Sandbox:iqra

SLE resident survival guide:

SLE Presentation Fatigue Fever Myalgia Joint tenderness Muscle weakness Weight changes Less common Presentation Dysphagia Peptic ulcer disease Intestinal pseudo-obstruction Protein-losing enteropathy Acute pancreatitis Pneumonitis Pleuritis Pulmonary hemorrhage Interstitial lung disease Pulmonary emboli Pulmonary hypertension Pericarditis Myocarditis Seizures Stroke Psychosis Nephrotic syndrome
Focused History Onset, duration and progression of symptoms History of weight changes (gain or loss) Anorexia Arthritis, arthralgias, or muscle pain Morning stiffness Skin rashes and their association to flare ups, especially after exposure to sunlight Medications and their association to flare ups Infections especially mononucleosis Sores in the mouth, nose, or other mucous membranes Symptoms of other organ failure Renal failure: Recent peripheral edema and weight gain Cardiac involvement: Tachycardia, dyspnea, chest pains History of having a pet Hair loss Job history Co-morbid conditions include: Other rheumatologic and autoimmune diseases Hypertension Diabetes, immunodeficiency Seizures, or other nervous system symptoms Family history of rheumatologic diseases
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 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 For more pictures of the rash presentation in lupus, click here. HEENT Ophthalmology 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 Mostly painless Mostly in lower nasal septum and bilateral and parallel Nasal perforation secondary to vasculitis may happen rarely Oral ulcers 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 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 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 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 Abdominal distention Ascites Due to nephrotic syndrome Abdominal pain Due to mesentric vasculitis Hepatomegaly Splenomegaly Costo-vertebral angle tenderness Extremities 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 Patient is usually oriented to persons, place, and time based on the disease course Cognitive impairment Hallucinations Visual Auditory Memory deficit Loose associations Impoverished thought content Illogical thinking Bizarre disorganised or catatonic behaviour
Laboratory Workup CBC with DC SMA-7 AST, ALT, LDH, bilirubin, and ALP Creatine kinase Blood cultures, at least 2 sets Urinalysis with microscopic examination Urine cultures Erythrocyte sedimentation rate C-reactive protein Gamma-glutamyl transferase Coombs test Cold agglutinins Ferritin Angiotensin-converting enzyme Thyroid peroxidase and anti-thyroglobulin antibodies Antinuclear antibodies Rheumatoid factor Cryoglobulins CMV serology and heterophile antibody test if ⊕ atypical lymphocytes Q fever serology if ⊕ exposure to livestocks HIV serology Serum protein electrophoresis Tuberculin skin test Fecal occult blood test
Imaging Study Chest Radiograph Chest radiograph should be considered as a part of the initial diagnostic workup. Echocardiography Echocardiography should be considered when suspecting endocarditis. Abdominal Ultrasonography Abdominal ultrasonography should be considered when suspecting hepatobiliary pathology. Chest CT Scan Chest CT scan may detect nodular lesions (s/o malignancy or fungal/mycobacterial/nocardial infection) or mediastinal adenopathy (s/o lymphoma, histoplasmosis, or sarcoidosis). Abdominal CT Scan Abdominal CT scan should be considered when suspecting intra-abdominal abscess or malignancy. Positron Emission Tomography PET may be useful in localizing the nidus of fever of unknown origin.
Other Investigation Lymph Node Biopsy Lymph node biopsy may be useful when suspecting lymphoma, lymphogranuloma venereum, toxoplasmosis, and Kikuchi disease. Granuloma may indicate disorders associated with granulomatous inflammation (eg, tuberculosis, sarcoidosis) or lymphoma. Bone Marrow Biopsy Bone marrow biopsy may be considered when suspecting intracellular infectious pathogens or hematologic malignancies. Discontinuation of Nonessential Medications Nonessential medications should be discontinued. Defervescence in less than 72 hours after discontinuing the culprit medication suggests drug fever. Rechallenge with the offending agent usually results in recurrence of drug fever. Trial of Empiric Antibiotics Therapeutic trials of antimicrobial agents may be considered if other techniques fail to disclose the etiology. An infectious etiology is likely if abatement of fever occurs after the administration of empiric antibiotics. Naproxen Test Naproxen test (375 mg twice daily) can be used to distinguish neoplastic fever from other etiologies. Naproxen test is considered positive when there is a rapid or sustained abatement of fever during the 3 days of the trial period. Defervescence within 12 hours occurs in almost all patients with neoplastic fever. Fever recurs after discontinuation of naproxen in patients with neoplasms. Naproxen demonstrated no antipyretic activity against fever in patients with occult infection.