Systemic lupus erythematosus physical examination: Difference between revisions

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{{Systemic lupus erythematosus}}
{{Systemic lupus erythematosus}}


{{CMG}}; {{AE}} {{RT}} {{KS}}
{{CMG}}; {{AE}} {{MIR}}


==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==
{| class="wikitable"
!Organ system
!Disease
!Physical exam
!
!
|-
| rowspan="7" |Gastrointestinal involvement
|Dysphagia
|
*Retrosternal chest pain
*Heartburn
*Regurgitation
*Odynophagia
|
|
|-
|peptic ulcer disease
|
*Epigastric pain
*Food-provoked epigastric discomfort and fullness
*Early satiety
*Nausea
|
|
|-
|Intestinal pseudo-obstruction
|
*Abdominal pain
*Bloating
*Distension
|
|
|-
|Protein-losing enteropathy
|
*Profound edema
*Hypoalbuminemia
*Severe diarrhea
|
|
|-
|Acute pancreatitis
|
*Severe persistent epigastric pain often radiating to the back
|
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|-
|Mesenteric vasculitis
|
*Abdominal pain
*Food aversion
*Weight loss
*Nausea
*Vomiting
*Diarrhea
**Due to chronic mesenteric ischemia
|
|
|-
|Primary peritonitis
|
* Abdominal bloating or distention
* Nausea and vomiting
* Diarrhea
* Constipation or the inability to pass gas
* Anorexia
|
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|-
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|Hepatits
|
* Fatigue
* Anorexia
* Jaundice
* Hepatomegaly
* Ascites
|
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|-
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|-
| rowspan="7" |Pulmonary involvement
|Pleural disease
|
*Cough
*Dyspnea
*Fever
|
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|-
|Acute pneumonitis
|
*Fever
*Cough (sometimes with hemoptysis)
*Dyspnea/ physical examination reveals tachypnea, tachycardia, basilar crackles (may be late inspiratory), and hypoxemia
|
|
|-
|Pulmonary hemorrhage
|
*Dyspnea
*Cough
*Hemoptysis
|
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|-
|Interstitial lung disease
|
*May be asymptomatic
*Chronic nonproductive cough
*Dyspnea
*Decreased exercise tolerance
|
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|-
|Thromboembolic disease
|
*Dyspnea
*Sharp chest pain that may become worse with deep breathing or coughing
|
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|-
|Pulmonary hypertension
|
*Dyspnea
*Palpitations
*Fatigue
*Impaired exercise tolerance
*Weakness
*Syncope
*Edema
*Increased abdominal girth/ phE=pulmonary hypertension (loud second heart sound) or cor pulmonale (eg, peripheral edema, ascites, hepatomegaly)/
|
|
|-
|Shrinking lung
|
*Dyspnea
*Pleuritic chest pain (episodic)
|
|
|-
| rowspan="6" |Cardiac involvement
|Valvular disease
|
*most often valve thickening, nodules, and regurgitation, and less frequently vegetations or stenotic lesions, is noted echocardiographically, and the presence of valvular lesions may increase the risk of serious complications
|
|
|-
|Nonbacterial thrombotic endocarditis (Libman-Sacks, verrucous endocarditis)
|
* may occur in patients with SLE and is associated with antiphospholipid antibodies (aPL).
|
|
|-
|Pericardial disease
|is noted in approximately one-half of patients with SLE at some time in the course of their disease. Diagnostic pericardiocentesis is suggested for those in whom purulent pericarditis is suspected and for those who do not respond to treatment with nonsteroidal antiinflammatory drugs (NSAIDs) and/or glucocorticoids.
|
|
|-
