokalp S, Bor M, Tasdemir M, Sever L, Arisoy N (2013). "Ambulatory blood pressure and subclinical cardiovascular disease in patients with juvenile-onset systemic lupus erythematosus". Pediatr. Nephrol. 28 (2): 305–13. doi:10.1007/s00467-012-2317-3. PMID 23052654.
  16. ↑ Tian XP, Zhang X (2010). "Gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment". World J. Gastroenterol. 16 (24): 2971–7. PMC 2890936. PMID 20572299.
  17. ↑ Alves SC, Fasano S, Isenberg DA (2016). "Autoimmune gastrointestinal complications in patients with systemic lupus erythematosus: case series and literature review". Lupus. 25 (14): 1509–1519. doi:10.1177/0961203316655210. PMID 27329649.
  18. ↑ Fawzy M, Edrees A, Okasha H, El Ashmaui A, Ragab G (2016). "Gastrointestinal manifestations in systemic lupus erythematosus". Lupus. 25 (13): 1456–1462. doi:10.1177/0961203316642308. PMID 27055518.
  19. ↑ Li Z, Xu D, Wang Z, Wang Y, Zhang S, Li M, Zeng X (2017). "Gastrointestinal system involvement in systemic lupus erythematosus". Lupus: 961203317707825. doi:10.1177/0961203317707825. PMID 28523968.
  20. ↑ Zoma A (2004). "Musculoskeletal involvement in systemic lupus erythematosus". Lupus. 13 (11): 851–3. doi:10.1191/0961203303lu2021oa. PMID 15580980.
  21. ↑ Gabba A, Piga M, Vacca A, Porru G, Garau P, Cauli A, Mathieu A (2012). "Joint and tendon involvement in systemic lupus erythematosus: an ultrasound study of hands and wrists in 108 patients". Rheumatology (Oxford). 51 (12): 2278–85. doi:10.1093/rheumatology/kes226. PMID 22956550.
  22. ↑ Grossman JM (2009). "Lupus arthritis". Best Pract Res Clin Rheumatol. 23 (4): 495–506. doi:10.1016/j.berh.2009.04.003. PMID 19591780.
  23. ↑ Zhu KK, Xu WD, Pan HF, Zhang M, Ni J, Ge FY, Ye DQ (2014). "The risk factors of avascular necrosis in patients with systemic lupus erythematosus: a meta-analysis". Inflammation. 37 (5): 1852–64. doi:10.1007/s10753-014-9917-y. PMID 24862229.
  24. ↑ Voulgari PV, Kosta P, Argyropoulou MI, Drosos AA (2013). "Avascular necrosis in a patient with systemic lupus erythematosus". Joint Bone Spine. 80 (6): 665. doi:10.1016/j.jbspin.2013.03.018. PMID 23731640.
  25. ↑ Cojocaru IM, Cojocaru M, Tănăsescu R, Burcin C, Atanasiu AN, Silosi I (2008). "Detection of autoantibodies to ribosome P in lupus patients with neurological involvement". Rom J Intern Med. 46 (3): 239–42. PMID 19366083.
  26. ↑ Madrane S, Ribi C (2012). "[Central neuropsychiatric involvement in systemic lupus erythematosus]". Rev Med Suisse (in French). 8 (337): 848–53. PMID 22594009.
  27. ↑ Sivri A, Hasçelik Z, Celiker R, Başgöze O (1995). "Early detection of neurological involvement in systemic lupus erythematosus patients". Electromyogr Clin Neurophysiol. 35 (4): 195–9. PMID 7555923.
  28. ↑ Juncal Gallego L, Almuíña Simón C, Muíños Esparza LF, Díaz Soto R, Ramil Fraga C, Quiroga Ordóñez E (2009). "[Systemic lupus erythematosus with fulminant neurological involvement]". An Pediatr (Barc) (in Spanish; Castilian). 70 (2): 202–4. doi:10.1016/j.anpedi.2008.09.009. PMID 19217587.
  29. ↑ 29.00 29.01 29.02 29.03 29.04 29.05 29.06 29.07 29.08 29.09 29.10 29.11 29.12 29.13 29.14 29.15 29.16 29.17 29.18 29.19 29.20 29.21 29.22 29.23 29.24 29.25 29.26 29.27 29.28 29.29 29.30 29.31 29.32 29.33 29.34 29.35 29.36 29.37 29.38 29.39 29.40 29.41 29.42 29.43 29.44 29.45 29.46 29.47 29.48 29.49 29.50 29.51 29.52 29.53 29.54 29.55 29.56 29.57 29.58 29.59 29.60 29.61 29.62 29.63 29.64 29.65 29.66 29.67 29.68 29.69 29.70 29.71 29.72 29.73 29.74 29.75 29.76 29.77 "Dermatology Atlas".
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