Lupus nephritis physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{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== | ||
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** 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| | <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]].''' | '''For more pictures of the rash presentation in lupus, click [[Systemic lupus eryhthematosus physical examination:Gallery|here]].''' | ||
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
- Fever higher than 38 after the exclusion of infection
- Tachycardia/bradycardia depends on the accompanying complication
- Tachypnea/bradypnea depends on the accompanying complication
Skin[1][2][3]
- Cyanosis
- Secondary to respiratory complications
- Jaundice
- Secondary to hepatitis
- Pallor
- Secondary to anemia
- Generalised erythema
- Bruises
- Secondary to thrombocytopenia
- Urticaria
- Bullous lesions
- Sclerodactyly
- 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
- 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>
</figure-inline></figure-inline>
For more pictures of the rash presentation in lupus, click here.
HEENT
- Ophthalmology[4][5]
- 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)
- Cataract
- Optic nerve atrophy
- Icteric sclera
- Cotton wool spots in the retina in ophthalmoscopic exam
- Nasal ulcers[6]
- Mostly painless
- Mostly in lower nasal septum and bilateral and parallel
- Nasal perforation secondary to vasculitis may happen rarely
- Oral ulcers[7][8]
- 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[9][10]
- Jugular venous distension
- Secondary to hypertension and cardiac complications
- Lymphadenopathy
- Lymph nodes are soft, non-tender, discrete
- Usually detected in the cervical, axillary, and inguinal
Lungs[11][12][13]
- 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[14][10][15]
- Chest tenderness or discomfort upon palpation
- May be due to costochondritis
- Diastolic murmur, or 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[16][17][18][19]
- Abdominal distention
- Ascites
- Due to nephrotic syndrome
- Abdominal pain
- Due to mesentric vasculitis
- Hepatomegaly
- Splenomegaly
- Costo-vertebral angle tenderness
Extremities[20][21][22][23][24]
- Clubbing
- Cyanosis
- 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
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
- ↑ Parodi A, Cozzani E (2014). "Cutaneous manifestations of lupus erythematosus". G Ital Dermatol Venereol. 149 (5): 549–54. PMID 25077888.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Robson AK, Burge SM, Millard PR (1992). "Nasal mucosal involvement in lupus erythematosus". Clin Otolaryngol Allied Sci. 17 (4): 341–3. PMID 1526055.
- ↑ 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.
- ↑ 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.
- ↑ Melikoglu MA, Melikoglu M (2008). "The clinical importance of lymphadenopathy in systemic lupus erythematosus". Acta Reumatol Port. 33 (4): 402–6. PMID 19107085.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Zoma A (2004). "Musculoskeletal involvement in systemic lupus erythematosus". Lupus. 13 (11): 851–3. doi:10.1191/0961203303lu2021oa. PMID 15580980.
- ↑ 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.
- ↑ Grossman JM (2009). "Lupus arthritis". Best Pract Res Clin Rheumatol. 23 (4): 495–506. doi:10.1016/j.berh.2009.04.003. PMID 19591780.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Madrane S, Ribi C (2012). "[Central neuropsychiatric involvement in systemic lupus erythematosus]". Rev Med Suisse (in French). 8 (337): 848–53. PMID 22594009.
- ↑ 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.
- ↑ 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.