Systemic lupus erythematosus

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Systemic lupus erythematosus
Classification and external resources
Drawing of the typical "butterfly rash" found in lupus
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Systemic lupus erythematosus
Classification and external resources
Drawing of the typical "butterfly rash" found in lupus
eMedicinemed/2228 emerg/564

Systemic lupus erythematosus Listeni/sɪˈstɛmɪk ˈlpəs ˌɛrɪθməˈtsəs/, often abbreviated as SLE or lupus, is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage.[1] It is both a type II[2] and a type III hypersensitivity reaction in which bound antibody-antigen pairs (immune complexes) precipitate and cause a further immune response.

SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. The disease occurs nine times more often in women than in men, especially in women in child-bearing years ages 15 to 35, and is also more common in those of non-European descent.[2][3][4]

There is no cure for SLE. It is treated with immunosuppression, mainly with cyclophosphamide, corticosteroids and other immunosuppressants. SLE can be fatal. The leading cause of death is from cardiovascular disease due to accelerated atherosclerosis. Survival for people with SLE in the United States, Canada, and Europe has risen to approximately 95% at five years, 90% at 10 years, and 78% at 20 years,[2] and now approaches that of matched controls without lupus.

Childhood systemic lupus erythematosus generally presents between the ages of 3 and 15, with girls outnumbering boys 4:1, and typical skin manifestations being butterfly eruption on the face and photosensitivity.[1]

Lupus is Latin for wolf. In the 18th century, when lupus was just starting to be recognized as a disease, it was thought that it was caused by the bite of a wolf.[5] This may have been because of the distinctive rash characteristic of lupus. (Once full-blown, the round, disk-shaped rashes heal from the inside out, leaving a bite-like imprint.)

Signs and symptoms

Common symptoms of SLE.[6]

SLE is one of several diseases known as "the great imitators" because it often mimics or is mistaken for other illnesses.[7] SLE is a classical item in differential diagnosis,[3] because SLE symptoms vary widely and come and go unpredictably. Diagnosis can thus be elusive, with some people suffering unexplained symptoms of untreated SLE for years.

Common initial and chronic complaints include fever, malaise, joint pains, myalgias, fatigue, and temporary loss of cognitive abilities. Because they are so often seen with other diseases, these signs and symptoms are not part of the diagnostic criteria for SLE. When occurring in conjunction with other signs and symptoms (see below), however, they are considered suggestive.[8]


Micrograph showing vacuolar interface dermatitis, as may be seen in SLE. H&E stain.

As many as 30%[citation needed] of sufferers have some dermatological symptoms (and 65%[citation needed][inconsistent] suffer such symptoms at some point), with 30% to 50%[citation needed][inconsistent] suffering from the classic malar rash (or butterfly rash) associated with the disease. Some may exhibit thick, red scaly patches on the skin (referred to as discoid lupus). Alopecia; mouth, nasal, urinary tract and vaginal ulcers, and lesions on the skin are also possible manifestations. Tiny tears in delicate tissue around the eyes can occur after even minimal rubbing.


The most commonly sought medical attention is for joint pain, with the small joints of the hand and wrist usually affected, although all joints are at risk. The Lupus Foundation of America estimates more than 90 percent of those affected will experience joint and/or muscle pain at some time during the course of their illness.[9] Unlike rheumatoid arthritis, lupus arthritis is less disabling and usually does not cause severe destruction of the joints. Fewer than ten percent of people with lupus arthritis will develop deformities of the hands and feet.[9] SLE patients are at particular risk of developing osteoarticular tuberculosis.[10]

A possible association between rheumatoid arthritis and SLE has been suggested,[11] and SLE may be associated with an increased risk of bone fractures in relatively young women.[12]


Anemia is common in children with SLE[13] and develops in about 50% of cases.[14] Low platelet and white blood cell counts may be due to the disease or a side effect of pharmacological treatment. People with SLE may have an association with antiphospholipid antibody syndrome[15] (a thrombotic disorder), wherein autoantibodies to phospholipids are present in their serum. Abnormalities associated with antiphospholipid antibody syndrome include a paradoxical prolonged partial thromboplastin time (which usually occurs in hemorrhagic disorders) and a positive test for antiphospholipid antibodies; the combination of such findings have earned the term "lupus anticoagulant-positive". Another autoantibody finding in SLE is the anticardiolipin antibody, which can cause a false positive test for syphilis.[citation needed]


A person with SLE may have inflammation of various parts of the heart, such as pericarditis, myocarditis, and endocarditis. The endocarditis of SLE is characteristically noninfective (Libman-Sacks endocarditis), and involves either the mitral valve or the tricuspid valve. Atherosclerosis also tends to occur more often and advances more rapidly than in the general population.[16][17][18]


Lung and pleura inflammation can cause pleuritis, pleural effusion, lupus pneumonitis, chronic diffuse interstitial lung disease, pulmonary hypertension, pulmonary emboli, pulmonary hemorrhage, and shrinking lung syndrome.


Painless hematuria or proteinuria may often be the only presenting renal symptom. Acute or chronic renal impairment may develop with lupus nephritis, leading to acute or end-stage renal failure. Because of early recognition and management of SLE, end-stage renal failure occurs in less than 5%[citation needed] of cases.

A histological hallmark of SLE is membranous glomerulonephritis with "wire loop" abnormalities.[19] This finding is due to immune complex deposition along the glomerular basement membrane, leading to a typical granular appearance in immunofluorescence testing.


Neuropsychiatric syndromes can result when SLE affects the central or peripheral nervous systems. The American College of Rheumatology defines 19 neuropsychiatric syndromes in systemic lupus erythematosus.[20] The diagnosis of neuropsychiatric syndromes concurrent with SLE is one of the most difficult challenges in medicine, because it can involve so many different patterns of symptoms, some of which may be mistaken for signs of infectious disease or stroke.[21]

The most common neuropsychiatric disorder people with SLE have is headache,[22] although the existence of a specific lupus headache and the optimal approach to headache in SLE cases remains controversial.[23] Other common neuropsychiatric manifestation of SLE include cognitive dysfunction, mood disorder, cerebrovascular disease,[22] seizures, polyneuropathy,[22] anxiety disorder, and psychosis. It can rarely present with intracranial hypertension syndrome, characterized by an elevated intracranial pressure, papilledema, and headache with occasional abducens nerve paresis, absence of a space-occupying lesion or ventricular enlargement, and normal cerebrospinal fluid chemical and hematological constituents.[24]

More rare manifestations are acute confusional state, Guillain-Barré syndrome, aseptic meningitis, autonomic disorder, demyelinating syndrome, mononeuropathy (which might manifest as mononeuritis multiplex), movement disorder (more specifically, chorea), myasthenia gravis, myelopathy, cranial neuropathy and plexopathy.


Neural symptoms contribute to a significant percentage of morbidity and mortality in patients with lupus.[25] As a result, the neural side of lupus is being studied in hopes of reducing morbidity and mortality rates.[20] The neural manifestation of lupus is known as neuropsychiatric systemic lupus erythematosus (NPSLE). One aspect of this disease is severe damage to the epithelial cells of the blood–brain barrier.

