Systemic Lupus

Erythematosus (SLE)
 • SLE is the classic model of autoimmune disease
• SLE is a systemic rheumatic disorder and the term
used most often for the group of disorders that
includes SLE and other multi system disorders
• Lupus erythematosus = "red wolf" (erythematous
rash)
• There are 11 criteria for the diagnosis of SLE and for a
Overview definitive diagnosis, patients must meet at least FOUR
of these criteria
• Two of the criteria are a positive ANA and the
detection of antibodies to Sm, dsDNA or cardiolipin
• 20-30% of SLE patient have antibodies to
Sm (high probability of SLE)
• 60% of SLE patients have antibodies to
dsDNA (indicator of ACTIVE SLE)
 • 10-15 times more common in FEMALES
• More common in BLACKS than in whites
• Around 1.4 million Americans have lupus
• Survival rate is estimated to be higher than 90%
EPIDEMIOLOGY at 10 years after diagnosis
• Highest mortality rate: patients with renal or
CNS involvement
• Two most frequent cause of death: RENAL
FAILURE and infectious complications
 • Idiopathic
• Primary defect in the regulation of the
immune system is considered important in
the pathogenesis of the disorder
• Genetic
• Hormonal
• estrogen, thus more common in
ETIOLOGY FEMALES
• Antiphospholipid syndrome:
associated with miscarriages
• Environmental factors
• UV light, bacterial and viral infections
• Alteration in the DNA secondary to UV
exposure stimulates autoantibody
production esp. anti-DNA
 • Fever >37.8°C
• Weight loss
• Malaise
• Musculoskeletal
• Arthralgia, arthritis, osteonecrosis
• Cutaneous: "Butterfly rash" over the bridge of

Clinical the nose, urticaria, angioedema,

nonthrombocytopenic purpura, scale
formation, ulcerations of genital and oral
Manifestations membranes, alopecia, Reynaud's
phenomenon
• Anti-Ro(SS-A), Anti-La(SS-B)
• Increased susceptibility to common and
opportunistic infections
• most common cause of death among
hospitalized patients
• usually secondary to administration of
immunosuppressants
 • Renal
• Due to infiltration of immune
complexes and complements to
basement membrane of glomerulus
leading to acute glomerulonephritis
• Proteinuria
• Lymphadenopathy - increased incidence of
lymphoma
Clinical • Serositis - inflammation of the
mesothelium, associated with
Manifestations thrombophlebitis
• Tachycardia, CHF, massive hemoptysis
• Infarction and perforation of the bowel
mucosa and viscera
• Neuropsychiatric - antiribosomal P
antibodies
 1. Discoid (cutaneous) lupus
• Always limited to the skin and is identified
by the biopsy of the rash that may appear

Forms of SLE on the face, neck and scalp.

• Does NOT involve body's internal organs
• May transform into systemic form
• Accounts for 10% of all cases of lupus
 2. Systemic lupus
• Usually more severe than discoid lupus and
can affect the skin, joints and almost ANY
organ or body system, including the lungs,
kidneys,heart and brain
Forms of SLE • Remission (near asymptomatic) and flare
(symptomatic) period
• Accounts for 70% of the cases of lupus, in
50% of the cases, a major organ will be
affected
 3. Drug-induced lupus
• Occurs after the use of some prescribed drugs
• Most frequently implicated drugs include
hydralazine hydrochloride and procainamide
hydrochloride.
• Procainamide hydrochloride: does NOT
induce antibodies to dsDNA
Forms of SLE • ANA's are usually HISTONE-dependent and are
NOT the only ANAs present in the blood
• Predominated by pulmonary and polyserositic
signs and symptoms (have NO renal or CNS
involvement)
• Symptoms usually fade when the drugs are
discontinued.
 4. Neonatal lupus
• Rare condition acquired from
transplacental passage of maternal
autoantibodies esp. Anti-Ro/SS-A or anti-
Forms of SLE La/SS-B
• Can affect the skin, heart and blood of the
fetus and newborn
• NOT a systemic lupus
 • SLE is characterized by the LOSS OF
TOLERANCE to nuclear antigens
• Presence of ANAs
• Deposition of immune complexes in tissues
multiorgan involvement
• Decreased complement levels
• Circulating anticoagulants

