Systemic lupus erythematosus natural history, complications and prognosis: Difference between revisions
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*[[Malignancies]] | *[[Malignancies]] | ||
=== Factors associated with flare up: === | === Factors associated with flare up:<ref name="pmid1893619">{{cite journal |vauthors=Deguchi Y, Kishimoto S |title=Tumour necrosis factor/cachectin plays a key role in autoimmune pulmonary inflammation in lupus-prone mice |journal=Clin. Exp. Immunol. |volume=85 |issue=3 |pages=392–5 |year=1991 |pmid=1893619 |pmc=1535595 |doi= |url=}}</ref> === | ||
* [[Stress]] (emotional etc.) | * [[Stress]] (emotional etc.) | ||
* [[Sunlight]] | * [[Sunlight]] | ||
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!Frequency | !Frequency | ||
|- | |- | ||
| rowspan="8" |Gastrointestinal | | rowspan="8" |Gastrointestinal system | ||
|[[Dysphagia]] | |||
| | | | ||
* Usually due to an underlying [[esophageal motility disorder]] | * Usually due to an underlying [[esophageal motility disorder]] | ||
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|↑↑↑ | |↑↑↑ | ||
|- | |- | ||
|[[Peptic ulcer disease]] | |||
| | | | ||
* Due to | * Due to | ||
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|↑ | |↑ | ||
|- | |- | ||
|[[Intestinal pseudo-obstruction|Intestinal pseudo-obstruction]] | |||
| | | | ||
* May lead to [[Gastrointestinal obstruction|mechanical obstruction]] of the small or large bowel in the absence of an anatomic lesion | * May lead to [[Gastrointestinal obstruction|mechanical obstruction]] of the small or large bowel in the absence of an anatomic lesion | ||
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|↓↓ | |↓↓ | ||
|- | |- | ||
|[[Protein-losing enteropathy|Protein-losing enteropathy]] | |||
| | | | ||
* Occurs in patients with clinically severe SLE with multi-organ involvement | * Occurs in patients with clinically severe SLE with multi-organ involvement | ||
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|↓↓ | |↓↓ | ||
|- | |- | ||
|[[Hepatitis]] | |||
| | | | ||
* May be due to: | * May be due to: | ||
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|↑ | |↑ | ||
|- | |- | ||
|[[Acute pancreatitis|Acute pancreatitis]] | |||
| | | | ||
* Occurs usually in the setting of active SLE | * Occurs usually in the setting of active SLE | ||
|↓ | |↓ | ||
|- | |- | ||
|[[Mesenteric vascular occlusion|Mesenteric vasculitis]] | |||
| | | | ||
* Mostly involve: | * Mostly involve: | ||
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|↓↓ | |↓↓ | ||
|- | |- | ||
|[[Acute cholecystitis]] | |||
| | | | ||
* Due to periarterial [[fibrosis]] and [[Vasculitis|acute vasculitis]] | * Due to periarterial [[fibrosis]] and [[Vasculitis|acute vasculitis]] | ||
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|↓↓ | |↓↓ | ||
|- | |- | ||
| rowspan="6" |Pulmonary | | rowspan="6" |Pulmonary involvement | ||
|[[Pleural disease|Pleural disease]] | |||
| | | | ||
* May lead to: | * May lead to: | ||
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|↑ | |↑ | ||
|- | |- | ||
|[[Pneumonitis|Acute pneumonitis]] | |||
| | | | ||
* Fulminant form of diffuse lung injury | * Fulminant form of diffuse lung injury | ||
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|↓↓ | |↓↓ | ||
|- | |- | ||
|[[Pulmonary hemorrhage]] | |||
| | | | ||
* Pulmonary alveolar hemorrhage: | * Pulmonary alveolar hemorrhage: | ||
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|↓↓ | |↓↓ | ||
|- | |- | ||
|[[Pulmonary hypertension]] | |||
| | | | ||
* Increased pressure in the [[pulmonary artery]] or [[lung]] [[Pulmonary circulation|vasculature]] | * Increased pressure in the [[pulmonary artery]] or [[lung]] [[Pulmonary circulation|vasculature]] | ||
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|↑ | |↑ | ||
|- | |- | ||
|[[Thromboembolic disease]] | |||
| | | | ||
