College Answer

SLE is a chronic inflammatory disease, presumably auto-immune, which occurs predominantly in women, and can affect almost all organ systems. These can masquerade as many different conditions, and can make workup very complex. Clinical features (and examples of ways they would influence management) include:

•    Fatigue (common and debilitating)- care with differential diagnosis

•    Fever (episodic and related to activity of disease)- need to exclude sepsis, potential for un-necessary antibiotics

•    Arthritis (painful, migratory and asymmetrical; rarely deforming)- care with positioning, may need analgesia

•    Skin changes (butterfly rash, and hair loss)- care with handling

•    Raynaud’s phenomenon- caution with vasoconstrictors, pulse oximeters, arterial lines

•    Renal dysfunction (usually glomerulonephritis)- avoid nephrotoxins, adjust drug doses

•    Pleurisy and pleural effusions- need to diagnose, exclude other conditions

•    Pericarditis and Libman-Sacks (verrucous) endocarditis- may require TOE or surgery

•    Increased incidence of coronary artery disease- need to be aware of problem in otherwise young females without risk factors!

•    Delerium, psychosis and seizures- complex management and diagnostic problem

•    Thrombosis in association with anti-phospholipid antibodies- need to diagnose, and may need treatment for pro-coagulant state

•    Abnormal haematology (leukopenia, anaemia, thrombocytopenia)- may need further investigation

•    Lymphadenopathy and splenomegaly- may make suspicious of alternative disease process; may ned further investigation

•    Auto-immune disease and immunosuppressive therapy (eg. corticosteroids, cyclophosphamide)- at particular risk of infections in immunosuppressed. Early and aggressive workup and initial treatment may be required. Aware of potential for adrenal suppression.

Discussion

This question would benefit from a structured tabulated answer.