Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

SLE · Systemic Lupus Erythematosus

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In one line

·In lupus, the immune system loses its brake and makes antibodies (immune proteins) that attack the body's own tissues — skin, joints, kidneys, blood, brain, and heart lining — causing swelling and damage wherever the antibodies land.

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Normal physiology

·Normally, your immune system has a built-in safety brake called immune tolerance that stops it from attacking your own cells, and type I interferons (chemical alarms that fight viruses) stay quiet unless a real germ invades. Keep that picture in mind, because every lupus symptom is a break from that normal quiet state.

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What goes wrong

·In lupus, the immune system's safety brake fails. Cells that should have been deleted or silenced during training survive and start making autoantibodies — immune proteins that attack your own DNA, cell surfaces, and tissues. At the same time, your cells keep pouring out type I interferons (especially interferon-alpha) even when no virus is present, which revs up the whole immune system nonstop. Those autoantibodies clump together with your own proteins into immune complexes that get stuck in tiny blood vessels, especially in the skin, kidneys, joints, and the thin sacs around the heart and lungs. White blood cells swarm to those clumps and release chemicals that cause swelling, bleeding, and scarring. Triggers like UV light, Epstein-Barr virus, cigarette smoke, and hormones (especially estrogen) can flip this switch in someone whose genes already set the stage.

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Hallmark signs

·Malar rash (butterfly rash across the nose and cheeks)
·Joint pain and swelling (arthritis), especially in hands, wrists, and knees
·Extreme tiredness (fatigue) that does not go away with rest
·Photosensitivity (rashes or feeling sick after sun exposure)
·Fever without infection
·Mouth or nose sores (usually painless)
·Kidney problems (proteinuria, blood in urine, or rising creatinine) with little or no pain
·Seizures, headache, confusion, or stroke-like symptoms

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Red flags · escalate now

·New seizure, severe headache, confusion, or sudden weakness on one side of the body (possible brain lupus or stroke)
·Sudden shortness of breath, chest pain, or coughing up blood (possible blood clot in the lung, heart inflammation, or lung bleeding)
·Swelling of the legs and face with foamy urine or much less urine than usual (kidney failure may be starting)
·Fever over 100.4°F (38°C) — could be infection (lupus suppresses immunity and treatments do too) or a severe lupus flare
·Severe abdominal pain, especially with nausea or vomiting (possible inflammation of blood vessels in the gut, which can cause bleeding or tissue death)

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Workup

·ANA (antinuclear antibody) by immunofluorescence
·Anti-dsDNA antibody (anti-double-stranded DNA)
·Anti-Smith (anti-Sm) antibody
·Complement levels (C3 and C4)
·Urinalysis with microscopy and urine protein-to-creatinine ratio
·Complete blood count (CBC) with differential
·Anti-phospholipid antibodies (lupus anticoagulant, anti-cardiolipin, anti-β2-glycoprotein I)
·Kidney biopsy (if proteinuria or rising creatinine)

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Treatment

·Hydroxychloroquine 200–400 mg daily (all patients, indefinitely)
·Low-dose corticosteroids during flares (prednisone 0.5–1 mg/kg/day, then taper over weeks)
·Mycophenolate mofetil 1–3 g/day or cyclophosphamide IV (induction for lupus nephritis), then mycophenolate or azathioprine for maintenance
·Belimumab 10 mg/kg IV every 4 weeks (or 200 mg subcutaneous weekly) for active skin, joint, or serosa disease despite standard therapy
·Rituximab 1 g IV on days 1 and 15 (for refractory lupus nephritis or severe cytopenias)
·Warfarin with target INR 2–3 (or 3–4 for arterial clots) in antiphospholipid syndrome with lupus
·Strict photoprotection (broad-spectrum SPF 50+ sunscreen daily, avoid sun 10 AM–4 PM, wear long sleeves and wide-brim hats)

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NCLEX trap

·ANA is sensitive — it catches lupus — but not specific. Many other diseases (rheumatoid arthritis, thyroid problems, even healthy people) can have a positive ANA. You need ANA PLUS clinical findings (butterfly rash, joint pain, kidney or heart lining inflammation, blood cell problems) PLUS anti-dsDNA or anti-Sm antibodies to diagnose lupus. ANA alone is not enough.
·Lupus nephritis (the kidney being attacked by antibodies) can damage the kidney quietly for weeks before creatinine (a waste product that builds up when the kidney fails) rises. Check urine protein and look at the urine under the microscope in every lupus patient, even if creatinine is normal. Protein in the urine is the early warning sign that the kidney is under attack.
·Hydroxychloroquine (a drug that calms the immune system and protects against flares) is the backbone for all lupus patients — it reduces flares and improves survival. Steroids (prednisone) are for flares only, and you want to use the lowest dose for the shortest time because long-term steroids cause weight gain, high blood sugar, bone thinning, and infection risk. For lupus nephritis, you add mycophenolate or cyclophosphamide (strong immune-calming drugs) to protect the kidneys.
·Lupus is systemic — the whole body is affected. Antibodies attack skin, joints, kidneys, lungs, heart lining, blood cells, and brain. If you only treat the rash and miss kidney inflammation (nephritis) or heart lining inflammation (pericarditis), the patient can die from kidney failure or heart tamponade (fluid squeezing the heart).
·Fever in lupus could be a flare, but infection is common too because lupus drugs (steroids, mycophenolate, cyclophosphamide) weaken the immune system. You must rule out infection (blood cultures, chest X-ray, urinalysis) before assuming fever equals flare and giving more steroids. Steroids make infection worse.
·Antiphospholipid syndrome (antibodies that make blood clot too easily) occurs in 10–15% of lupus patients and causes blood clots in veins and arteries, stroke, and miscarriage. If a lupus patient has an unexplained clot, stroke, or repeated miscarriage, screen with anticardiolipin antibodies, anti-beta-2 glycoprotein I antibodies, and lupus anticoagulant. Treatment is lifelong warfarin (a blood thinner), not just hydroxychloroquine.

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