Systemic lupus erythematosus physical examination

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Differentiating Systemic lupus erythematosus from other Diseases

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Kiran Singh, M.D. [3]

Overview

Physical Examination

Appearance of the Patient

  • This section should give a general description of what a patient with the disease you are describing may look like.
  • If patients typically appear normal, you may write: Patients are usually well-appearing.
  • 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 here.

Vital Signs

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.

  • High-grade / low-grade fever
  • Hypothermia / hyperthermia may be present
  • Tachycardia with regular pulse or (ir)regularly irregular pulse
  • 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

●Rheumatoid nodules

●Calcinosis cutis

Bullous eruptions (resulting from damage to the basal layer of the epidermis)

●Urticaria

●Cutis laxa/anetoderma

●Acanthosis nigricans

●Erythema multiforme

●Leg ulcers

●Palisaded neutrophilic and granulomatous dermatitis

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)

HEENT

  • Sclerodactyly
  • 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

Neck

Lungs

  • 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

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
  • S1
  • S2
  • S3
  • S4
  • 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

Abdomen

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

Write additional pathognomonic findings, such as discharge that resembles cottage cheese for C. albicans vulvovaginitis / fish-odor for T. vaginalis ifnection

Extremities

  • Clubbing
  • Cyanosis
  • Pitting/non-pitting edema of the upper/lower extremities
  • Muscle atrophy
  • Fasciculations in the upper/lower extremity

Neuromuscular

  • Patient is usually oriented to persons, place, and time
  • Altered mental status
  • 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

Absent/present dysdiadochokinesia (palm tapping test)

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

Raynaud phenomenon vasospastic process

blanching of the nail beds, fingers, and toes (and occasionally ears, nose, tongue, and nipples) with accompanying pain

Vasculitis urticarial vasculitis: lesions may remain for more than 24 hours and frequently evolve into painful petechiae or purpura that may heal with hyperpigmentation

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 

Skin

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. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 "Dermatology Atlas".
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