Lupus has a wide range of symptoms which span the body. The neurological symptoms include headaches,[22] depression, seizures, cognitive dysfunction, mood disorder, cerebrovascular disease,[22] polyneuropathy,[22] anxiety disorder, psychosis, and in some extreme cases, personality disorders.[26] In certain regions, depression reportedly affects up to 60% of women suffering from SLE.[27]


SLE causes an increased rate of fetal death in utero and spontaneous abortion (miscarriage). The overall live-birth rate in SLE patients has been estimated to be 72%.[28] Pregnancy outcome appears to be worse in SLE patients whose disease flares up during pregnancy.[29]

Neonatal lupus is the occurrence of SLE symptoms in an infant born from a mother with SLE, most commonly presenting with a rash resembling discoid lupus erythematosus, and sometimes with systemic abnormalities such as heart block or hepatosplenomegaly.[30] Neonatal lupus is usually benign and self-limited.[30]


Fatigue in SLE is probably multifactorial and has been related to not only disease activity or complications such as anemia or hypothyroidism, but also to pain, depression, poor sleep quality, poor physical fitness and lack of social support.[31][32]


There is no one specific cause of SLE. There are, however, a number of environmental triggers and a number of genetic susceptibilities.[33][34]


The first mechanism may arise genetically. Research indicates SLE may have a genetic link. SLE does run in families, but no single causal gene has been identified. Instead, multiple genes appear to influence a person's chance of developing lupus when triggered by environmental factors. The most important genes are located in the HLA region on chromosome 6, where mutations may occur randomly (de novo) or may be inherited. HLA class I, class II, and class III are associated with SLE, but only classes I and II contribute independently to increased risk of SLE.[35] Other genes which contain risk variants for SLE are IRF5, PTPN22, STAT4,[36] CDKN1A,[37] ITGAM, BLK,[36] TNFSF4 and BANK1.[38] Some of the susceptibility genes may be population specific.[36]

Environmental triggers

The second mechanism may be due to environmental factors. These factors may not only exacerbate existing SLE conditions, but also trigger the initial onset.[citation needed]

Researchers have sought to find a connection between certain infectious agents (viruses and bacteria), but no pathogen can be consistently linked to the disease. Some researchers have found that women with silicone gel-filled breast implants have produced antibodies to their own collagen, but it is not known how often these antibodies occur in the general population, and there are no data that show these antibodies cause connective tissue diseases such as SLE.[citation needed]

Drug reactions

Drug-induced lupus erythematosus is a (generally) reversible condition that usually occurs in people being treated for a long-term illness. Drug-induced lupus mimics SLE. However, symptoms of drug-induced lupus generally disappear once the medication that triggered the episode is stopped. More than 38 medications can cause this condition, the most common of which are procainamide, isoniazid, hydralazine, quinidine, and phenytoin.[3]

Non-Systemic forms of lupus

Discoid (cutaneous) lupus is limited to skin symptoms and is diagnosed by biopsy of rash on the face, neck, scalp or arms. Approximately 5% of patients with DLE progress to SLE.[citation needed]


One manifestation of SLE is abnormalities in apoptosis, a type of programmed cell death in which aging or damaged cells are neatly disposed of as a part of normal growth or functioning.

In SLE, the body's immune system produces antibodies against itself, particularly against proteins in the cell nucleus. SLE is triggered by environmental factors that are unknown.

In order to preserve homeostasis, the immune system must balance between being sensitive enough to protect against infection, and becoming sensitized to attack the body's own proteins (autoimmunity). During an immune reaction to a foreign stimulus, such as bacteria, virus, or allergen, immune cells that would normally be deactivated due to their affinity for self tissues can be abnormally activated by signaling sequences of antigen-presenting cells. Thus triggers may include viruses, bacteria, allergens (IgE and other hypersensitivity), and can be aggravated by environmental stimulants such as ultraviolet light and certain drug reactions. These stimuli begin a reaction that leads to destruction of other cells in the body and exposure of their DNA, histones, and other proteins, particularly parts of the cell nucleus. The body's sensitized B-lymphocyte cells will now produce antibodies against these nuclear-related proteins. These antibodies clump into antibody-protein complexes which stick to surfaces and damage blood vessels in critical areas of the body, such as the glomeruli of the kidney; these antibody attacks are the cause of SLE. Researchers are now identifying the individual genes, the proteins they produce, and their role in the immune system. Each protein is a link on the autoimmune chain, and researchers are trying to find drugs to break each of those links.[3][39][40]

SLE is a chronic inflammatory disease believed to be a type III hypersensitivity response with potential type II involvement.[41] Reticulate and stellate acral pigmentation should be considered a possible manifestation of SLE and high titers of anti-cardiolipin antibodies, or a consequence of therapy.[42]

Abnormalities in cell death signaling

Tingible body macrophages (TBMs) – large phagocytic cells in the germinal centers of secondary lymph nodes – express CD68 protein. These cells normally engulf B cells that have undergone apoptosis after somatic hypermutation. In some people with SLE, significantly fewer TBMs can be found, and these cells rarely contain material from apoptotic B cells. Also, uningested apoptotic nuclei can be found outside of TBMs. This material may present a threat to the tolerization of B cells and T cells. Dendritic cells in the germinal center may endocytose such antigenic material and present it to T cells, activating them. Also, apoptotic chromatin and nuclei may attach to the surfaces of follicular dendritic cells and make this material available for activating other B cells that may have randomly acquired self-specificity through somatic hypermutation.[43] Necrosis, a pro-inflammatory form of cell death, is increased in T lymphocytes, due to mitochondrial dysfunction, oxidative stress, and depletion of ATP.[44]

Clearance deficiency

Clearance deficiency

Impaired clearance of dying cells is a potential pathway for the development of this systemic autoimmune disease. This includes deficient phagocytic activity and scant serum components in addition to increased apoptosis.

Monocytes isolated from whole blood of SLE sufferers show reduced expression of CD44 surface molecules involved in the uptake of apoptotic cells. Most of the monocytes and tingible body macrophages (TBMs), which are found in the germinal centres of lymph nodes, even show a definitely different morphology; they are smaller or scarce and die earlier. Serum components like complement factors, CRP, and some glycoproteins are, furthermore, decisively important for an efficiently operating phagocytosis. With SLE, these components are often missing, diminished, or inefficient.

