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INTRODUCTION STEP 1: CASE ASCERTAINMENT STEP 2: DIAGNOSING LUPUS STEP 3: PRINCIPLES OF MANAGEMENT OF LUPUS STEP 4: LIFE & LUPUS REFERENCES APPENDICES ABOUT THE AUTHORS
CONTENTS
Step 2: Diagnosing Lupus
On ward rounds, the late Professor Nicholson was taken to the bedside of a young Rastafarian woman who was admitted with hypertension, proteinuria and renal failure. With lupus being a strong possibility — conditions like primary vasculitis or infection-associated glomerulonephritis were less common — it was reported that the patient had no joint pain, no chest pain, no oral ulcers, no hair loss, no rashes. After a short pause Professor Nicholson approached the patient asking, “Do you have any bald patches?”— she unhesitatingly said “yes,” flipping her long dreadlocs to reveal an extensive discoid lesion with scarring alopecia. The embarrassing lesson here is that doctors need to ensure that they are understood, use probing open-ended questions and sometimes ask the same question in different ways. The physical examination must also be consistently meticulous.
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Joints
COMMON CLINICAL FEATURES OF LUPUS
The most common feature of lupus is an inflammatory polyarthritis that mimics rheumatoid arthritis. The small joints of the hand and the knees are typically affected with evidence of synovitis and joint effusions and over 30 minutes of early morning stiffness. In some patients with inflamed joints the physical findings may be subtle.
Fig 3.1: Swelling of the knees with effusions distending the suprapatellar region
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Step 2: Diagnosing Lupus
Fig 3.16: Discoid rash in a “butterfly” distribution
Fig 3.17: Severe discoid lupus with scarring alopecia, note lip involvement
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Fig 3.18: “Lupus hair”straightening of the hair texture and non-scarring alopecia
Fig 3.19: Atrophic depressed discoid scars due to accompanying subcutaneous fat atrophy
Step 2: Diagnosing Lupus
Subacute cutaneous lupus
Fig 3.20: Scarred depigmented discoid lesions with secondary squamous cell carcinoma in the right hand of this patient
Fig 3.21: Extensive discoid lesions on one forearm while the other has only a few small lesions. This illustrates photoexacerbation of discoid lupus on the arm exposed to frequent sunlight in this driver
Subacute cutaneous lupus is a non-scarring photosensitive rash that is more common in Caucasian patients hence has not been commonly seen in Barbados.
Fig 3.22: Lupus patient with subacute cutaneous lupus occurring days after spending a day at the beach. The rash spared areas of the back covered by the swimsuit.
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Step 2: Diagnosing Lupus
After a case of lupus is diagnosed it is important to identify factors that may negatively impact on patient outcomes such as low socioeconomic status, low education attainment, low selfefficacy, lack of a family or social network, and psychological issues such as depression and anxiety. Management of patients with these confounders goes far beyond the pharmaceutical prescription to involve referrals to social workers, psychologists and a host of social support services and charities.
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Fig 3.36: Sample prescription to reduce risk of renal flare in a 24-year-old who has controlled lupus nephritis and is the working mother of a toddler
PRINCIPLES OF MANAGEMENT OF LUPUS
STEP 3
Lupus patients require close long-term follow-up with the frequency of assessment dictated by the severity of the disease. Management involves use of background medication, system-specific medication, treatment of comorbidities, infection prevention and attention to quality-of-life issues. Background medication in lupus consists of: Hydroxychloroquine 5mg/kg daily (ideal body weight to a max. of 400mg daily) which has a therapeutic effect for joint and skin disease as well as being antithrombotic, positively affecting lipid profiles and reducing the risk of development of Type 2 Diabetes Mellitus. Vitamin D3 400 units daily thought to ameliorate inflammatory markers Sunblock/sun-precautions
These interventions are simple and safe enough to be prescribed by the non-specialist.
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