• SLE patients are known to produce multiple

autoantibodies

Laboratory Findings • Polyclonal B cell activation

• Formation of autoantigens
• Abberations in the T and B cell functions
• Reduced Ts, hyperproduction of Th
cells
• Formation of lympho cytotoxic
antibodies
 • Hematologic and hemostatic
• Normocytic normochromic anemia
• Positive DAT
• Lymphocytopenia
• Thrombocytopenia due to removal of
antiphospholipid antibody-coated
platelets
Laboratory Findings • Presence of lupus anticoagulant
(causes false positive in
nontreponemal tests for SYPHILIS)
• lupus anticoagulant is a
prothrombin activator, thus its
presence is associated with
THROMBOSIS rather than
bleeding
 • Serologic
• High titers of anti-DNA antibodies
• Reduced complement levels (low
CH50)
DIAGNOSTIC • Presence of complement breakdown
products (C3d, C3c)

EVALUATION • Presence of cryoglobulins

• Anti-nuclear antibodies
• ANA procedure - screening tool
for SLE, replaced the LE test
 • Heterogeneous group of antibodies (IgG, IgM or
IgA) produced against a variety of antigens within
the cell nucleus.
• React with whole nucleus or nuclear components in
host components
• ANAs have NO organ or species specificity
Antinuclear • ANAs are found in other diseases (e.g. RA)
• ANAs are associated with certain drugs and are
Antibodies (ANAs) found in older adults WITHOUT the disease
• Therefore, ANA is NOT diagnostic of SLE, their
presence cannot confirm the disease but their
absence EXCLUDES the diagnosis of SLE except
when the patient is chemically
immunosupressed
 I. Antibodies to DNA
• Antibody to native (ds) DNA (Anti-dsDNA)
• Seen primarily in SLE
• Reacts with the kinetoplast of the
hemoflagellate Crithidia luciliae, the substrate
used to detect anti-native DNA antibodies by
indirect immunofluorescence
• (GOLD STANDARD for testing)

Antinuclear • Indicator of ACTIVE SLE

• Antibody to denatured (ss) DNA (Anti-ssDNA)
Antibodies (ANAs) II. Antibody to histones
• Seen in drug-induced SLE. Induced by procainamide
and hydralazine
• Demonstration of only anti histone antibodies may
be useful in distinguishing drug-induced lupus from
SLE
 III. Antibody to nonhistone proteins
1. Anti-Sm: found almost EXCLUSIVELY to patients with
SLE
• Smith antigen: a nuclear acidic protein
extractable by aqueous solution
2. Anti-deoxyribonucleoprotein(DNP)/LE serum factor:
give rise to LE cell, found in more than 90% of
Antinuclear untreated SLE
3. Anti-Robert(Ro) soluble substance-A (SS-A) -

Antibodies (ANAs) associated with SLE skin disease and neonatal SLE
syndrome
4. Anti-Lane(La) soluble substance-B (SS-B) -
associated with primary and secondary Sjogren's
syndrome, presence in SLE indicates MILD disease.
Presence ALONE indicates primary Sjogren syndrome
5. Membrane specific antibodies to neutrophils and
platelets and autoantibodies to lymphocytes:
SPECIFIC to SLE
 IV. Antibody to nucleolar antigens

Antinuclear • U3-RNA-protein complex

• 7-2-RNP
Antibodies (ANAs) • RNA polymerase I
• PM-Scl (polymyositis-scleroderma overlap)
 1. ANA screening
• Indirect immunofluorescence