Recent research has found an association between certain lupus patients (especially those with lupus nephritis) and an impairment in degrading neutrophil extracellular traps (NETs). These were due to DNAse1 inhibiting factors, or NET protecting factors in patient serum, rather than abnormalities in the DNAse1 itself.[45] DNAse1 mutations in lupus have so far only been found in some Japanese cohorts.[46]

The clearance of early apoptotic cells is an important function in multicellular organisms. It leads to a progression of the apoptosis process and finally to secondary necrosis of the cells if this ability is disturbed. Necrotic cells release nuclear fragments as potential autoantigens, as well as internal danger signals, inducing maturation of dendritic cells (DCs), since they have lost their membranes' integrity. Increased appearance of apoptotic cells also simulates inefficient clearance. That leads to maturation of DCs and also to the presentation of intracellular antigens of late apoptotic or secondary necrotic cells, via MHC molecules. Autoimmunity possibly results by the extended exposure to nuclear and intracellular autoantigens derived from late apoptotic and secondary necrotic cells. B and T cell tolerance for apoptotic cells is abrogated, and the lymphocytes get activated by these autoantigens; inflammation and the production of autoantibodies by plasma cells is initiated. A clearance deficiency in the skin for apoptotic cells has also been observed in people with cutaneous lupus erythematosus (CLE).[47]

Germinal centres

Accumulation in germinal centers

In healthy conditions, apoptotic lymphocytes are removed in germinal centres (GC) by specialized phagocytes, the tingible body macrophages (TBM), which is why no free apoptotic and potential autoantigenic material can be seen. In some people with SLE, accumulation of apoptotic debris can be observed in GC because of an ineffective clearance of apoptotic cells. In close proximity to TBM, follicular dendritic cells (FDC) are localised in GC, which attach antigen material to their surface and, in contrast to bone marrow-derived DC, neither take it up nor present it via MHC molecules.

Autoreactive B cells can accidentally emerge during somatic hypermutation and migrate into the germinal center light zone. Autoreactive B cells, maturated coincidentally, normally do not receive survival signals by antigen planted on follicular dendritic cells, and perish by apoptosis. In the case of clearance deficiency, apoptotic nuclear debris accumulates in the light zone of GC and gets attached to FDC. This serves as a germinal centre survival signal for autoreactive B-cells. After migration into the mantle zone, autoreactive B cells require further survival signals from autoreactive helper T cells, which promote the maturation of autoantibody-producing plasma cells and B memory cells. In the presence of autoreactive T cells, a chronic autoimmune disease may be the consequence.

Anti-nRNP autoimmunity

Autoantibodies to nRNP A and nRNP C initially targeted restricted, proline-rich motifs. Antibody binding subsequently spread to other epitopes. The similarity and cross-reactivity between the initial targets of nRNP and Sm autoantibodies identifies a likely commonality in cause and a focal point for intermolecular epitope spreading.[48]


Elevated expression of HMGB1 was found in the sera of patients and mice with systemic lupus erythematosus, high mobility group box 1 (HMGB1) is a nuclear protein participating in chromatin architecture and transcriptional regulation. Recently, there is increasing evidence HMGB1 contributes to the pathogenesis of chronic inflammatory and autoimmune diseases due to its proinflammatory and immunostimulatory properties.[49]


Microphotograph of a histological section of human skin prepared for direct immunofluorescence using an anti-IgG antibody. The skin is from a person with systemic lupus erythematosus and shows IgG deposits at two different places: The first is a bandlike deposit along the epidermal basement membrane ("lupus band test" is positive); the second is within the nuclei of the epidermal cells (antinuclear antibodies are present).

Laboratory tests

Antinuclear antibody (ANA) testing and anti-extractable nuclear antigen (anti-ENA) form the mainstay of serologic testing for SLE. Several techniques are used to detect ANAs. Clinically the most widely used method is indirect immunofluorescence (IF). The pattern of fluorescence suggests the type of antibody present in the patient's serum. Direct immunofluorescence can detect deposits of immunoglobulins and complement proteins in the patient's skin. When skin not exposed to the sun is tested, a positive direct IF (the so-called lupus band test) is an evidence of systemic lupus erythematosus.[50]

ANA screening yields positive results in many connective tissue disorders and other autoimmune diseases, and may occur in normal individuals. Subtypes of antinuclear antibodies include anti-Smith and anti-double stranded DNA (dsDNA) antibodies (which are linked to SLE) and anti-histone antibodies (which are linked to drug-induced lupus). Anti-dsDNA antibodies are highly specific for SLE; they are present in 70% of cases, whereas they appear in only 0.5% of people without SLE.[3] The anti-dsDNA antibody titers also tend to reflect disease activity, although not in all cases.[3] Other ANA that may occur in SLE sufferers are anti-U1 RNP (which also appears in systemic sclerosis), SS-A (or anti-Ro) and SS-B (or anti-La; both of which are more common in Sjögren's syndrome). SS-A and SS-B confer a specific risk for heart conduction block in neonatal lupus.[51]

Other tests routinely performed in suspected SLE are complement system levels (low levels suggest consumption by the immune system), electrolytes and renal function (disturbed if the kidney is involved), liver enzymes, and complete blood count.

The lupus erythematosus (LE) cell test was commonly used for diagnosis, but it is no longer used because the LE cells are only found in 50–75% of SLE cases, and they are also found in some people with rheumatoid arthritis, scleroderma, and drug sensitivities. Because of this, the LE cell test is now performed only rarely and is mostly of historical significance.[52]

Diagnostic criteria

Some physicians make a diagnosis on the basis of the American College of Rheumatology (ACR) classification criteria. The criteria, however, were established mainly for use in scientific research including use in randomized controlled trials which require higher confidence levels, so many people with SLE may not pass the full criteria.


The American College of Rheumatology (ACR) established eleven criteria in 1982,[53] which were revised in 1997[54] as a classificatory instrument to operationalise the definition of SLE in clinical trials. They were not intended to be used to diagnose individuals and do not do well in that capacity. For the purpose of identifying patients for clinical studies, a person has SLE if any 4 out of 11 symptoms are present simultaneously or serially on two separate occasions. Useful mnemonic for remembering the diagnostic findings or symptoms of SLE is SOAP BRAIN MD (S=serositis, O=oral ulcers, A=arthritis, P=photosensitivity, pulmonary fibrosis, B=blood cells, R=renal, Raynauds, A=ANA, I=immunologic (anti-Sm, anti-dsDNA), N=neuropsych, M=malar rash, D=discoid rash), however, not in order of diagnostic importance.

  1. Malar rash (rash on cheeks); sensitivity = 57%; specificity = 96%.[55]
  2. Discoid rash (red, scaly patches on skin that cause scarring); sensitivity = 18%; specificity = 99%.[55]
  3. Serositis: Pleurisy (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart); sensitivity = 56%; specificity = 86% (pleural is more sensitive; cardiac is more specific).[55]
  4. Oral ulcers (includes oral or nasopharyngeal ulcers); sensitivity = 27%; specificity = 96%.[55]
  5. Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion; sensitivity = 86%; specificity = 37%.[55]
  6. Photosensitivity (exposure to ultraviolet light causes rash, or other symptoms of SLE flareups); sensitivity = 43%; specificity = 96%.[55]
  7. Blood—hematologic disorder—hemolytic anemia (low red blood cell count) or leukopenia (white blood cell count<4000/µl), lymphopenia (<1500/µl) or thrombocytopenia (<100000/µl) in the absence of offending drug; sensitivity = 59%; specificity = 89%.[55] Hypocomplementemia is also seen, due to either consumption of C3[56] and C4 by immune complex-induced inflammation or to congenitally complement deficiency, which may predispose to SLE.
  8. Renal disorder: More than 0.5 g per day protein in urine or cellular casts seen in urine under a microscope; sensitivity = 51%; specificity = 94%.[55]
  9. Antinuclear antibody test positive; sensitivity = 99%; specificity = 49%.[55]
  10. Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody, and/or false positive serological test for syphilis; sensitivity = 85%; specificity = 93%.[55] Presence of anti-ss DNA in 70% of cases (though also positive with rheumatic disease and healthy persons).[57]
  11. Neurologic disorder: Seizures or psychosis; sensitivity = 20%; specificity = 98%.[55]

