Differentiating systemic lupus erythematosus from other diseases: Difference between revisions

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Revision as of 19:18, 11 July 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

Systemic lupus erythematosus (SLE) must be differentiated from other diseases that cause skin rash, arthritis, positive autoimmune serology, weight loss, fevers and chronic pain, such as rheumatoid arthritis(RA), mixed connective tissue disease (MCTD), systemic sclerosis (SSc), dermatomyositis (DM), polymyositis(PM), and other autoimmune diseases.

Differentiating systemic lupus erythematosus from other diseases

Systemic lupus erythematosus (SLE) must be differentiated from other diseases that cause skin rash, arthritis, positive autoimmune serology, weight loss, fevers and chronic pain, such as rheumatoid arthritis(RA), mixed connective tissue disease (MCTD), systemic sclerosis (SSc), dermatomyositis (DM), polymyositis(PM), and other autoimmune diseases.

Differetiating SLE from other diseases that cause arthritis and rash

n		Arthritis					Auto-antibodies							Raynaud phenamon	Rash pattern	Distinguishing/specific features
n		Polyarthritis	Tenderness	Edema	Deformity /Erosion	Pattern	ANA	RF	Anti-CCp	anti U1RNP	AntiSm	AntiRo	Anti-dsDNA	Raynaud phenamon	Rash pattern	Distinguishing/specific features
Systemic lupus erythematosus						Small joints
Rheumatoid arthritis (RA)		+	+	+	+	Small and large joints		↑↑	↑↑					+
Rhupus		+	+	+	+	Small and large joints	↑	↑	↑	↑	↑		↑	+	Patients with overlapping features of both SLE and RA Serologies consistent with both SLE and RA	Erosive arthropathy that is atypical for SLE
Mixed connective tissue disease (MCTD)^[1]					+	Small and large joints		↑↑	↑					+	A mix disease with overlapping features of SLE, systemic sclerosis (SSc), and polymyositis (PM) Antibodies against U1 ribonucleoprotein (RNP)
Undifferentiated connective tissue disease (UCTD)		+				Small and large joints	↑	↑			↑			+	erythematous macules, patches, or papules with delicate scale mostly in lower extremities	sclerodactyly telangiectasias calcinosis malignant hypertension acute renal failure
Systemic sclerosis (SSc)		+/-	+	+	+/-		↑↑				↑		↑	+	skin thickening and hardening Edematous swelling and erythema	Sclerodactyly Telangiectasias Calcinosis Malignant hypertension acute renal failure
Sjögren’s syndrome 15485020		+/-	+/-			Lower extremity and axiallary creases	↑					↑			Xerosis Scaly skin Annular erythema	Keratoconjunctivitis sicca Xerostomia
Vasculitis	Giant cell		+	+											Rare	cranial branches of arteries visual loss
	Takayasu		+/-	+/-											Erythema nodosum Pyoderma gangrenosum
	Poly-arteritis nodosa		+/-												tender erythematous nodules Purpura Livedo reticularis Bullous or vesicular eruption
Behçet’s syndrome		+/-	+/-	+/-											acneiform lesions Papulo-vesiculo-pustular eruptions Superficial thrombophlebitis	Male dominancy ANA-negative
Kikuchi’s disease			+/-				↑/↓								Transient skin rashes Malar rash Erythematous macules, patches, papules, or plaques	May be associated with SLE
Serum sickness		+/-	+	+/-											pruritic rash urticarial and/or serpiginous macular rash	Negative ANA Self-limited
Psoriatic arthritis						Small and large joints
Human parvovirus B19 infection		+	+			Small joints										Flu-like symptoms Hematologic abnormalities such as leukopenia and thrombocytopenia

References

↑ Cappelli S, Bellando Randone S, Martinović D, Tamas MM, Pasalić K, Allanore Y, Mosca M, Talarico R, Opris D, Kiss CG, Tausche AK, Cardarelli S, Riccieri V, Koneva O, Cuomo G, Becker MO, Sulli A, Guiducci S, Radić M, Bombardieri S, Aringer M, Cozzi F, Valesini G, Ananyeva L, Valentini G, Riemekasten G, Cutolo M, Ionescu R, Czirják L, Damjanov N, Rednic S, Matucci Cerinic M (2012). ""To be or not to be," ten years after: evidence for mixed connective tissue disease as a distinct entity". Semin. Arthritis Rheum. 41 (4): 589–98. doi:10.1016/j.semarthrit.2011.07.010. PMID 21959290.