Laboratory 2. Complement assays

• C3, C4 assay - decreased

Evaluation • Presence of complement breakdown

products C3d, C3c
3. Detection of cryoglobulins
• Nephelometry
 • Based on the use of fluorescein conjugated AHG
• Mouse liver or kidney substrates or cell-cultured
fibroblasts may be used as antigens and are fixed to
the slides.
• Use of Hep-2 cell substrate is the primary
screening test for the diagnosis of systemic
rheumatic disorders (SRD's)

Indirect • If ANA is present in the patient's serum, it will bind to

the nuclei of the cells in the substrates. It will then be

Immunofluorescence incubated with FITC-labeled AHG and then washed

with a buffer. If ANAs are present, AHG will bind and
will demonstrate fluorescence under UV light. The
slides must be examined as soon as possible.
• (+) GREEN OR GOLD FLUORESCENCE
• If slides cannot be immediately examined, it can be
stored in the dark for up to 48 hours before being
read.
 • There will be several different patterns of
fluorescence depending of the specificity of
the ANA involved.

Indirect • NOTE: a positive ANA screening test is NOT

diagnostic of SLE but a negative ANA test
RULES OUT a diagnosis of SLE.
Immunofluorescence • Hep-2 slides will detect all major ANAs but
detection of anti-Ro/SS-A is affected by the
fixation method (Alcohol diminishes the
activity of anti-Ro/SS-A
 1. Diffused or homogenous
• The WHOLE nucleus fluoresce EVENLY
• Anti-DNA nucleoprotein antibodies
(antibodies to nDNA, dsDNA, ssDNA, DNP or
histones)
2. Peripheral (nuclear rim)
• Central protein of the nucleus is only LIGHTLY

Indirect stained or not stained at all, but the nuclear

margins fluoresce strongly and appear to
extend into the cytoplasm
Immunofluorescence • Associated with ACTIVE stage of SLE

Patterns 3. Speckled
• GRAINY pattern with numerous ROUND DOTS
of nuclear fluorescence, without staining of
the nuclei
• Occurs in the presence of antibody to
extractable nuclear antigen devoid of DNA or
histone (anti-RNP, anti-Sm)
 4. Nucleolar
• Reflects an antibody to nucleolar RNA (4-6s
RNP)
• Present in about 50% of patients with
Indirect scleroderma (PSS) and Sjogren's syndrome
and SLE
Immunofluorescence 5. Centromeric (discrete, speckled)
• Anti-centromere antibody reacts with
Patterns centromeric chromatin of metaphase and
interphase cells
• CREST syndrome (Calcinosis, Raynaud's
phenomenon, Esophageal dysfunction,
Sclerodactily, Telangiectasia)
DIFFUSE/
HOMOGENOUS
PERIPHERAL RIM
SPECKLED
NUCLEOLAR
CENTROMERE
Rapid Slide Test for • SLE latex test provides a suspension of
polystyrene latex particles coated with DNP

Antinucleoprotein • Thiae procedure is positive in SLE and SRDs

Autoimmune • Provides a qualitative screening test for the
presence of ANAs
Enzyme • It serves as an alternative to the IFA for
screening a patient’s serum for ANA
Immunoassay
 • Represents a rapid, sensitive, and specific
Automated Testing: method with the absence of subjective error in
interpretation of results

Multiplex • Two basic assay formats: planar array assays and

microbead assays
• BioPlex 2200: automated Luminex-based
Immunoassay system, performs a simultaneous analysis of 13
autoimmune analytes in a single tube
 • For lupus patients: reduce inflammation,
and maintain normal body functions
• For photosensitive patients, avoidance of
(excessive) sun exposure and the regular
application of sunscreens to prevent rashes
• Regular exercise
• Immunization

Treatment • Medications: Nonsteroidal antiinfammatory

drugs (NSAIDs), Acetaminophen, Steroids,
Antimalarials, Immunosuppressants,
immunosuppressive therapy,
Anticoagulants, Biological disease-
modifying antirheumatic drug (DMARD)
therapy
• Rituximab: used successfully for RA, but
studies have shown mixed results for the
treatment of SLE
The end