Other than the ACR criteria, people with lupus may also have:[58]

Criteria for individual diagnosis

Some people, especially those with antiphospholipid syndrome, may have SLE without four of the above criteria, and also SLE may present with features other than those listed in the criteria.[59][60][61]

Recursive partitioning has been used to identify more parsimonious criteria.[55] This analysis presented two diagnostic classification trees:

  1. Simplest classification tree: SLE is diagnosed if a person has an immunologic disorder (anti-DNA antibody, anti-Smith antibody, false positive syphilis test, or LE cells) or malar rash. It has sensitivity = 92% and specificity = 92%.
  2. Full classification tree: Uses 6 criteria. It has sensitivity = 97% and specificity = 95%.

Other alternative criteria have been suggested, e.g. the St. Thomas' Hospital "alternative" criteria in 1998.[62]


SLE cannot be prevented, but the consequences can be prevented.[63]

As longevity of people with SLE increases, the likelihood of complications also increases in four areas: cardiovascular disease, infections, osteoporosis, and cancer. Standard preventive measures, screening for related diseases may be necessary to deal with the increased risks due to the side effects of medications. Extra vigilance is considered warranted in particular for cancers affecting the immune system.[64]


The treatment of SLE involves preventing flares and reducing their severity and duration when they occur.

Treatment can include corticosteroids and anti-malarial drugs. Certain types of lupus nephritis such as diffuse proliferative glomerulonephritis require bouts of cytotoxic drugs. These drugs include cyclophosphamide and mycophenolate.

Hydroxychloroquine (HCQ) was approved by the FDA for lupus in 1955.[65] Some drugs approved for other diseases are used for SLE 'off-label'. In November 2010, an FDA advisory panel recommended approving belimumab (Benlysta) as a treatment for the pain and flare-ups common in lupus. The drug was approved by the FDA in March 2011.[66][67] N-acetylcysteine has been shown to reverse depletion of the natural anti-oxidant glutathione and to safely improve disease activity in a double-blind placebo-controlled pilot study.[68]


Due to the variety of symptoms and organ system involvement with SLE, its severity in an individual must be assessed in order to successfully treat SLE. Mild or remittent disease may, sometimes, be safely left untreated. If required, nonsteroidal anti-inflammatory drugs and antimalarials may be used. Medications such as Prednisone, Cellcept and Prograf have been used in the past. A number of potential treatments are in clinical trials.[69]

Disease-modifying antirheumatic drugs

Disease-modifying antirheumatic drugs (DMARDs) are used preventively to reduce the incidence of flares, the process of the disease, and lower the need for steroid use; when flares occur, they are treated with corticosteroids. DMARDs commonly in use are antimalarials such as Plaquenil and immunosuppressants (e.g. methotrexate and azathioprine). Plaquenil (hydroxychloroquine) is an FDA-approved antimalarial used for constitutional, cutaneous, and articular manifestations. Hydroxychloroquine has relatively few side effects, and there is evidence that it improves survival among people who have SLE.[65] Cyclophosphamide is used for severe glomerulonephritis or other organ-damaging complications. Mycophenolic acid is also used for treatment of lupus nephritis, but it is not FDA-approved for this indication, and FDA is investigating reports that it may be associated with birth defects when used by pregnant women.[70]

Immunosuppressive drugs

In more severe cases, medications that modulate the immune system (primarily corticosteroids and immunosuppressants) are used to control the disease and prevent recurrence of symptoms (known as flares). Depending on the dosage, people who require steroids may develop Cushing's syndrome, symptoms of which may include obesity, puffy round face, diabetes mellitus, increased appetite, difficulty sleeping and osteoporosis. These may subside if and when the large initial dosage is reduced, but long-term use of even low doses can cause elevated blood pressure and cataracts.

Numerous new immunosuppressive drugs are being actively tested for SLE. Rather than suppressing the immune system nonspecifically, as corticosteroids do, they target the responses of individual [types of] immune cells. Some of these drugs are already FDA-approved for treatment of rheumatoid arthritis.[65] See also Belimumab and Atacicept. Lupuzor has given encouraging results in a phase IIb trial.[71]


Since a large percentage of people with SLE suffer from varying amounts of chronic pain, stronger prescription analgesics (pain killers) may be used if over-the-counter drugs (mainly nonsteroidal anti-inflammatory drugs) do not provide effective relief. Potent NSAIDs such as indomethacin and diclofenac are relatively contraindicated for patients with SLE because they increase the risk of kidney failure and heart failure.[65]

Pain is typically treated with opioids, varying in potency based on the severity of symptoms. When opioids are used for prolonged periods, drug tolerance, chemical dependency, and addiction may occur. Opiate addiction is not typically a concern, since the condition is not likely to ever completely disappear. Thus, lifelong treatment with opioids is fairly common for chronic pain symptoms, accompanied by periodic titration that is typical of any long-term opioid regimen.

Intravenous Immunoglobulins (IVIGs)

Intravenous immunoglobulins may be used to control SLE with organ involvement, or vasculitis. It is believed that they reduce antibody production or promote the clearance of immune complexes from the body, even though their mechanism of action is not well-understood.[72] Unlike immunosuppressives and corticosteroids, IVIGs do not suppress the immune system, so there is less risk of serious infections with these drugs.[73]

Lifestyle changes

Avoiding sunlight is the primary change to the lifestyle of SLE sufferers, as sunlight is known to exacerbate the disease, as is the debilitating effect of intense fatigue. These two problems can lead to patients becoming housebound for long periods of time. Drugs unrelated to SLE should be prescribed only when known not to exacerbate the disease. Occupational exposure to silica, pesticides and mercury can also make the disease worsen.[33]

Renal transplantation

Renal transplants are the treatment of choice for end-stage renal disease, which is one of the complications of lupus nephritis, but the recurrence of the full disease is common in up to 30% of patients.[74]

Antiphospholipid syndrome

Antiphospholipid syndrome is also related to the onset of neural lupus symptoms in the brain. In this form of the disease the cause is very different from lupus: thromboses (blood clots or "sticky blood") form in blood vessels, which prove to be fatal if they move within the blood stream.[59] If the thromboses migrate to the brain, they can potentially cause a stroke by blocking the blood supply to the brain.

