Lupus nephritis physical examination: Difference between revisions

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{{Lupus nephritis}}
{{Lupus nephritis}}
{{CMG}}; {{AE}} {{CZ}}, {{RT}}
{{CMG}}; {{AE}}[[User:Okamal|Omer Kamal, M.D.]] [Mailto:okamal@bidmc.harvard.edu| [2]]  {{CZ}}, {{RT}}
==Overview==
==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|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==
===Vitals===
===Appearance of the Patient===
* [[Elevated body temperature]]
*Patient appears well in the earlier stages of the disease
* [[Hypertension|High blood pressure]]
*Patient appears ill in the late stages of the disease due to multi-organ involvement
===Vital Signs===
*[[Fever]] higher than 38 after the exclusion of [[infection]]
*[[Tachycardia]]/[[bradycardia]] 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> ===
*[[Cyanosis]]
**Secondary to [[respiratory]] complications
*[[Jaundice]]
**Secondary to [[hepatitis]]
*[[Pallor]]
**Secondary to [[anemia]]
*Generalised [[erythema]]
*[[Bruises]]
**Secondary to [[thrombocytopenia]]
*[[Urticaria]]
*[[Bullous|Bullous lesions]]
*[[Sclerodactyly]]
*Skin [[Ulcerations|ulceration]]
*[[Malar rash]]: the classic lupus ‘butterfly’ rash
** [[Erythema|Erythematous]], elevated [[Lesions|lesion]], [[Pruritis|pruritic]] or painful, in a [[malar]] distribution, commonly precipitated by exposure to sunlight
* 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
* [[Scarring]] [[chronic]] [[alopecia]]
** Mostly present on face, neck, and scalp
* [[Telangiectasias]]
* Dyspigmentation ([[hyperpigmentation]] or [[hypopigmentation]]) of skin in [[scar]] places
* Follicular plugging
** Discrete, [[erythematous]], slightly infiltrated [[plaques]] covered by a well-formed adherent scale that extends into dilated [[hair follicles]]
* [[Nodules]]
** 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)
* 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]]
* Periungual [[erythema]]
** Dilated tortuous loops of [[capillaries]] and a prominent subcapillary venous plexus along
** Involves the base of the nail and edges of the upper [[eyelid]]
<figure-inline><figure-inline>[[File:Systemic lupus erythematosus 055.jpg|512x512px]]</figure-inline></figure-inline>
'''For more pictures of the rash presentation in lupus, click [[Systemic lupus eryhthematosus physical examination:Gallery|here]].'''
 
===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>
**[[Nystagmus]]
**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]]
**[[Optic nerve atrophy]]
**[[Icterus|Icteric sclera]]
**[[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>
**Mostly painless
**Mostly in lower [[nasal septum]] and [[bilateral]] and parallel
**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>
**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]]
 
===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]]
**Secondary to [[hypertension]] and cardiac complications
*[[Lymphadenopathy]]
** [[Lymph node|Lymph nodes]] are soft, non-tender, discrete
** Usually detected in the [[cervical]], [[axillary]], and [[inguinal]]
 
===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>===
*Fine and coarse [[crackles]] upon auscultation of the [[lung]]
**May be due to [[pneumonitis]]
*In case of [[pleural effusion]]:
**Asymmetric [[tactile fremitus]]
**Asymmetric [[chest expansion]]
 
===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]]
*[[Ascites]]
**Due to [[nephrotic syndrome]]
*[[Abdominal pain]]
**Due to [[Vasculitis|mesentric vasculitis]]
*[[Hepatomegaly]]
*[[Splenomegaly]]
*Costo-vertebral angle tenderness


===Eyes===
===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>===
* Peri-orbital puffiness can be noticed in patients with advanced disease having [[renal failure]].
*[[Clubbing]]
*[[Cyanosis]]
*[[Muscle weakness|Muscle atrophy or weakness]]
*[[Livedo reticularis]]
**Reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
*[[Arthritis]]
**Symmetrical
**Polyarticular
**Mostly involve knees, carpal joints, and joints of the fingers, especially the proximal [[interphalangeal]] (PIP) joint
**Decrease  range of motion in affected joints
*Joints [[erythema]]
**Due to [[synovitis]]
*Joint effusion
*Muscle [[atrophy]]
*[[Fasciculations]] in the upper/lower extremity
*[[Claudication]]
*Loss of digit or limb


===Extremities===
===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>===
* [[Edema|Swelling]] around the legs, ankles or fingers.
*Patient is usually oriented to persons, place, and time based on the disease course
* Swollen joints
*[[Cognitive impairment]]
*[[Hallucination|Hallucinations]]
**[[Visual hallucinations|Visual]]
**[[Auditory hallucinations|Auditory]]
*Memory deficit
**Loose associations
**Impoverished thought content
**Illogical thinking
**Bizarre disorganised or catatonic behaviour


==References==
==References==
{{Reflist|2}}


{{reflist|2}}
{{WH}}
{{WH}}
{{WS}}
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[[Category: (name of the system)]]
[[Category:Disease]]
[[Category:Nephrology]]
[[Category:Autoimmune diseases]]

Latest revision as of 17:28, 20 July 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omer Kamal, M.D. [2] Cafer Zorkun, M.D., Ph.D. [2], Raviteja Guddeti, M.B.B.S. [3]

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]

<figure-inline><figure-inline></figure-inline></figure-inline> 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

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.

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