* Chronic [[inflammation]] that increase the risk of [[Thromboembolic disease|thromboembolic events]] | * Chronic [[inflammation]] that increase the risk of [[Thromboembolic disease|thromboembolic events]] | ||
|↑ | |↑ | ||
|- | |- | ||
|Shrinking lung syndrome | |||
| | | | ||
* Characterized by [[dyspnea]] and [[Dyspnea|shortness of breath]] (estimated prevalence approximately 0.5%) | * Characterized by [[dyspnea]] and [[Dyspnea|shortness of breath]] (estimated prevalence approximately 0.5%) | ||
|↓↓ | |↓↓ | ||
|- | |- | ||
| rowspan="5" |Cardiac | | rowspan="5" |Cardiac involvement | ||
|[[Cardiomegaly]] | |||
| | | | ||
* Due to: | * Due to: | ||
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|↑↑ | |↑↑ | ||
|- | |- | ||
|[[Valvular disease]] | |||
| | | | ||
* Different [[Valvular Diseases|valvular]] complications include: | * Different [[Valvular Diseases|valvular]] complications include: | ||
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|↑↑ | |↑↑ | ||
|- | |- | ||
|[[Pericardial disease]] | |||
| | | | ||
* [[Acute pericarditis]] | * [[Acute pericarditis]] | ||
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|↓ | |↓ | ||
|- | |- | ||
|[[Myocarditis]] | |||
| | | | ||
* Characterized by: | * Characterized by: | ||
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|↓ | |↓ | ||
|- | |- | ||
|[[Coronary heart disease|Coronary artery disease]] | |||
| | | | ||
* Mainly as a result of increased risk of [[Atheroma|atheromatous plaques]] due to autoimmune status of SLE | * Mainly as a result of increased risk of [[Atheroma|atheromatous plaques]] due to autoimmune status of SLE | ||
|↑↑ | |↑↑ | ||
|- | |- | ||
| rowspan="5" |Neurological | | rowspan="5" |Neurological involvement | ||
|[[Cognitive-shifting|Cognitive dysfunction]] | |||
| | | | ||
* May be temporarily affected by multiple, transient [[metabolic]] and systemic processes | * May be temporarily affected by multiple, transient [[metabolic]] and systemic processes | ||
|↑ | |↑ | ||
|- | |- | ||
|[[Stroke]] | |||
| | | | ||
* Increase risk of [[Ischemic stroke classification|thrombotic stroke]] due to [[Vasculopathy|small vessel vasculopathy]] | * Increase risk of [[Ischemic stroke classification|thrombotic stroke]] due to [[Vasculopathy|small vessel vasculopathy]] | ||
|↓ | |↓ | ||
|- | |- | ||
|[[Seizure|Seizures]] | |||
| | | | ||
* May happen secondary to [[increased intracranial pressure]]: | * May happen secondary to [[increased intracranial pressure]]: | ||
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|↑ | |↑ | ||
|- | |- | ||
|[[Psychosis]] | |||
| | | | ||
* Can indirectly influence [[Cognition|cognitive performance]] | * Can indirectly influence [[Cognition|cognitive performance]] | ||
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|↑↑ | |↑↑ | ||
|- | |- | ||
|[[Neuropathies]] | |||
| | | | ||
* [[Peripheral neuropathy]] | * [[Peripheral neuropathy]] | ||
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|↑↑ | |↑↑ | ||
|- | |- | ||
| rowspan="4" |Musculoskeletal | | rowspan="4" |Musculoskeletal involvement | ||
|[[Arthritis]] | |||
| | | | ||
*Mostly symmetrical and non-erosive arthritis | *Mostly symmetrical and non-erosive arthritis | ||
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|↑↑↑↑ | |↑↑↑↑ | ||
|- | |- | ||
|[[Osteonecrosis]] ([[Avascular necrosis]]) | |||
| | | | ||
* Most common in the [[Femoral|femoral head]] | * Most common in the [[Femoral|femoral head]] | ||
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|↓ | |↓ | ||
|- | |- | ||
|[[Subcutaneous tissue|Subcutaneous nodules]] | |||
| | | | ||
* Associated with active disease and flare ups | * Associated with active disease and flare ups | ||
|↑ | |↑ | ||
|- | |- | ||
|[[Osteoporosis]] | |||
| | | | ||
*Mostly due to [[glucocorticoid]] usage | *Mostly due to [[glucocorticoid]] usage | ||
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|↑ | |↑ | ||
|- | |- | ||
| rowspan="5" |Skin | | rowspan="5" |Skin disorder | ||
|[[Cutaneous lupus erythematosus]] | |||
| | | | ||