If this disorder is suspected in patients, brain scans are usually required for early detection. These scans can show localized areas of the brain where blood supply has not been adequate. The treatment plan for these patients requires anticoagulation. Often, low-dose aspirin is prescribed for this purpose, although for cases involving thrombosis anticoagulants such as warfarin are used.[75]

Management of pregnancy

While most infants born to mothers who have SLE are healthy, pregnant mothers with SLE should remain under medical care until delivery. Neonatal lupus is rare, but identification of mothers at highest risk for complications allows for prompt treatment before or after birth. In addition, SLE can flare up during pregnancy, and proper treatment can maintain the health of the mother longer. Women pregnant and known to have anti-Ro (SSA) or anti-La antibodies (SSB) often have echocardiograms during the 16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding vasculature.[63]

Contraception and other reliable forms of pregnancy prevention is routinely advised for women with SLE, since getting pregnant during active disease was found to be harmful. Lupus nephritis was the most common manifestation.


SLE is incurable, but treatable.

In the 1950s, most people diagnosed with SLE lived fewer than five years. Today, over 90% now survive for more than ten years, and many live relatively asymptomatically. 80-90% can expect to live a normal lifespan.[76])

Prognosis is typically worse for men and children than for women; however, if symptoms are present after age 60, the disease tends to run a more benign course. Early mortality, within 5 years, is due to organ failure or overwhelming infections, both of which can be altered by early diagnosis and treatment. The mortality risk is fivefold when compared to the normal population in the late stages, which can be attributed to cardiovascular disease from accelerated atherosclerosis, the leading cause of death for people with SLE.[65]

To reduce potential for cardiovascular issues, high blood pressure and high cholesterol should be prevented or treated aggressively. Steroids should be used at the lowest dose for the shortest possible period, and other drugs that can reduce symptoms should be used whenever possible.[65] High serum creatinine, hypertension, nephrotic syndrome, anemia and hypoalbuminemia are poor prognostic factors.[77]

The ANA is the most sensitive screening test for evaluation, whereas anti-Sm (anti-Smith) is the most specific. The dsDNA (double-stranded DNA) antibody is also fairly specific and often fluctuates with disease activity; as such, the dsDNA titre is sometimes useful to monitor disease flares or response to treatment.[78]


The rate of SLE varies considerably between countries, ethnicity, gender, and changes over time.[79] In the United States, one estimate of the prevalence of SLE is 53 per 100,000;[79] other estimates range from 322,000 to over 1 million.[80] In Northern Europe the rate is about 40 per 100,000 people.[81] SLE occurs more frequently and with greater severity among those of non-European descent.[80] That rate has been found to be as high as 159 per 100,000 among those of Afro-Caribbean descent.[79]

SLE, like many autoimmune diseases, affects females more frequently than males, at a rate of almost 9 to 1.[79] This is due to the presence of two X chromosomes in the female as opposed to the one X chromosome present in males. The X chromosome carries immunological related genes, which can mutate and contribute to the onset of SLE. The Y chromosome has no identified mutations associated with autoimmune disease.[82]

The incidence of SLE in the United States increased from 1.0 in 1955 to 7.6 in 1974. Whether the increase is due to better diagnosis or to increasing frequency of the disease is unknown.[79]

History and culture


There are several explanations ventured for the term lupus erythematosus. Lupus is Latin for wolf,[83] and "erythro" is derived from ερυθρός, Greek for "red." All explanations originate with the reddish, butterfly-shaped malar rash that the disease classically exhibits across the nose and cheeks.

  1. In various accounts, some doctors thought the rash resembled the pattern of fur on a wolf's face. More likely is that it is derived from the similarity in distribution to lupus vulgaris or chronic facial tuberculosis where the lesions are ragged and punched out and are said to resemble the bite of a wolf.
  2. Another account claims that the term "lupus" did not come from Latin directly, but from the term for a French style of mask that women reportedly wore to conceal the rash on their faces. The mask is called a "loup," French for "wolf."


The history of SLE can be divided into three periods: classical, neoclassical, and modern. The classical period began when the disease was first recognized in the Middle Ages and saw the description of the dermatological manifestation of the disorder. The term lupus is attributed to 12th-century physician Rogerius, who used it to describe the classic malar rash. The neoclassical period was heralded by Móric Kaposi's recognition in 1872 of the systemic manifestations of the disease. The modern period began in 1948 with the discovery of the LE cell (the lupus erythematosus cell—a misnomer, as it occurs with other diseases as well) and is characterised by advances in our knowledge of the pathophysiology and clinical-laboratory features of the disease, as well as advances in treatment.[84]

Medical historians have theorized that people with porphyria (a disease that shares many symptoms with SLE) generated folklore stories of vampires and werewolves, due to the photosensitivity, scarring, hair growth, and porphyrin brownish-red stained teeth in severe recessive forms of porphyria (or combinations of the disorder, known as dual, homozygous, or compound heterozygous porphyrias).[84]

Useful medication for the disease was first found in 1894, when quinine was first reported as an effective therapy. Four years later, the use of salicylates in conjunction with quinine was noted to be of still greater benefit. This was the best available treatment until the middle of the twentieth century, when Hench discovered the efficacy of corticosteroids in the treatment of SLE.[84]

Notable cases


Since lupus is considered to be currently incurable, current research is being geared towards finding a possible cause, a cure, and more effective treatment plans to extend and increase the quality of life for lupus patients.

A study called BLISS-76 tested the drug, Belimumab (HGS1006, LymphoStat-B ), a fully human monoclonal anti-BAFF (or anti-BLyS) antibody.[67] stimulates and extends the life of B lymphocytes, which produce antibodies against foreign and self cells.[108] The drug, branded Benlysta, was approved by the FDA in March 2011.[66]