[pmid21959290-1] Cappelli S, Bellando Randone S, Martinović D, Tamas MM, Pasalić K, Allanore Y, Mosca M, Talarico R, Opris D, Kiss CG, Tausche AK, Cardarelli S, Riccieri V, Koneva O, Cuomo G, Becker MO, Sulli A, Guiducci S, Radić M, Bombardieri S, Aringer M, Cozzi F, Valesini G, Ananyeva L, Valentini G, Riemekasten G, Cutolo M, Ionescu R, Czirják L, Damjanov N, Rednic S, Matucci Cerinic M (2012). ""To be or not to be," ten years after: evidence for mixed connective tissue disease as a distinct entity". Semin. Arthritis Rheum. 41 (4): 589–98. doi:10.1016/j.semarthrit.2011.07.010. PMID 21959290.

[1]

@@ Line 12: / Line 12: @@
 ===== Differetiating SLE from other diseases that cause [[arthritis]] and [[rash]] =====
 {| class="wikitable"
-! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |n
+! colspan="2" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |n
-! colspan="4" |Arthritis
+! colspan="5" |Arthritis
 ! colspan="7" |Auto-antibodies
-!
+! rowspan="2" |Raynaud phenamon
-! align="center" style="background:#4479BA; color: #FFFFFF;" + |Rash pattern
+! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Rash pattern
-! align="center" style="background:#4479BA; color: #FFFFFF;" + |Distinguishing/specific features
+! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Distinguishing/specific features
 |-
-!
-!
 !Polyarthritis
 !Tenderness
 !Edema
 !Deformity /Erosion
+!Pattern
 !ANA
 !RF
@@ Line 32: / Line 31: @@
 !AntiRo
 !Anti-dsDNA
-!Raynaud phenamon
+|-
-!
+| colspan="2" |[[Systemic lupus erythematosus]]
-!
+|
+|
+|
+|
+|Small joints
+|
+|
+|
+|
+|
+|
+|
+|
+|
+|
 |-
 | colspan="2" |[[Rheumatoid arthritis]] ([[Rheumatoid arthritis|RA]])
@@ Line 41: / Line 54: @@
 | +
 | +
+|Small and large joints
 |
 |↑↑
@@ Line 50: / Line 64: @@
 | +
 |
-* [[Serositis]]
+*
-* Sicca symptoms (photosensitivity, dry eyes, dry mouth)
-* [[Subcutaneous]] nodules
-* [[Anemia]]
-* [[Fatigue]]
-* Joint tenderness and swelling especially in early RA
-* [[Swan neck deformity|Swan neck deformities]], [[ulnar deviation]], and [[soft tissue]] laxity more common in RA but may seen in SLE as well
-* Positive [[Antinuclear antibodies|ANA]]: more common in SLE
-* Positive [[Rheumatoid factor]] ([[Rheumatoid factor|RF]]): more common in [[Rheumatoid arthritis|RA]]
 |
-* Joint deformities in [[Rheumatoid arthritis|RA]] are often more extensive, and frequently erosive on plain radiographs
+*
-* Presence of anti-cyclic citrullinated peptides (CCP)
 |-
 | colspan="2" |Rhupus
@@ Line 68: / Line 73: @@
 | +
 | +
+|Small and large joints
 |↑
 |↑
@@ Line 87: / Line 93: @@
 |
 | +
+|Small and large joints
 |
 |↑↑
@@ Line 106: / Line 113: @@
 |
 |
+|Small and large joints
 |↑
 |↑
@@ Line 129: / Line 137: @@
 |<nowiki>+</nowiki>
 |<nowiki>+/-</nowiki>
+|
 |↑↑
 |
@@ Line 153: / Line 162: @@
 |
 |
+|Lower extremity
+and
+axiallary creases
 |↑
 |
@@ Line 162: / Line 175: @@
 |
 |
-* Xerosis ry, scaly skin, most often affecting the lower extremities and axillary creases
+* Xerosis
-* annular erythema
+* Scaly skin
+* Annular erythema
 |
@@ Line 174: / Line 188: @@
 |<nowiki>+</nowiki>
 |<nowiki>+</nowiki>
+|
 |
 |
@@ Line 185: / Line 200: @@
 |
 * Rare
-*
 |
 * cranial branches of arteries