|Acute pericarditis
|Symptomatic often responds to an NSAID; those who do not tolerate or cannot take NSAIDs may use prednisone (0.5 to 1 mg/kg/day in divided doses)
|
|
|-
|Myocarditis
|in SLE can cause resting tachycardia, cardiomegaly, heart failure, conduction abnormalities, and/or arrhythmias.
myocarditis, we suggest initial treatment with high-dose glucocorticoids (Grade 2C). A typical regimen is methylprednisolone 1000 mg intravenously daily for three days.
|
|
|-
|Coronary heart disease
|
|
|
|-
| rowspan="6" |Neurological involvement
|Cognitive dysfunction
|
|
|
|-
|Stroke
|mechanisms are heterogenous in SLE and include arterial and venous thrombosis, cardiogenic embolism, and small vessel infarcts
|
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|-
|Seizures
|
|
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|-
|Psychosis
|
*Hallucinations visual
*Auditory
|
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|-
|Headache
|
|
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|-
|Neuropathies
|
|
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|-
|Genitourinary
|Nephrotic syndrome
|
*Hypertension
*Peripheral edema
*Foamy urine
*Weight gain
|
|
|-
| rowspan="6" |Musculoskeletal
|arthritis
|
* arthralgias
* effusions
* Decreased range of motion of both small and large joints
* Morning stiffness
|
|
|-
|avascular necrosis
|
* Asymptomatic
* Mild to moderate pain in groin and lower abdoman
|
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|-
|bone fragility fractures
|
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|-
|secondary pain amplification
|
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|-
|Avascular necrosis
|can occur in patients treated with corticosteroids
|
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|-
|Osteoporosis
|
* Loss of height
* Sudden back pain
|
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|-
|Skin disorder
|
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|-
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|-
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|}
===Appearance of the Patient===
===Appearance of the Patient===
*This section should give a general description of what a patient with the disease you are describing may look like.
*Patient appears well in the earlier stages of the disease
*If patients typically appear normal, you may write: Patients are usually well-appearing.
*Patient appears ill in the late stages of the disease due to multi-organ involvement
*You may include a physical description such as obese, thin, cachectic, ill appearing, diaphoretic etc. Mention in which cases these findings are present (e.g. well-appearing in early stages of cancer, cachectic in late stage cancer)
*For an example of the appearance of a patient section in the physical examination page, click [[Stomach cancer physical examination|here]].
===Vital Signs===
===Vital Signs===
<sup>Note: Vital signs traditionally include the temperature, blood pressure, heart rate, respiratory rate. The vital signs may also include oxygen saturation (at room air) and blood glycemia.</sup>
*[[Fever]] higher than 38 after the exclusion of [[infection]]
*Fever More than 38o C aft er the exclusion of infection
*[[Tachycardia]]/[[bradycardia]] depends on the accompanying complication
*High-grade / low-grade fever
*[[Tachypnea]]/[[bradypnea]] depends on the accompanying complication
*[[Hypothermia]] / hyperthermia may be present
 
