Systemic Lupus Erythematosus Diagnosis and Management

Introduction to SLE

The American College of Cardiology suggests that the combination of butterfly rash, arthralgia, and cardiac symptoms in a patient with multiple autoimmune conditions strongly suggests SLE 1
The American College of Cardiology recommends considering SLE in young women with over 50 times increased risk of myocardial infarction compared to age-matched controls 1

Autoimmune inflammatory arthritis, such as rheumatoid arthritis or seronegative arthritis, should be considered given intermittent joint pain and autoimmune predisposition 2, 3
Cardiac involvement from autoimmune disease, including myocarditis or pericarditis, is a possible diagnosis 3, 4

A complete rheumatologic panel, including ANA, RF, and anti-CCP antibodies, is essential to evaluate for SLE and inflammatory arthritis 2, 5, 6
Inflammatory markers, such as ESR and CRP, should be assessed to evaluate the degree of systemic inflammation 2, 3, 5
A complete blood count with differential is necessary to assess for cytopenias common in SLE 6
A comprehensive metabolic panel, including liver and kidney function, is required to evaluate organ involvement 6
Creatine kinase (CK) and troponin levels should be checked to rule out myositis and evaluate for myocardial involvement 4, 5, 6
Urinalysis with microscopy is necessary to assess for renal involvement in potential SLE 6

If ANA is positive or there is high clinical suspicion, additional autoantibody testing, including anti-dsDNA, anti-Smith, anti-Ro/SSA, and anti-La/SSB antibodies, should be performed 6
Complement levels (C3, C4) should be checked, as they are typically low in active SLE 6

An ECG should be performed to assess for pericarditis, arrhythmias, or conduction abnormalities 3
An echocardiogram is necessary if ECG is abnormal or if there are persistent cardiac symptoms to evaluate for pericardial effusion or myocardial dysfunction 3
X-rays of affected joints should be taken to assess for erosive changes 2, 5
Ultrasound of affected joints can identify synovitis and tenosynovitis not apparent on physical exam 2, 3

A detailed history, including duration and pattern of joint symptoms, number and distribution of affected joints, and description of rash, should be taken 2, 5, 6
A systematic joint examination with documentation of tender and swollen joint count is necessary 2, 5
A careful skin examination for active rash, photosensitivity, oral ulcers, and alopecia should be performed 5, 6
A cardiac examination for pericardial rub, murmurs, and irregular rhythm is essential 3

Early referral to rheumatology is crucial given the high suspicion for SLE or other serious autoimmune disease 5, 6
The patient has multiple risk factors for accelerated atherosclerosis, including T1DM, PCOS, Hashimoto's, perimenopause, and potential SLE, and should be screened for cardiovascular risk 1
Premature menopause would further increase cardiovascular risk, and the patient should be monitored accordingly 1

Transient butterfly rash should not be dismissed, as even brief episodes are significant in the context of other symptoms and autoimmune history 5, 6
Autoantibody testing should not be relied upon solely without clinical correlation, as negative initial ANA does not exclude SLE 6
Symptoms should not be attributed solely to perimenopause without excluding serious autoimmune disease 1
Infectious disease screening should not be delayed before initiating immunosuppressive therapy if treatment becomes necessary 6