Rav Immunol Sle Mkcap

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Many patients who use tumor necrosis factor α inhibitors develop autoantibodies,

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Many patients who use tumor necrosis factor α inhibitors develop autoantibodies, including antinuclear, anti–double-stranded DNA, and anti-Smith antibodies; rarely, these patients develop drug-induced lupus. Patients with this condition may present with typical manifestations of systemic lupus erythematosus but are particularly likely to have cutaneous and pleuropericardial involvement. Renal and neurologic manifestations are extremely rare.

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* Discoid lupus is characterized by

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* Discoid lupus is characterized by the presence of red-to-pink round, oval, or polycyclic papules and plaques involving the face, scalp, and ear canals accompanied by follicular plugging and eventual development of atrophic scarring and hypopigmentation.

This patient has discoid lupus, which is a

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rash in patients with drug-induced lupus typically manifests as

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rash in patients with drug-induced lupus typically manifests as nonscarring scaly circular erythematous plaques that affect the neck, trunk, and extensor surfaces of the arms

Front 4

NS lupus can be caused by

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NS lupus can be caused by vasculitis of the small vessels of the brain but also has been associated with the presence of antineuronal antibodies. MRI of the brain in affected patients may be normal or may reveal small areas of ischemia in the periventricular and subcortical white matter. Seizure also may develop in patients with this condition.

CNS lupus is a severe manifestation of SLE that is generally treated aggressively. Although few controlled trials on the treatment of CNS lupus have been performed to date, one small study demonstrated better outcomes in those treated with monthly pulse cyclophosphamide compared with monthly pulse methylprednisolone, with both of these agents used in conjunction with prednisone, 1 mg/kg/d.

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Mesenteric vasculitis

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This patient also has abdominal pain, nausea, vomiting, and blood per rectum. Her imaging studies are consistent with bowel ischemia. Mesenteric vasculitis is the most likely cause of this clinical presentation. Approximately one third of patients with active SLE who have abdominal pain have mesenteric vasculitis. This condition typically warrants immediate treatment with high-dose corticosteroids and intravenous cyclophosphamide; occasionally, surgical intervention is indicated.

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s usually effective in managing mild manifestations of SLE, including cutaneous and joint involvement.

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Hydroxychloroquine is usually effective in managing mild manifestations of SLE, including cutaneous and joint involvement. This medication also is an extremely effective disease-modifying agent in SLE and helps to prevent disease flares. Rarely, hydroxychloroquine causes an irreversible retinopathy, and regular ophthalmologic screening is indicated in patients using this agent.

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hypertension, ankle edema, hematuria, proteinuria, hypoalbuminemia, and erythrocyte casts on urinalysis

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hypertension, ankle edema, hematuria, proteinuria, hypoalbuminemia, and erythrocyte casts on urinalysis are highly suggestive of lupus nephritis despite the absence of renal insufficiency. To prevent irreversible renal damage, early treatment with a high-dose corticosteroid such as prednisone is indicated for patients whose condition raises strong suspicion for lupus nephritis. Whether renal biopsy is necessary in this clinical situation in order to establish a diagnosis remains uncertain, and treatment with high-dose corticosteroids would not significantly alter subsequent biopsy results.

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c

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Pregnancy outcomes in pregnant women with recently or currently active SLE at the time of conception tend to be poor, and pregnancy in this setting is associated with an increased risk of intrauterine growth restriction and premature birth. Furthermore, pregnant patients with SLE, particularly those with renal manifestations, have an increased risk of preeclampsia. Active SLE is therefore a relative contraindication to pregnancy

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* In women treated with cyclophosphamide, coadministration of leuprolide acetate helps to maintain fertility and provide contraception.

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* In women treated with cyclophosphamide, coadministration of leuprolide acetate helps to maintain fertility and provide contraception.

This patient has active systemic lupus erythematosus (SLE), lupus nephritis,

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* Hydroxychloroquine is safe

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Key Point

* Hydroxychloroquine is safe to use in pregnancy and is useful for preventing systemic lupus erythematosus flares.

This patient has systemic lupus

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Pregnancy may trigger SLE flares, and, if needed,

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Pregnancy may trigger SLE flares, and, if needed, prednisone can be used during pregnancy. However, the addition of prednisone would not be warranted in a patient with no signs of active SLE, and corticosteroids generally are not used prophylactically