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
=== 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> ===
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
===Skin===
*[[Cyanosis]]
*[[Cyanosis]]
**Secondary to [[respiratory]] complications
*[[Jaundice]]
*[[Jaundice]]
**Secondary to [[hepatitis]]
*[[Pallor]]
*[[Pallor]]
*Bruises
**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]]
[[File:Systemic lupus erythematosus 055.jpg|300px]]
'''For more pictures of the rash presentation in lupus, click [[Systemic lupus eryhthematosus physical examination:Gallery|here]].'''


●Rheumatoid nodules
===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>
●Calcinosis cutis
**[[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]])
Bullous eruptions (resulting from damage to the basal layer of the epidermis)
**[[Cataract]]
 
**[[Optic nerve atrophy]]
●Urticaria
**[[Icterus|Icteric sclera]]
 
**[[Cotton wool spots]] in the [[retina]] in [[Ophthalmoscopy|ophthalmoscopic exam]]
●Cutis laxa/anetoderma
*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
●Acanthosis nigricans
**Mostly in lower [[nasal septum]] and [[bilateral]] and parallel
 
**Nasal perforation secondary to [[vasculitis]] may happen rarely
●Erythema multiforme
*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
●Leg ulcers
**White plaques with areas of [[erythema]], or punched-out erosions or ulcers with surrounding [[erythema]] on the soft or hard palate or [[buccal mucosa]]


●Palisaded neutrophilic and granulomatous dermatitis
===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>===
* Scarring chronic alopecia
* Skin ulceration
* malar rash. The classic lupus ‘butterfly’ rash
** erythematous, elevated lesion, pruritic or painful, in a malar distribution, commonly precipitated by exposure to sunlight
* Generalised erythema
* Bullous lesions
* annular or psoriasiform skin lesions      strongly associated with anti-Ro (SS-A) and anti-La (SS-B) antibodies/ as small, erythematous, slightly scaly papules that evolve into either a psoriasiform (papulosquamous) or annular form /shoulders, forearms, neck, and upper torso
* discrete, erythematous, slightly infi ltrated plaques covered by a well-formed adherent scale that extends into dilated hair follicles (follicular plugging)/ face, neck, and scalp, but also occur on the ears, and infrequently on the upper torso/ heal, leaving depressed central scars, atrophy, telangiectasias, and dyspigmentation (hyper- or hypopigmentation).
* firm nodular lesion with or without an overlying cutaneous lesion=Lupus profundus/  oft en painful
* photodistributed lesions with chronic pink indurated plaques or broad lesions that are slow to heal.= Lupus tumidus
* Alopecia
* Scarring alopecia is a complication of discoid lupus that typically aff ects the scalp
* thin hair that easily fractures=lupus hair/ along the frontal hairline:  associated with disease activity, and grows back normally as the disease subsides
* 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/  Oral ulcers in SLE are usually painless
Note: To describe a rash, always report additional details that include the color (e.g. erythematous), shape (e.g. flat / bullous), dermarcation (e.g. well-circumscribed / diffuse), location (e.g. truncal / on the face / on the extremities), enclosing fluid (e.g. vesicular / filled with pus, clear), and if possible smell (e.g. foul-smelling / odorless)
 
Lymphadenopathy especially during active flare/  Lymph nodes are typically soft , non-tender, discrete, and usually detected in the cervical, axillary, and inguinal/ more likely to present with constitutional symptoms/
===HEENT===
*Sclerodactyly
*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)
*cataract
*Retinal change or optic atrophy
*
*Abnormalities of the head/hair may include ___
*Evidence of trauma
*Icteric sclera
*[[Nystagmus]]
*Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
*Ophthalmoscopic exam may be abnormal with findings of ___
*Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
*[[Exudate]] from the ear canal
*Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
*Inflamed nares / congested nares
*[[Purulent]] exudate from the nares
*Facial tenderness
*Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
*‘cotton wool’ spots in the retina visible on ophthalmoscopy or fl uorescein angiography due to retinal artery inflammation
*Corneal and conjunctiva involvement is usually part of Sjögren’s syndrome associated with SLE
===Neck===
*[[Jugular venous distension]]
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
**Secondary to [[hypertension]] and cardiac complications
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Lymphadenopathy]]  
*[[Thyromegaly]] / thyroid nodules
** [[Lymph node|Lymph nodes]] are soft, non-tender, discrete
*[[Hepatojugular reflux]]
** Usually detected in the [[cervical]], [[axillary]], and [[inguinal]]
===Lungs===
*Pleuritic pain with or without a pleural eff usion / usually bilateral
*interstitial lung disease (ILD)
*Acute lupus pneumonitis presenting as cough, dyspnoea, pleuritic pain, hypoxaemia, and fever//Chest radiographs reveal unilateral or bilateral infi ltrates.
*Pulmonary haemorrhage is a rare but potentially catastrophic complication of SLE/  diff use alveolar infi ltrates, hypoxaemia, dyspnoea, and anaemia are characteristic
*Alveolar haemorrhage usually occurs in patients with a known history of SLE, high titres of anti-DNA antibodies, and active extrapulmonary disease
*Th e ‘shrinking lung syndrome’ is characterised by progressive dyspnoea and small lung volumes on chest radiographs,
*
*
*
*
*
*Asymmetric chest expansion / Decreased chest expansion
*Lungs are hypo/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
*
*fine bibasilar inspiratory crackles (Velcro crackles): due to Pulmonary fi brosis (physical and radiographical)
*
*Pleural fibrosis
Pulmonary hypertension (right ventricular prominence, or loud P2)
*