See also


  1. ^ a b James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
  2. ^ a b c "Harrison's Internal Medicine, 17th ed. Chapter 313. Systemic Lupus Erythematosus". Retrieved 2011-08-06. 
  3. ^ a b c d e f Anisur Rahman and David A. Isenberg (February 28, 2008). "Review Article: Systemic Lupus Erythematosus". N Engl J Med 358 (9): 929–939. doi:10.1056/NEJMra071297. PMID 18305268. 
  4. ^ "LUPUS FOUNDATION OF AMERICA". Retrieved 2007-07-04. 
  5. ^ Blotzer JW (June 1983). "Systemic lupus erythematosus I: historical aspects.". Md State Med J 32 (6): 439–41. PMID 6348430. 
  6. ^ MedicineNet: Systemic Lupus (cont.) Last Editorial Review: 2009-01-30
  7. ^ "Lupus, "The Great Imitator"". University Health Care. Retrieved 2009-02-03. [dead link]
  8. ^ "Lupus: Symptoms —". Retrieved 2008-07-14. 
  9. ^ a b Joint and Muscle Pain Lupus Foundation of America
  10. ^ Hodkinson B, Musenge E, Tikly M (February 2009). "Osteoarticular tuberculosis in patients with systemic lupus erythematosus". QJM 102 (5): 321–8. doi:10.1093/qjmed/hcp015. PMID 19246552. 
  11. ^ Hemminki K, Li X, Sundquist J, Sundquist K (February 2009). "Familial associations of rheumatoid arthritis with autoimmune diseases and related conditions". Arthritis Rheum. 60 (3): 661–8. doi:10.1002/art.24328. PMID 19248111. 
  12. ^ Mendoza-Pinto C, García-Carrasco M, Sandoval-Cruz H, et al. (February 2009). "Risk factors of vertebral fractures in women with systemic lupus erythematosus". Clin. Rheumatol. 28 (5): 579–85. doi:10.1007/s10067-009-1105-3. PMID 19224131. 
  13. ^ Lam, SK; Quah, TC (1990). "Anemia in systemic lupus erythematosus.". The Journal of the Singapore Paediatric Society 32 (3-4): 132–6. PMID 2133750. 
  14. ^ Giannouli, S (1 February 2006). "Anaemia in systemic lupus erythematosus: from pathophysiology to clinical assessment". Annals of the Rheumatic Diseases 65 (2): 144–148. doi:10.1136/ard.2005.041673. PMC 1798007. PMID 16079164. 
  15. ^ Syuto T, Shimizu A, Takeuchi Y, et al. (February 2009). "Association of antiphosphatidylserine/prothrombin antibodies with neuropsychiatric systemic lupus erythematosus". Clin. Rheumatol. 28 (7): 841–5. doi:10.1007/s10067-009-1123-1. PMID 19224124. 
  16. ^ Yu Asanuma, M.D., Ph.D., Annette Oeser, B.S., Ayumi K. Shintani, Ph.D., M.P.H., Elizabeth Turner, M.D., Nancy Olsen, M.D., Sergio Fazio, M.D., Ph.D., MacRae F. Linton, M.D., Paolo Raggi, M.D., and C. Michael Stein, M.D. (December 2003). "Premature coronary-artery atherosclerosis in systemic lupus erythematosus". N Engl J Med 349 (25): 2407–14. doi:10.1056/NEJMoa035611. PMID 14681506. 
  17. ^ Bevra Hannahs Hahn, M.D. (December 2003). "Systemic lupus erythematosus and accelerated atherosclerosis". N Engl J Med 349 (25): 2379–80. doi:10.1056/NEJMp038168. PMID 14681501. 
  18. ^ Mary J. Roman, M.D., Beth-Ann Shanker, A.B., Adrienne Davis, A.B., Michael D. Lockshin, M.D., Lisa Sammaritano, M.D., Ronit Simantov, M.D., Mary K. Crow, M.D., Joseph E. Schwartz, Ph.D., Stephen A. Paget, M.D., Richard B. Devereux, M.D., and Jane E. Salmon, M.D. (December 2003). "Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus". N Engl J Med 349 (25): 2399–2406. doi:10.1056/NEJMoa035471. PMID 14681505. 
  19. ^ "General Pathology Images for Immunopathology". Retrieved 2007-07-24. 
  20. ^ a b "The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes". Arthritis Rheum. 42 (4): 599–608. April 1999. doi:10.1002/1529-0131(199904)42:4<599::AID-ANR2>3.0.CO;2-F. PMID 10211873. 
  21. ^ Neuwelt CM and Young RG (April 2, 2009). "Managing neuropsychiatric lupus: Top 10 clinical pearls". The Journal of Musculoskeletal Medicine 26 (4). [dead link]
  22. ^ a b c d e f Honczarenko K, Budzianowska A, Ostanek L (2008). "Neurological syndromes in systemic lupus erythematosus and their association with antiphospholipid syndrome". Neurol. Neurochir. Pol. 42 (6): 513–7. PMID 19235104. 
  23. ^ Omdal R (2002). "Some controversies of neuropsychiatric systemic lupus erythematosus". Scand. J. Rheumatol. 31 (4): 192–7. doi:10.1080/030097402320318369. PMID 12369649. 
  24. ^ Xue Z, Wang X, Liu F, et al. (February 2009). "Intracranial hypertension syndrome in systemic lupus erythematosus: Clinical analysis and review of the literature". J. Huazhong Univ. Sci. Technol. Med. Sci. 29 (1): 107–11. doi:10.1007/s11596-009-0123-3. PMID 19224175. 
  25. ^ West SG (September 1996). "Lupus and the central nervous system". Curr Opin Rheumatol 8 (5): 408–14. doi:10.1097/00002281-199609000-00004. PMID 8941443. 
  26. ^ "Lupus site (SLE)". Retrieved 2009-11-06. 
  27. ^ Zakeri Z, Shakiba M, Narouie B, Mladkova N, Ghasemi-Rad M, Khosravi A (January 2011). "Prevalence of depression and depressive symptoms in patients with systemic lupus erythematosus: Iranian experience". Rheumatol Int 32 (5): 1179–87. doi:10.1007/s00296-010-1791-9. PMID 21253731. 
  28. ^ Smyth, Andrew; Guilherme H.M. Oliveira, Brian D. Lahr, Kent R. Bailey, Suzanne M. Norby, Vesna D. Garovic (November 2010). "A Systematic Review and Meta-Analysis of Pregnancy Outcomes in Patients with Systemic Lupus Erythematosus and Lupus Nephritis". Clinical Journal of the American Society of Nephrology 5 (11): 2060–2068. doi:10.2215/CJN.00240110. PMC 3001786. PMID 20688887. 
  29. ^ Cortés‐Hernández, J.; J. Ordi‐Ros, F. Paredes, M. Casellas, F. Castillo, and M. Vilardell‐Tarres (December 2001). "Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies". Rheumatology 41 (6): 643–650. doi:10.1093/rheumatology/41.6.643. PMID 12048290. Retrieved 20 April 2011. 
  30. ^ a b > neonatal lupus Citing: Dorland's Medical Dictionary for Health Consumers. Copyright 2007
  31. ^ D'Cruz DP (April 2006). "Systemic lupus erythematosus". BMJ 332 (7546): 890–4. doi:10.1136/bmj.332.7546.890. PMC 1440614. PMID 16613963. 
  32. ^ Jump RL, Robinson ME, Armstrong AE, Barnes EV, Kilbourn KM, Richards HB (September 2005). "Fatigue in systemic lupus erythematosus: contributions of disease activity, pain, depression, and perceived social support". J. Rheumatol. 32 (9): 1699–705. PMID 16142863. 