*[[Erythema]] in a [[malar]] distribution over the cheeks and nose (but sparing the [[nasolabial folds]]), which appears after sun exposure | *[[Erythema]] in a [[malar]] distribution over the cheeks and nose (but sparing the [[nasolabial folds]]), which appears after sun exposure | ||
|↑ | |↑ | ||
|- | |- | ||
|[[Photosensitivity]] | |||
| | | | ||
* Common theme for skin [[lesions]] associated with SLE | * Common theme for skin [[lesions]] associated with SLE | ||
|↑↑↑ | |↑↑↑ | ||
|- | |- | ||
|[[Alopecia|Non-scarring alopecia]] | |||
| | | | ||
* May occur at some point during the course of their disease | * May occur at some point during the course of their disease | ||
|↑ | |↑ | ||
|- | |- | ||
|Oral and nasal ulcers | |||
| | | | ||
* Usually painless | * Usually painless | ||
|↑↑ | |↑↑ | ||
|- | |- | ||
|Discoid lesions | |||
| | | | ||
* More [[inflammatory]] | * More [[inflammatory]] | ||
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|↑ | |↑ | ||
|- | |- | ||
| rowspan="2" | | | rowspan="2" |Very rare disorders | ||
|[[Malignancy]] | |||
| | | | ||
* [[Non-Hodgkin lymphoma|Non-Hodgkin’s lymphoma]] | * [[Non-Hodgkin lymphoma|Non-Hodgkin’s lymphoma]] | ||
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|↓↓↓ | |↓↓↓ | ||
|- | |- | ||
|[[Diabetes mellitus]] | |||
| | | | ||
* Increase predisposition to: | * Increase predisposition to: | ||
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* High overall disease activity | * High overall disease activity | ||
=== Prognosis markers: === | === Prognosis markers:<ref name="pmid24881804">{{cite journal |vauthors=Lisnevskaia L, Murphy G, Isenberg D |title=Systemic lupus erythematosus |journal=Lancet |volume=384 |issue=9957 |pages=1878–88 |year=2014 |pmid=24881804 |doi=10.1016/S0140-6736(14)60128-8 |url=}}</ref> === | ||
===== Serum anti ds-DNA titres correlated with: ===== | ===== Serum anti ds-DNA titres correlated with: ===== | ||
** [[Lupus nephritis]] | ** [[Lupus nephritis]] |
Revision as of 18:57, 30 July 2017
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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
Common complications of systemic lupus erythematosus include dermatitis, nephritis and arthritis. Prognosis is generally poor, and the 10-year mortality rate of patients with systemic lupus erythematosus is approximately 40%. The disease course can be divided into 4 subcategories based on the course of the disease: developmental phase, preclinical phase, clinical phase, and comorbid complication phase.
Natural History
Systemic lupus erythematosus (SLE) is an autoimmune disease. SLE is a disease of waxing and waning, with possible flare up episodes. SLE usually develops in the second and third decade of life, although it can presents any age, and start with mild symptoms such as fatigue, fever, and skin rashes. Without treatment, the patient will develop symptoms of end organ damage, which will eventually lead to death in most of the patients.
The disease course can be divided into 4 subcategories based on the course of the disease:
Developmental phase:
- Genetic mutations
- UV radiation exposure
- Smoking
Preclinical phase:
- Mostly associated with auto-immune antibody production
- Autoantibodies common to other systemic autoimmune diseases
- Proceeds with a more disease-specific clinically overt autoimmune phase
Clinical phase:
- The phase due to damages of the autoantibodies to the body tissues (mostly related to disease itself)
- Inflammation
- Involvement of first organs
- Flares
- Involvement of additional organs
- Early damages (e.g. alopecia, fixed erythema, cognitive dysfunction, valvular heart disease, avascular necrosis, tendon rupture, Jaccoud’s arthropathy, and osteoporosis)
Comorbidity-complication phase
The phase of damages due to complications of longstanding disease, immunosuppressive therapy, and end organ damages (irreversible damages and complications)
Factors associated with flare up:[1]
- Stress (emotional etc.)
