Symptoms of Systemic Lupus Erythematosus (SLE)
SLE presents with a wide range of symptoms affecting multiple organ systems, most commonly including constitutional symptoms, mucocutaneous manifestations, and musculoskeletal complaints such as fatigue, lupus-specific rash, mouth ulcers, alopecia, joint pain, and myalgia. 1
Common Clinical Manifestations
Constitutional Symptoms
- Fatigue (often severe and persistent)
- Fever (typically low-grade)
- Weight loss
- General malaise
Mucocutaneous Manifestations
- Malar (butterfly) rash across cheeks and nose
- Discoid rash (raised, scaly patches)
- Photosensitivity (skin rash after sun exposure)
- Oral or nasal ulcers
- Alopecia (hair loss)
- Raynaud's phenomenon (fingers turning white/blue in cold)
Musculoskeletal Symptoms
- Arthritis (joint pain, swelling, and stiffness)
- Myalgia (muscle pain)
- Morning stiffness
- Joint deformities (in chronic cases)
Renal Involvement
- Proteinuria
- Hematuria
- Edema
- Hypertension
- Kidney dysfunction (in severe cases)
Hematologic Abnormalities
- Anemia
- Leukopenia
- Lymphopenia
- Thrombocytopenia
Neuropsychiatric Manifestations
- Headaches
- Cognitive dysfunction
- Seizures
- Psychosis
- Depression
- Anxiety
Cardiopulmonary Manifestations
- Pleuritis
- Pericarditis
- Chest pain
- Shortness of breath
Diagnosis
Diagnosis is based on clinical presentation and laboratory findings. According to the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology classification criteria, SLE can be diagnosed with 96.1% sensitivity and 93.4% specificity when a patient meets at least four of the eleven criteria 2.
Key laboratory findings include:
- Antinuclear antibodies (ANA)
- Anti-double-stranded DNA antibodies
- Anti-Smith antibodies
- Low complement levels (C3, C4)
- Antiphospholipid antibodies
Treatment Approach
First-Line Therapy
- Hydroxychloroquine (200-400 mg/day) is recommended for all SLE patients and should be continued indefinitely as it significantly reduces mortality. 3
- Low-dose glucocorticoids (prednisone ≤7.5 mg/day) for the shortest time possible
Additional Treatments Based on Severity
Mild disease (skin, joints):
- NSAIDs for joint pain
- Topical steroids for skin manifestations
- Methotrexate, leflunomide, or azathioprine for inadequate response
Moderate to severe disease (major organ involvement):
- Methylprednisolone pulses followed by oral prednisone
- Mycophenolate mofetil or cyclophosphamide (especially for lupus nephritis)
- Belimumab, anifrolumab, or voclosporin (newer approved biologics)
Lupus nephritis:
- Class III/IV: Methylprednisolone pulses followed by oral prednisone with mycophenolate mofetil or cyclophosphamide
- Class V: Prednisone with mycophenolate mofetil
Non-Pharmacological Management
- Sun protection (UV light avoidance, sunscreen, protective clothing) 4
- Regular exercise to improve aerobic capacity and reduce fatigue 4
- Psychosocial interventions (cognitive behavioral therapy, group therapy) to improve quality of life and reduce anxiety and depression 4
Monitoring and Prevention
- Regular monitoring of disease activity every 1-3 months
- Assessment of renal function, proteinuria, hemogram, complement levels, and anti-DNA levels
- Osteoporosis prevention with calcium and vitamin D
- Management of cardiovascular risk factors (hypertension, dyslipidemia, diabetes)
- Prevention of infections in immunosuppressed patients
Common Pitfalls and Caveats
- Delayed diagnosis: SLE can mimic many other conditions, leading to delayed diagnosis and treatment.
- Overtreatment: Intensifying therapy based on serological activity alone may lead to overtreatment.
- Undertreatment: Failing to recognize major organ involvement can lead to irreversible damage.
- Medication non-adherence: Patient education is crucial for treatment adherence, especially with hydroxychloroquine.
- Ignoring comorbidities: SLE patients have increased risk of cardiovascular disease, osteoporosis, and infections that require proactive management.
SLE is a complex disease with variable presentation and course. Early recognition of symptoms, prompt initiation of appropriate treatment, and regular monitoring are essential for optimal outcomes and prevention of long-term organ damage.