  33. ^ a b D'Cruz DP, Khamashta MA, Hughes GR (February 2007). "Systemic lupus erythematosus". Lancet 369 (9561): 587–96. doi:10.1016/S0140-6736(07)60279-7. PMID 17307106. Retrieved 2009-02-01. 
  34. ^ Kanta H, Mohan C (March 2009). "Three checkpoints in lupus development: central tolerance in adaptive immunity, peripheral amplification by innate immunity and end-organ inflammation". Genes Immun. 10 (5): 390–6. doi:10.1038/gene.2009.6. PMID 19262576. 
  35. ^ Martens HA, Nolte IM, van der Steege G, et al. (March 2009). "An extensive screen of the HLA region reveals an independent association of HLA class I and class II with susceptibility for systemic lupus erythematosus". Scand. J. Rheumatol. 38 (4): 1–7. doi:10.1080/03009740802552469. PMID 19255932. 
  36. ^ a b c Yang W, Ng P, Zhao M, et al. (February 2009). "Population differences in SLE susceptibility genes: STAT4 and BLK, but not PXK, are associated with systemic lupus erythematosus in Hong Kong Chinese". Genes Immun. 10 (3): 219–26. doi:10.1038/gene.2009.1. PMID 19225526. 
  37. ^ Kim K, Sung YK, Kang CP, Choi CB, Kang C, Bae SC (March 2009). "A regulatory SNP at position -899 in CDKN1A is associated with systemic lupus erythematosus and lupus nephritis". Genes Immun. 10 (5): 482–6. doi:10.1038/gene.2009.5. PMID 19262578. 
  38. ^ Rhodes B, Vyse TJ (November 2008). "The genetics of SLE: an update in the light of genome-wide association studies". Rheumatology (Oxford) 47 (11): 1603–11. doi:10.1093/rheumatology/ken247. PMID 18611920. 
  39. ^ Mary K. Crow (February 28, 2008). "Collaboration, Genetic Associations, and Lupus Erythematosus". N Engl J Med 358 (9): 956–961. doi:10.1056/NEJMe0800096. PMID 18204099. 
  40. ^ Geoffrey Hom, Robert R. Graham, Barmak Modrek, et al. (February 28, 2008). "Association of Systemic Lupus Erythematosus with C8orf13–BLK and ITGAM–ITGAX". N Engl J Med 358 (9): 900–9. doi:10.1056/NEJMoa0707865. PMID 18204098. 
  41. ^ "University of South Carolina School of Medicine lecture notes, Immunology, Hypersensitivity reactions. General discussion of hypersensitivity, not specific to SLE". 2010-07-07. Retrieved 2011-08-06. 
  42. ^ Scheinfeld NS, DiCostanzo DD, Cohen SR (December 2003). "Reticulate and stellate acral pigmentation associated with systemic lupus erythematosus and high titers of circulating anticardiolipin antibodies: a possible association with acral microlivedo". Journal of drugs in dermatology : JDD 2 (6): 674–6. PMID 14711150. 
  43. ^ Gaipl US, Kuhn A, Sheriff A, et al. (2006). "Clearance of apoptotic cells in human SLE". Curr. Dir. Autoimmun. Current Directions in Autoimmunity 9: 173–87. doi:10.1159/000090781. ISBN 3-8055-8036-3. PMID 16394661. 
  44. ^ Gergely P Jr, Grossman C, Niland B, Puskas F, Neupane H, Allam F, Banki K, Phillips PE, Perl A. "Mitochondrial hyperpolarization and ATP depletion in patients with systemic lupus erythematosus.". 
  45. ^ Hakkim A, Fürnrohr BG, Amann K, et al. (May 2010). "Impairment of neutrophil extracellular trap degradation is associated with lupus nephritis". Proc. Natl. Acad. Sci. U.S.A. 107 (21): 9813–8. doi:10.1073/pnas.0909927107. PMC 2906830. PMID 20439745. 
  46. ^ Yasutomo K, Horiuchi T, Kagami S, et al. (2001). "Mutation of DNASE1 in people with systemic lupus erythematosus". Nat. Genet. 28 (4): 313–4. doi:10.1038/91070. PMID 11479590. 
  47. ^ Gaipl US, Munoz LE, Grossmayer G, et al. (2007). "Clearance deficiency and systemic lupus erythematosus (SLE)". J. Autoimmun. 28 (2–3): 114–21. doi:10.1016/j.jaut.2007.02.005. PMID 17368845. 
  48. ^ Poole BD, Schneider RI, Guthridge JM, et al. (February 2009). "Early targets of nuclear RNP humoral autoimmunity in human systemic lupus erythematosus". Arthritis Rheum. 60 (3): 848–859. doi:10.1002/art.24306. PMC 2653589. PMID 19248110. 
  49. ^ Pan HF, Wu GC, Li WP, Li XP, Ye DQ (February 2009). "High Mobility Group Box 1: a potential therapeutic target for systemic lupus erythematosus". Mol. Biol. Rep. 37 (3): 1191–5. doi:10.1007/s11033-009-9485-7. PMID 19247800. 
  50. ^ Ther Clin Risk Manag. 2011; 7: 27–32. The lupus band test in systemic lupus erythematosus patients. Adam Reich, Katarzyna Marcinow, and Rafal Bialynicki-Birula
  51. ^ Buyon JP, Clancy RM (December 2003). "Maternal autoantibodies and congenital heart block: mediators, markers, and therapeutic approach". Semin. Arthritis Rheum. 33 (3): 140–54. doi:10.1016/j.semarthrit.2003.09.002. PMID 14671725. 
  52. ^ NIM encyclopedic article on the LE cell test[dead link]
  53. ^ "Article on the classification of rheumatic diseases". 2011-06-08. Retrieved 2011-08-06. 
  54. ^ "Revision of's diagnostic criteria". 2011-06-08. Retrieved 2011-08-06. 
  55. ^ a b c d e f g h i j k l Edworthy SM, Zatarain E, McShane DJ, Bloch DA (1988). "Analysis of the 1982 ARA lupus criteria data set by recursive partitioning methodology: new insights into the relative merit of individual criteria". J. Rheumatol. 15 (10): 1493–8. PMID 3060613. 
  56. ^ Weinstein, A; Bordwell, B; Stone, B; Tibbetts, C; Rothfield, NF (February 1983). "Antibodies to native DNA and serum complement (C3) levels. Application to diagnosis and classification of systemic lupus erythematosus.". The American journal of medicine 74 (2): 206–16. doi:10.1016/0002-9343(83)90613-7. PMID 6600582. 
  57. ^ "UpToDate Patient information article on DNA antibodies". Retrieved 2011-08-06. 
  58. ^ "Common Symptoms of Lupus". Lupus Foundation of America. Retrieved 7 June 2013. 
  59. ^ a b Asherson RA, Cervera R, de Groot PG, et al. (2003). "Catastrophic antiphospholipid syndrome: international consensus statement on classification criteria and treatment guidelines". Lupus 12 (7): 530–4. doi:10.1191/0961203303lu394oa. PMID 12892393. 
  60. ^ Sangle S, D'Cruz DP, Hughes GR (2005). "Livedo reticularis and pregnancy morbidity in patients negative for antiphospholipid antibodies". Ann. Rheum. Dis. 64 (1): 147–8. doi:10.1136/ard.2004.020743. PMC 1755191. PMID 15608315. 
