SLE is awfully uneven in its manifestations and most of the symptoms are due to the consequences of vasculitis or, inflammation of the blood vessels. Mild cases may complain only of joint pains and fatigue, and sometimes difficult to diagnose.
General symptoms of SLE
Fever is a common problem during exacerbations, occurring in up to 50% of patients. They complain of obvious malaise and tiredness and these symptoms do not correlate with the activity or, severity of the organ based complications of the disease.
The joints and muscles affection in SLE
Joint involvement is the commonest clinical entity and affect more than 90% of the patients. They frequently present with complains resembling Rheumatoid Arthritis (RA) with symmetrical small joint arthralgia. Joints are painful but typically appear clinically normal, although at times there may be slight soft-tissue swelling surrounding the joint. Deformity due to joint capsule and tendon contraction is uncommon, as are bony erosions.
Hardly ever, major joint deformity resembling RA (known as Jaccoud's arthropathy) may be found. Aseptic necrosis affecting the hip or knee joint is an infrequent complication of the disease.
Myalgia is the complain of up to 50% of patients but a true myositis is found only in less than 5%. of them. Overlapping of any connective tissue disorder is likely if myositis is prominent.
The skin and SLE
Skin is affected in SLE in about 75% of cases. Butterfly shaped erythema, in a distribution on the cheeks of the face and across the bridge of the nose typical of SLE. Vasculitic lesions on the finger tips and around the nail folds, purpura or, tiny bleeding spots and urticaria are commonly found. In about one-third of patients photosensitivity is found, and stretched exposure to sunlight can lead to exacerbations of the condition in them. Livedo reticularis, palmar and plantar rashes, pigmentation and alopecia are also found in some patients.
Involvement of lungs in SLE
Approximately 50% of SLE patients usually get lung involvement sometime during the course of the disease. Recurrent pleurisy and pleural effusions or, fluid around the lugs are the commonest manifestations and are usually bilateral. Pneumonitis and atelectasis or, solidification may also be found; ultimately a restrictive lung defect develops with loss of lung volumes and elevated hemi diaphragms. This 'shrinking lung syndrome' is not clearly understood but may have a neuromuscular foundation. Not often, pulmonary fibrosis may occcur, more commonly in overlap syndromes. Intrapulmonary haemorrhage associated with vasculitis is a not common but potentially life-threatening complication.
Effect of SLE in heart and cardiovascular system
The heart is affected in 25% of SLE patients. Pericarditis, with small (pericardial effusions) collection of fluid detected by echocardiography, is common. A mild myocarditis also occurs, leads to arrhythmias. Lesions in the Aortic valve and a cardiomyopathy can infrequently be found. A non-infective endocarditis involving the mitral valve (Libman-Sacks syndrome) is very exceptional finding. Raynaud's, vasculitis, arterial and venous thromboses may appear, especially in association with the antiphospholipid syndrome. There is an increased incidence of atherosclerotic disorder in SLE. This partly due to the treatment with corticosteroids but more likely that SLE itself is the cause
SLE and the kidneys
Though Autopsy examination shows that histological changes in the kidneys are fairly common finding, but clinical renal problems manifests in only approximately 30% of patients. All patients should undergo regular screening of urine for blood and protein. Proteinuria should be measured and any haematuria should be examined immediately for urinary casts or fragmented red cells which suggest glomerulonephritis. Renal vein thrombosis may be found in nephrotic syndrome or associated with procoagulant antiphospholipid antibodies.
Nervous system involvement in SLE
Involvement of the nervous system in SLE is present in up to 60%of patients and symptoms may change. There may be a slight depression but sometimes more severe psychiatric problems occur. Epilepsy, migraines, cerebellar ataxia,
aseptic meningitis, cranial nerve lesions, cerebrovascular disease or a polyneuropathy are sometimes seen.
The eyes in SLE
Retinal vasculitis in SLE can cause infarcts (cytoid bodies) which appear as hard exudates, and haemorrhages in retina. Episcleritis, conjunctivitis or optic neuritis, may also occur but blindness is infrequent. Secondary Sjogren's syndrome can sometimes be seen in about 15% of cases.
Involvement of the gastrointestinal system in SLE
SLE causes gastrointestinal symptoms, of which mouth ulcers are the most common and may be the first symptom. These ulcers can be painless or become painful after being secondarily infected. Mesenteric vasculitis can produce inflammatory lesions in small bowel in the form of infarction or perforation. Liver involvement is not common, but lupoid antibodies are detected in autoimmune hepatitis. Pancreatitis is also rare.
Pregnancy and SLE
Fertility is generally normal except in severe form of the disease and there is no major bar to gofor pregnancy. Barrier methods of contraception rather than the pill are suitable in SLE. Recurrent miscarriages is common and these seems to be associated with antiphospholipid antibodies. Remission and exacerbations is common during pregnancy tenure with frequent exacerbations is also common following the delivery of the baby i.e. postpartum. The usual management of the disease is continued during pregnancy. Hypertension is controlled with proper medications. With gross renal involvement with SLE and high level of antiphospholipid antibodies, fetal loss is more than 25%.
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