Lupus erythematosus is a form of autoimmune disease that primarily affects young women and is distinguished by broad vascular damage in the skin, articular tissues, heart, serous membranes, and kidneys (Reisner and Reisner, 2022, p. 143). Lupus pathogenesis is not completely understood. However, Systemic lupus erythematosus starts with the body’s immune system inaccurately recognizing one or more components of the cell’s nucleus as foreign, seeing it as an antigen. The immune system starts to develop antibodies to the nuclear antigen. In particular, B cells begin to overproduce antibodies with the help of multiple cytokines, such as the B lymphocyte stimulator, which is overexpressed in SLE.
The antibodies and antigens form antigen body complexes and tend to get trapped in the capillaries of visceral structures. The antibodies also act to destroy host cells. It is thought that those two mechanisms are responsible for the majority of the clinical manifestations of this disease process (Hinkle et al., 2022, pg. 1098).
List two (2) possible differential diagnoses.
Rheumatoid Arthritis (RA): Common symptoms include joint discomfort, edema, and stiffness. Both Lupus and RA are autoimmune disorders affecting the joints. On the other hand, lupus can cause a wide range of systemic signs that extend beyond the joints, affecting many organs and tissues (Hinkle et al., 2022, pg. 1093).
Psoriatic Arthritis is an auto-immune inflammatory arthritis associated with the skin disease psoriasis, which starts in the skin with an exaggerated immune response to environmental factors and then spreads to the joins in genetically susceptible individuals. It also includes ligaments, tendons, skin, and nail damage. Signs and symptoms include Fatigue, synovitis, general aches, and inflammatory back pains. At the same time, Lupus is known for its overall systemic consequences, which include skin rashes, renal involvement, fever, weight loss, and other organ manifestations (Hinkle et al., 2022, pg. 1107).
What is a typical clinical correlation to this?
Typical clinical correlations include the malar rash, a complex deposition in the skin that affects both cheeks, and hematologic manifestations such as hemolytic anemia, leukopenia, thrombocytopenia, and renal glomerular injury such as lupus nephritis. This can result in symptoms such as proteinuria (protein in the urine), hematuria (blood in the urine), and impaired kidney function (Reisner and Reisner, 2022, p. 143).
References:
Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth’s textbook of medical-surgical nursing. 15th edition. Philadelphia, Wolters Kluwer Health.
Reisner E. G. & Reisner H. M. (2022). Crowley’s An Introduction to Human Disease: Pathology and Pathophysiology Correlations (Eleventh ed.).
Jones & Bartlett Learning.
Edited by Geraldine Seide on Jan 13
SLE is from multiple phenotypes that affect the immunopathogenic pathways (Angel et al., 2023). It is an autoimmune disease and can target organs and even the central nervous system (Angel et al., 2023). The epidemiology of SLE can be seen varying depending on the population size and area. In Georgia and Michigan SLE was about 72.1 to74.4 per 100,000 people (Angel et al., 2023). When looking at Caucasians and African Americans they have a report of about 5.6 to 100,000, with African Americans having the highest rate (Angel et al., 2023). When it comes to males vs females SLE tends to affect women that have entered childbearing age, the ratio of females to males is 9 to 1 (Angel et al., 2023).
When men do report having SLE it usually occurs on the skin and can appear more severe (Angel et al., 2023).
The cellular etiology of SLE is unknown, but there are “several genetic, immunological, endocrine, and environmental factors that play a role in the etiopathogenesis of SLE” (Angel et al., 2023). There isn’t an exact inheritance pattern for SLE, but often times it can be found in monozygotic twins. Female sex hormone can influence SLE, estrogen can cause the stimulation of “CD8+ and CD4+ T cells, B cells, macrophages, thymocytes, the release of some specific cytokines, and the expression of HLA and endothelial cell adhesion molecules” (Angel et al., 2023). Estrogen can also cause B cell activation which leads to modulation of lymphocytes and plasmacytoid dendritic cell activation, this being said estrogen can cause SLE trigger symptoms (Angel et al., 2023). When looking at environmental factors that flare SLE, ultraviolet rays from the sun can cause apoptosis which can appear as a rash (Angel Jet al., 2023).
3. Why did this patient have a positive VDRL test?
Referring to image 2 in this case study of the kidney, the patient with SLE will have a false positive for syphilis. If a patient has lupus they may develop antibodies such as cardiolipin. A VDRL test is meant to detect antibodies that are against the phospholipid cardiolipin (Siegelman & McNerney). A syphilis patient also produces cardiolipin, hence the false positive in the lupus patient (VDRL, 2023).
8. List two (2) possible differential diagnoses
One possible diagnosis is that the patient could be having an autoimmune reaction. They could have had a a virus such as EBV that triggered an autoimmune response. HLA cells can also cause autoimmune diseases leading to SLE. Viral arthritis like EBV can be a differential diagnosis for SLE due to its trigger of inflammatory responses, stiffness or joints, and rash (Tiwari & Bergman, 2023). EBV can also lead to a fever such as the one the patient had for 2 weeks.
Another possible diagnosis could be rheumatoid arthritis. This is because both include joint stiffness and inflammation, which can lead to pain in the chest, hands, feet, and joints. The patient in the case complained of joint pain and chest pain. However, SLE typically has a rash as seen in the images, on the nose and cheek. Where rheumatoid arthritis isn’t accompanied by a rash (Barhum, 2023).
References
Angel A, Vaillant, J., Goyal, A., & Varacallo, M. (2023, August 4). Systemic lupus erythematosus – statpearls – NCBI bookshelf. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK535405/
Barhum, L. (2023, September 19). Everything to know about diagnosing ra and differential diagnoses. Verywell Health.
https://www.verywellhealth.com/rheumatoid-arthritis-differential-diagnosis-5222018#:~:text=SLE%20¡s%20different%20from%20RA,cause%20damage%20to%20the%20kidneys.
Siegelman, M. H., & McNerney, M. E. (n.d.). Diseases of immunity.
https://coursewareobjects.elsevier.com/objects/elr/Kumar/pathology/casestudies/imm2/record0005.html
Tiwari, V., & Bergman, M. (2023, July 4). Viral arthritis – statpearls – NCBI bookshelf. National Library of Medicine.
https://www.ncbi.nlm.nih.gov/books/NBK531.07/
VDRL. ucsfhealth.org. (2023, October 31). https://www.ucsfhealth.org/medical-tests/vdrl-test