Pictorial case study: Systemic lupus erthematosus

The case
A 56-year-old woman presented with a two-week history of generalised aches and pains. She felt very unwell and had noticed swelling of the small joints of the body. Past history included rheumatic fever as a child and she took phenoxymethylpenicillin until the age of 10. Current medication included ibuprofen and antidepressants.

On examination she had swelling and decreased range of movement of the distal and proximal interphalangeal joints and metacarpophalangeal joints, and pedal oedema. There was no rash. Her BP was 110/85mmHg and her temperature was 37°C.

What is the diagnosis, management and differential diagnosis?

Diagnosis and management
The diagnosis is systemic lupus erythematosus (SLE), a non-organ-specific autoimmune disease in which antinuclear antibodies (ANA) occur. It is common in Afro-Caribbean and Asian patients. In the UK the peak age of diagnosis is 30–40 years.

SLE causes musculoskeletal, skin, renal, CNS, pulmonary and cardiovascular symptoms. It can cause splenomegaly, lymph adenopathy and recurrent abortions. In laboratory tests 95 per cent of patients are ANA positive.

The presence of antibodies directed against double stranded DNA is exclusive to SLE. Around 40 per cent of patients are rheumatoid factor positive.

Possible different diagnosis

  • Rheumatoid arthritis.
  • Reactive arthritis.
  • Viral infection.
  • Sarcoidosis and vasculitis.

Differential diagnosis
Rheumatoid arthritis

  • Can present at any age, but is most common in middle age.
  • Usually starts with symmetrical small joint involvement.
  • Around 95 per cent of patients are rheumatoid factor positive.
  • Early referral can improve disease progression. 

Contributed by Dr Latha Meda, a salaried GP in Runcorn, Halton

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