- Sunlight
- Ultraviolet light
- Infection
- Injuries
- Surgery
- Pregnancy
- Abrupt discontinuation of medications
- Treatment noncompliance
- Medications
- Immunizations
- Lupus nephritis
- Presence of neurologic complications
- Presence of vasculitis
- Elevated anti-dsDNA
- Low C3 level
Complications
Complications that can develop as a result of prolonged activation of systemic lupus erythematosus or the SLE therapy are:
Organ | Disease | Description | Frequency |
---|---|---|---|
Gastrointestinal system | Dysphagia |
|
↑↑↑ |
Peptic ulcer disease |
|
↑ | |
Intestinal pseudo-obstruction |
|
↓↓ | |
Protein-losing enteropathy |
|
↓↓ | |
Hepatitis |
|
↑ | |
Acute pancreatitis |
|
↓ | |
Mesenteric vasculitis |
|
↓↓ | |
Acute cholecystitis |
|
↓↓ | |
Pulmonary involvement | Pleural disease |
|
↑ |
Acute pneumonitis |
|
↓↓ | |
Pulmonary hemorrhage |
|
↓↓ | |
Pulmonary hypertension |
|
↑ | |
Thromboembolic disease |
|
↑ | |
Shrinking lung syndrome |
|
↓↓ | |
Cardiac involvement | Cardiomegaly | ↑↑ | |
Valvular disease |
|
↑↑ | |
Pericardial disease | ↓ | ||
Myocarditis |
|
↓ | |
Coronary artery disease |
|
↑↑ | |
Neurological involvement | Cognitive dysfunction |
|
↑ |
Stroke |
|
↓ | |
Seizures |
|
↑ | |
Psychosis |
|
↑↑ | |
Neuropathies |
|
↑↑ | |
Musculoskeletal involvement | Arthritis |
|
↑↑↑↑ |
Osteonecrosis (Avascular necrosis) |
|
↓ | |
Subcutaneous nodules |
|
↑ | |
Osteoporosis |
|
↑ | |
Skin disorder | Cutaneous lupus erythematosus |
|
↑ |
Photosensitivity |
|
↑↑↑ | |
Non-scarring alopecia |
|
↑ | |
Oral and nasal ulcers |
|
↑↑ | |
Discoid lesions |
|
↑ | |
Very rare disorders | Malignancy | ↓↓↓ | |
Diabetes mellitus |
|
↓ |
Prognosis
The prognosis of systemic lupus erythematosus is ranging from a benign illness to an extremely rapid progressive disease that can lead to a fulminant organ failure and death. Without treatment, systemic lupus eryhtematosus will result in a very high mortality rate, with a report of more than 60% mortality rate during the mid-20th century. SLE is associated with a 10 year mortality of more than 50% among patient with nephritis. The presence of nephritis is associated with a particularly poor prognosis among patients with SLE. The increase in survival rate of patients and better prognosis may be due to increased disease recognition with more sensitive diagnostic tests, earlier diagnosis or treatment, the inclusion of milder cases, increasingly judicious therapy, and prompt treatment of complications. Although improvement in SLE diagnosis have led to better prognosis, the mortality rate among SLE patients is still 5 times more than normal population.
Poor prognostic factors for SLE survival:
- Presence of nephritis (especially diffuse proliferative glomerulonephritis)
- Hypertension
- Male sex
- Young age
- Older age at presentation
- Low socioeconomic status
- Black race: Higher rate of nephritis
- Presence of antiphospholipid antibodies
- High overall disease activity
Prognosis markers:[2]
- Lupus nephritis
- Progression to end-stage renal disease
- Increased disease severity
- Damage or poor survival
- Features of the antiphospholipid syndrome (APS)
- CNS involvement
- Severe lupus nephritis
- Increase in mortality rate
SLE in men compared to women:
- Less photosensitivity
- More serositis
- Older age at diagnosis
- Higher 1 year mortality compared to women
SLE in the elderly (>65) compared to middle age prevalency:
- Lower incidence of:
- Greater prevalence of:
- Serositis
- Pulmonary involvement
- Sicca syndrome
- Musculoskeletal manifestations
References
- ↑ Deguchi Y, Kishimoto S (1991). "Tumour necrosis factor/cachectin plays a key role in autoimmune pulmonary inflammation in lupus-prone mice". Clin. Exp. Immunol. 85 (3): 392–5. PMC 1535595. PMID 1893619.
- ↑ Lisnevskaia L, Murphy G, Isenberg D (2014). "Systemic lupus erythematosus". Lancet. 384 (9957): 1878–88. doi:10.1016/S0140-6736(14)60128-8. PMID 24881804.