Pulmonary fi brosis (physical and radiographical)
===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]]


Shrinking lung (radiograph)
===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]]


Pleural fi brosis (radiograph)
===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


Pulmonary infarction (radiograph)
===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>===
*
 
===Heart===
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1.2C the .22lub.22.28components M1 and T1.29|S1]]
*[[Heart sounds#Second heart tone S2 the .22dub.22.28components A2 and P2.29|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
*Pericarditis Pericardial pain with at least one of rub or eff usion.
*diastolic murmur, or systolic murmur >3/6 due to valvular disease
*Chest pain or discomfort secondary to costochondritis
 
Pericarditis/  Pericardial eff usions/  fever, dyspnoea, tachycardia, and congestive heart failure/ f left ventricular dysfunction, non-specifi c ST-T wave changes, segmental wall motion abnormalities, and decreased ejection fraction are found in >80% of patients/ accelerated, premature atherosclerosis/ valvular heart disease/ increased risk for myocardial infarction or stroke/ diff use thickening of the mitral and aortic valves followed by vegetations, valvular regurgitation, and stenosis/
 
===Abdomen===
*[[Abdominal distention]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
*Splenomegaly
*Splenic atrophy and functional hyposplenism
*Dyspepsia/ peptic ulcers
*Abdominal pain/ usually acompanied with nausea and vomiting
*acute abdomen with nausea, vomiting, diarrhoea, GI bleeding, and fever as a result of mesentric vasculitis
*Hepatomegaly due to hepatitis
*lupoid hepatits= hepatits due to autoimmune disease of sle
*Ascitis= uncommon/ if found usually associated with perforation or infection or Congestive heart failure and hypoalbuminaemia secondary to nephrotic syndrome
*
*
===Back===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally (may also be referred to as Murphy's punch sign, which is different from Murphy's sign that suggests cholecystitis. To avoid confusion, write "costovertebral angle tenderness")
*Buffalo hump
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
<sup>Write additional pathognomonic findings, such as discharge that resembles cottage cheese for ''C. albicans'' vulvovaginitis / fish-odor for ''T. vaginalis'' ifnection</sup>
===Extremities===
*[[Clubbing]]
*[[Clubbing]]
*[[Cyanosis]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*[[Muscle weakness|Muscle atrophy or weakness]]
*Muscle atrophy
*[[Livedo reticularis]]
*Fasciculations in the upper/lower extremity
**Reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
*
*[[Arthritis]]
*Claudication
**Symmetrical
*loss of digit or limb=sign
**Polyarticular
*Venous thrombosis with swelling, ulceration or venous stasis
**Mostly involve knees, carpal joints, and joints of the fingers, especially the proximal [[interphalangeal]] (PIP) joint
*digital clubbing due to pulmonary fibrosis
**Decrease  range of motion in affected joints
pain and stiffness of joints
*Joints [[erythema]]
 
**Due to [[synovitis]]
synovitis: May be transient (resolving within a few days in some patients), migratory, and reversible
*Joint effusion
 