  61. ^ Hughes GR, Khamashta MA (2003). "Seronegative antiphospholipid syndrome". Ann. Rheum. Dis. 62 (12): 1127. doi:10.1136/ard.2003.006163. PMC 1754381. PMID 14644846. 
  62. ^ Hughes GR (1998). "Is it lupus? The St. Thomas' Hospital "alternative" criteria". Clin. Exp. Rheumatol. 16 (3): 250–2. PMID 9631744. 
  63. ^ a b "Handout on Health: Systemic Lupus Erythematosus". The National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health. August 2003. Retrieved 2007-11-23. 
  64. ^ Yazdany J (2008). "Strategies for preventive care in systemic lupus erythematosus". The Journal of Musculoskeletal Medicine. 
  65. ^ a b c d e f Vasudevan AR and Ginzler EM (August 4, 2009). "Established and novel treatments for lupus". The Journal of Musculoskeletal Medicine 26 (8). 
  66. ^ a b "FDA approves first new lupus drug in 56 years". Retrieved 6 May 2011. 
  67. ^ a b Vincent FB, Morand EF and Mackay F (2012). "BAFF and innate immunity: new therapeutic targets for systemic lupus erythematosus". Immunology and cell biology 90 (3): 293–303. doi:10.1038/icb.2011.111. PMID 22231653. Retrieved 10 January 2012. 
  68. ^ Lai ZW, Hanczko R, Bonilla E, Caza TN, Clair B, Bartos A, Miklossy G, Jimah J, Doherty E, Tily H, Francis L, Garcia R, Dawood M, Yu J, Ramos I, Coman I, Faraone SV, Phillips PE, Perl A. "N-acetylcysteine reduces disease activity by blocking mammalian target of rapamycin in T cells from systemic lupus erythematosus patients: a randomized, double-blind, placebo-controlled trial.". 
  69. ^ "Table 1. Current lupus drugs in development". 2009. 
  70. ^ FDA Alert: Mycophenolate Mofetil (marketed as CellCept) and Mycophenolic Acid (marketed as Myfortic). May 16, 2008. 
  71. ^ "ImmuPharma Announces Final Results Of PhaseIIb Study Of LUPUZOR™ In Lupus". Retrieved 2011-08-06. 
  72. ^ "Handout on Health: Systemic Lupus Erythematosus, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, U.S. Department of Health and Human Services". Retrieved 2010-10-13. 
  73. ^ "Intravenous Immunoglobulins (IVIGs) in Lupus Central Station, sourced from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, U.S. Department of Health and Human Services". Retrieved 2010-10-13. 
  74. ^ Cochat P, Fargue S, Mestrallet G, et al. (February 2009). "Disease recurrence in paediatric renal transplantation". Pediatr. Nephrol. 24 (11): 2097–108. doi:10.1007/s00467-009-1137-6. PMC 2753770. PMID 19247694. 
  75. ^ Danchenko N, Satia JA, Anthony MS (2006). "Epidemiology of systemic lupus erythematosus: a comparison of worldwide disease burden". Lupus 15 (5): 308–18. doi:10.1191/0961203306lu2305xx. PMID 16761508. 
  76. ^ "Prognosis and a Hopeful Future". Lupus Foundation of America website. Retrieved 14 December 2010. 
  77. ^ "Poor prognostic factors,Sudheer, SLE document". Retrieved 2011-08-06. 
  78. ^ EARLY STEROIDS MAY PREVENT RELAPSES IN LUPUS, P Jarman (Published in Journal Watch (General) July 18, 1995)
  79. ^ a b c d e Danchenko N, Satia JA, Anthony MS (2006). "Epidemiology of systemic lupus erythematosus: a comparison of worldwide disease burden". Lupus 15 (5): 308–18. doi:10.1191/0961203306lu2305xx. PMID 16761508. 
  80. ^ a b "OMHD|AMH|Factsheets|Lupus". 
  81. ^ Rahman A, Isenberg DA (February 2008). "Systemic lupus erythematosus". N. Engl. J. Med. 358 (9): 929–39. doi:10.1056/NEJMra071297. PMID 18305268. 
  82. ^ Tsokos GC (December 2011). "Systemic lupus erythematosus". N. Engl. J. Med. 365 (22): 2110–21. doi:10.1056/NEJMra1100359. PMID 22129255. 
  83. ^ "Definition in". Retrieved 2012-10-24. 
  84. ^ a b c Hochberg MC (October 1991). "The history of lupus erythematosus". Md Med J 40 (10): 871–3. PMID 1943516. 
  85. ^ Celebrities with Lupus: Charles Kuralt. Updated: August 11, 2008.
  86. ^ Cramer, Gary. Former chess coach named to Hall of Fame. Penn State Intercom, 26 September 2002.
  87. ^ Famous Lupus Patient: Ferdinand Marcos. Updated: August 11, 2008.
  88. ^ Flannery O'Connor (1925–1964). New Georgia Encyclopedia. Sarah Gordon, Georgia College and State University. Updated 2008-03-21
  89. ^ 1963: Labour leader Hugh Gaitskell dies. On This Day, BBC News, 18 January 1963.
  90. ^ A battle with the wolf. Gardner, Anthony. Mail on Sunday, October 10, 2008.
  91. ^ J Dilla/Jay Dee, Retrieved February 2, 2009.
  92. ^ Larry King Live interview, CNN, 1 June 2010.
  93. ^ "Lady Gaga & Lupus — Larry King Interview". National Ledger. June 2, 2010. Retrieved June 3, 2010. 
  94. ^ "Lady Gaga 'can't walk,' postpones shows". USA Today. February 13, 2013. Retrieved February 13, 2013. 
  95. ^ Jewett-Tennant, Jeri. Celebrities with Lupus: Lauren Schuler Donner. Updated: August 28, 2008.
  96. ^ [1], CNN Entertainment, 29 September 2009.
  97. ^ [2], Lupus Foundation of America, 20 April 2011.
  98. ^ Hirschhorn N, Greaves IA (2007). "Louisa May Alcott: her mysterious illness". Perspect. Biol. Med. 50 (2): 243–59. doi:10.1353/pbm.2007.0019. PMID 17468541. 
  99. ^ Celebrities with Lupus: Mary Elizabeth McDonough. Updated: October 28, 2008.
  100. ^ Jewett-Tennant, Jeri. Celebrities with Lupus: Mercedes Scelba-Shorte. Updated: August 28, 2008.
  101. ^ Jewett-Tennant, Jeri. Celebrities with Lupus: Michael Jackson. Updated: August 11, 2008.
  102. ^ Mclellan, Dennis. Michael Wayne, 68; Producer, Guardian of His Father's Legacy. Los Angeles Times, April 4, 2003.
  103. ^ Jewett-Tennant, Jeri. Celebrities with Lupus: Ray Walston. Updated: August 11, 2008.
  104. ^ Angie Davidson interviews top glamour model Sophie Howard,, accessed 21 November 2008
  105. ^ In the Beginning, 1949–1954 — Teddi King. Retrieved February 2, 2009.
  106. ^ Jewett-Tennant, Jeri. Celebrities with Lupus: Tim Raines. Updated: August 28, 2008
  107. ^ "LUPUS FORCES SINGER TONI BRAXTON INTO LA HOSPITAL". AP. Retrieved 8 December 2012. 
  108. ^ Bliss76 Study – UNC School of Medicine. Retrieved 2009-11-30.

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