Systemic Lupus Erythematosus: Statement Analysis
Statements (a), (c), and (e) are TRUE; statements (b) and (d) are FALSE.
Statement-by-Statement Analysis
a) Clinical presentation may be that of fever of unknown origin - TRUE
SLE commonly presents with fever at disease onset. Most (50-60%) neuropsychiatric SLE events occur at disease onset or within the first year after SLE diagnosis, commonly (40-50%) in the presence of generalized disease activity 1. Fever is a recognized nonspecific symptom of SLE that can dominate the initial presentation 2. The multisystem nature of SLE means fever may be the predominant feature before other manifestations become apparent, making it a legitimate presentation as fever of unknown origin.
b) Serositis fluid has very low glucose levels - FALSE
This statement is incorrect. Serositis in SLE (pleural or pericardial effusion) does not characteristically produce very low glucose levels. Unlike infectious or rheumatoid effusions where glucose may be markedly decreased, lupus serositis typically produces exudative effusions with relatively preserved glucose levels. The fluid is inflammatory in nature but does not demonstrate the profound glucose depression seen in bacterial infections or rheumatoid disease.
c) Renal involvement is primarily glomerular - TRUE
Lupus nephritis is fundamentally a glomerular disease. When SLE affects the kidneys, the pathology centers on immune complex deposition in glomeruli, leading to various patterns of glomerulonephritis (Classes I-VI). The characteristic "full-house" immunofluorescence pattern seen in lupus nephritis reflects glomerular immune complex deposition 3. While tubulointerstitial involvement can occur, the primary and defining pathology is glomerular.
d) CNS involvement primarily manifests as intracerebral hemorrhage - FALSE
This statement is definitively false. Common (cumulative incidence >5%) neuropsychiatric manifestations include cerebrovascular disease and seizures; intracerebral hemorrhage is exceptionally rare 1. The EULAR guidelines clearly state that atherosclerotic/thrombotic/embolic cerebrovascular disease is common, hemorrhagic stroke is rare, and stroke caused by vasculitis is very rare in SLE patients 1.
The most frequent CNS manifestations are:
- Cerebrovascular disease (thrombotic/embolic) - common (>5%)
- Seizures - common (>5%)
- Cognitive dysfunction - relatively uncommon (1-5%)
- Major depression - relatively uncommon (1-5%)
- Acute confusional state - relatively uncommon (1-5%)
Intracerebral hemorrhage as an initial presentation is "exceptionally rare and diagnostically challenging" with an incidence of only 0.4-1.5% 4.
e) Pulmonary embolism is often associated with antiphospholipid syndrome - TRUE
This statement is unequivocally true. Antiphospholipid antibodies are strong risk factors (at least fivefold increased risk) for cerebrovascular disease and other thrombotic events 1. Pulmonary thromboembolism is particularly common in the association between SLE and antiphospholipid syndrome 5, 6. The EULAR guidelines emphasize that antiplatelet/anticoagulation therapy is indicated when manifestations are related to antiphospholipid antibodies, particularly thrombotic cerebrovascular disease 1.
Clinical Pitfalls to Avoid
- Do not assume all CNS lupus presents with hemorrhage - thrombotic events vastly outnumber hemorrhagic ones
- Do not confuse lupus serositis with infectious or rheumatoid effusions - the biochemical profiles differ significantly
- Always screen for antiphospholipid antibodies in SLE patients with thromboembolic events - this changes management from immunosuppression to anticoagulation 1
- Recognize that fever at presentation may be the dominant feature before other diagnostic criteria become apparent