*Muscle [[atrophy]]
===Neuromuscular===
*[[Fasciculations]] in the upper/lower extremity
*Patient is usually oriented to persons, place, and time
*[[Claudication]]
*Altered mental status
*Loss of digit or limb
*Glasgow coma scale is ___ / 15
*Clonus may be present
*Hyperreflexia / hyporeflexia / areflexia
*Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*Muscle rigidity
*Proximal/distal muscle weakness unilaterally/bilaterally
*____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*
*Cognitive impairment (eg, memory defi cit, diffi culty with calculation, poor concentration, diffi culty in spoken or written language, impaired performance level) or major psychosis
*Seizure Recent onset. Exclude metabolic, infectious or drug-related causes
*Psychosis Altered ability to function in normal activity due to severe disturbance in the perception of reality. Includes hallucinations; incoherence; marked loose associations; impoverished thought content; marked illogical thinking; bizarre disorganised or catatonic behaviour. Exclude the presence of uraemia and off ending drugs
*Organic brain syndrome Altered mental function with impaired orientation or impaired memory or other intellectual function, with rapid onset and fl uctuating clinical features. Includes a clouding of consciousness with a reduced capacity to focus and an inability to sustain attention on environment and at least two of the following: perceptual disturbance, incoherent speech, insomnia or daytime drowsiness, increased or decreased psychomotor activity. Exclude metabolic infectious and drug-related causes
*
*Lupus headache Severe, persistent headache; may be migrainous
*Vasculitis Ulceration, gangrene, tender fi nger nodules, periungal infarction, splinter haemorrhages. Vasculitis confi rmed by biopsy or angiogram
*Arthritis More than two joints with pain and signs of infl ammation
*Proximal muscle aching or weakness
*Muscle atrophy or weakness
*Osteoporosis with fracture or vertebral collapse
 
Absent/present dysdiadochokinesia (palm tapping test)
{| class="wikitable"
!
!
!
!
|-
|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
|
|-
|
|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
 
|
|-
|
|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
|Periungual erythema
|due to dilated tortuous loops of capillaries and a prominent subcapillary venous plexus along the base of the nail
 
can also happen along edges of the upper eyelid
|
|-
|
|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
===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
|-
*[[Cognitive impairment]]
|
*[[Hallucination|Hallucinations]]
|Raynaud phenomenon
**[[Visual hallucinations|Visual]]
|vasospastic process
**[[Auditory hallucinations|Auditory]]
blanching of the nail beds, fingers, and toes (and occasionally ears, nose, tongue, and nipples) with accompanying pain
*Memory deficit
|
**Loose associations
|-
**Impoverished thought content
|
**Illogical thinking
|Vasculitis
**Bizarre disorganised or catatonic behaviour
|urticarial vasculitis: lesions may remain for more than 24 hours and frequently evolve into painful petechiae or purpura that may heal with hyperpigmentation
==Gallery==
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
|
|-
|Nail abnormalities
|
|pitting, ridging, and onycholysis
|
|-
|Mucosal manifestations
|
|Oral involvement : white plaques, areas of erythema, or punched-out erosions or ulcers with surrounding erythema on the soft or hard palate or buccal mucosa
 
painless oral ulcers
 
hyperkeratosis, atrophy of rete processes, and superficial and deep inflammatory infiltrates; edema in the lamina propria, continuous or patchy periodic acid-Schiff (PAS)-positive deposits in the basement membrane zone, deposition of intercellular mucin, and deposits of immunoglobulin and complement at the dermal-epidermal junction 
 
Nasal ulcers: lower nasal septum and tend to be bilateral and parallel
 
Nasal perforation, possibly secondary to vasculitis rare but may happen
 
|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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|-
|
|
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|-
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|}
 
====Skin====


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Image:Discoid lupus erythematosus28.jpg|Discoid lupus erythematosus. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
Image:Discoid lupus erythematosus28.jpg|500px|Discoid lupus erythematosus. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>




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Latest revision as of 19:03, 4 August 2017

Systemic lupus erythematosus Microchapters

Home

Patient Information

Overview

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Causes

Differentiating Systemic lupus erythematosus from other Diseases

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Diagnostic Criteria

History and Symptoms

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Laboratory Findings

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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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