@@ Line 203: / Line 217: @@
 |
 |
-* erythema nodosum or pyoderma gangrenosum
+|
+* Erythema nodosum
+* Pyoderma gangrenosum
 |
 |-
@@ Line 219: / Line 235: @@
 |
 |
-* tender erythematous nodules, purpura, livedo reticularis, ulcers, and bullous or vesicular eruption
+|
+* tender erythematous nodules
+* Purpura
+* Livedo reticularis
+* Bullous or vesicular eruption
 |
 |-
@@ Line 236: / Line 256: @@
 |
 |
-* acneiform lesions, papulo-vesiculo-pustular eruptions, pseudofolliculitis, nodules, erythema nodosum (septal panniculitis), superficial thrombophlebitis, pyoderma gangrenosum-type lesions, erythema multiforme-like lesions, and palpable purpura.
+|
+* acneiform lesions
+* Papulo-vesiculo-pustular eruptions
+* Superficial thrombophlebitis
 |
 * Male dominancy
@@ Line 244: / Line 267: @@
 |
 |<nowiki>+/-</nowiki>
+|
 |
 |
@@ Line 254: / Line 278: @@
 |
 |
-|Transient skin rashes similar to rubella or drug-induced eruptions
+|
+* Transient skin rashes
+* Malar rash
-malar rash
+* Erythematous macules, patches, papules, or plaques
-* erythematous macules, patches, papules, or plaques
 |
 * May be associated with SLE
-*
 |-
 | colspan="2" |Serum sickness
@@ Line 266: / Line 290: @@
 |<nowiki>+</nowiki>
 |<nowiki>+/-</nowiki>
+|
 |
 |
@@ Line 282: / Line 307: @@
 * Self-limited
 |-
-| rowspan="9" |Infections
+| colspan="2" |Psoriatic arthritis
-| rowspan="7" |Viruses
 |
 |
 |
 |
+|Small and large joints
 |
 |
@@ Line 297: / Line 322: @@
 |
 |
-* Human [[parvovirus]] B19:
-** Flu-like symptoms ([[fever]],[[malaise]], [[dry cough]], loss of appetite, [[body aches]])
-** Hematologic abnormalities such as [[leukopenia]] and [[thrombocytopenia]]
-** [[Arthralgias]] or [[arthritis]]
-| rowspan="9" |
-* Serologic assays can be diagnostic for many of these viruses
-|-
 |
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-* [[Epstein Barr virus|EBV]]
-** May lead to a positive [[ANA]]<ref name="pmid3020161">{{cite journal |vauthors=Sculley DG, Sculley TB, Pope JH |title=Reactions of sera from patients with rheumatoid arthritis, systemic lupus erythematosus and infectious mononucleosis to Epstein-Barr virus-induced polypeptides |journal=J. Gen. Virol. |volume=67 ( Pt 10) |issue= |pages=2253–8 |year=1986 |pmid=3020161 |doi=10.1099/0022-1317-67-10-2253 |url=}}</ref>
-|-
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|[[Human Immunodeficiency Virus (HIV)|Human immunodeficiency virus]] ([[HIV]])
-|-
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|[[Hepatitis B virus]] ([[HBV]])
-|-
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|[[Hepatitis C virus]] ([[HCV]])
-|-
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|[[Cytomegalovirus]] ([[CMV]])
-|-
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|[[Epstein Barr virus|Epstein-Barr virus]] ([[EBV]])
-|-
-| rowspan="2" |Bacterias
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|[[Salmonella]]
 |-
+| colspan="2" |Human [[parvovirus]] B19 infection
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
 |
 |
+|Small joints
 |
 |
@@ Line 416: / Line 339: @@
 |
 |
+*
 |
-|[[Mycobacterium tuberculosis]]
+* Flu-like symptoms
+* Hematologic abnormalities such as [[leukopenia]] and [[thrombocytopenia]]
 |}