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Systemic Lupus Erythematosus

August 28, 2017

Introduction to SLE

Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disorder of unknown cause that can involve joints, kidneys, serous surfaces, and vessel walls and that occurs predominantly in young women but also in children. 90% of patients are young women in their late teens to mid-30s when the disease onset occurs. It is more common among blacks and Asians than whites. Although the origin of SLE is not yet known, both large population studies and animal models of SLE indicate that it could be caused by a combination of genetic, immunologic, hormonal and possibly environmental factors.
 

Clinical Manifestations

Virtually any organ system may be involved in SLE. SLE is a clinical diagnosis; no one test or feature is fully diagnostic of the disease. Symptoms may come and go, and different symptoms may appear at different times during the course of the disease. Many patient’s clinical syndromes evolve over time, and only after several years are they recognized as having SLE. 
Clinical Manifestations

 

Fatigue

Fatigue is a nearly universal complaint of persons with SLE, even when no other manifestations of the disease are present. The person should be evaluated for factors that may exacerbate fatigue, such as overexertion, insomnia, depression, stress, anemia, and other inflammatory diseases. 

Weight Changes
Many people with SLE experience changes in weight. At least one-half of people report weight loss before being diagnosed with SLE. Weight loss in SLE persons may be attributed to a decreased appetite, side effects of medications, gastrointestinal problems, or fever. Weight gain can occur in some people and may be due in part to prescribed medications, especially corticosteroids, or fluid retention from kidney disease. 

Fever

Episodic fever is experienced by more than 80 percent of SLE patients, and there is no particular fever pattern. Although high fevers can occur during a Lupus flare, low-grade fevers are more frequently seen. 

Infections

The most common infections for SLE patients are respiratory, urinary tract, and skin infections. SLE affects the immune system, thus reducing the body’s ability to prevent and fight infection. In addition, many of the drugs used to treat SLE also suppress the function of the immune system, thereby further depressing the ability to fight infection. A complicating infection is often the cause of an elevated temperature in a person with SLE. The person’s white blood count (WBC) may be normal to elevated with an infection, but low with SLE alone. However, certain medications, such as immunosuppressives, will suppress the WBC even in the presence of fever. Therefore, it is important to rule out other causes of a fever, including an infection or a drug reaction. 

Dermatologic Manifestations 

Approximately 80 percent of people with SLE have some kind of skin manifestations. Varying levels of pain and itching may affect a person’s ability to carry out activities of daily living. Pruritus accompanies many types of skin lesions.
The classic sign of SLE is the “butterfly” rash extending over the cheeks and bridge of the nose. This rash ranges from a faint blush to a severe eruption with scaling and photosensitive. Between 55 and 85 percent of people develop this rash at some time in the course of the disease.  

 

Malar Rash 

  

Other rashes may occur elsewhere on the face and ears, upper arms, shoulders, chest, and hands.Panniculitis can cause subcutaneous nodular lesions. Vasculitic skin lesions may include mottled erythema on the palms and fingers, periungual erythema, nail-fold infarcts, urticaria, and palpable purpura.

 

 

 

 

 erythema on the neck shoulder and chest 

 

erythema around ear lobe 

 

 

 

erythema on the palm

 

 

 

 

 

 

 

 

 

 

 

 

erythema on the fingures 

periungual erythema 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discoid Lupus Erythematosus (DLE) is seen in 15-30 percent of people with SLE. The rash is characterized by various-sized, erythematous,well-defined, scaly patches. 

 

 

 

Discoid Rash 

 

 

 

 

 

 

 

 

 

 

 

 

Some patients may develop mouth, vaginal, or nasal ulcers. Alopecia occurs in about one-half of SLE people. Most hair loss is diffuse, but it may be patchy. It can be scarring or nonscarring. Alopecia may also be caused by corticosteroids, infection, or immunosuppressive drugs. 

 

Raynaud’s phenomenon is an extreme spasm of blood vessels in response to cold or stress. The fingers and /or toes become white and /or blue, and may become red on re-warming, which frequently occurs in patients with SLE. For most of the patients it is mild, but some severe case may develop painful skin ulcers or gangrene on the fingers or toes. Attacks of Raynaud’s phenomenon can cause a deep tingling feeling in the hands and feet that can be very uncomfortable. 

 

 

 

Raynaud’s Syndrome 


 

 
 
 

 

 

Musculoskeletal Manifestations

Anthralgia or arthritis is experienced by 95 percent of SLE people at some time during the course of the disease. Joint pain is the initial symptom in about one-half of people eventually diagnosed with SLE. Morning stiffness and joint and muscle aching can also occur. Joint pain may be migratory; it is typically symmetric but is asymmetric in many people. The joints most commonly involved are those of the fingers, wrists, and knees; less commonly involved are the elbows, ankles, and shoulders. Several joint complications may occur in SLE people, including Jaccoud’s anthropathy and osteonocrosis. Subcutaneous nodules, especially in the small joints of the hands, are seen in about 5 percent of people. Tendinitis, tendon rupture, and carpal tunnel syndrome are seen occasionally. 

 

Hematologic Manifestations

Anemia, which is common in SLE people, reflects insufficient bone marrow activity, shortened Red Blood Count (RBC) life span, or poor iron uptake. Aspirin, NSAIDs, and prednisone can cause stomach bleeding and exacerbate the condition.
 

Thrombocytopenia (low platelet count) in SLE is a common clinical manifestation affecting up to one third of patients. People with SLE may have an association with antiphospholipid antibody syndrome (a thrombotic disorder), wherein autoantibodies to phospholipids are present in their serum. This is a disorder of coagulation that causes blood clots (thrombosis) in both arteries and veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery. Thrombocytopenia may occur and may respond to low-dose corticosteroids. Mild forms may not need to be treated, but a severe form requires high-dose corticosteroid or cytotoxic drugs. An elevated erythrocyte sedimentation rate (ESR) is a common finding in active SLE, but it does not always mirror disease activity. 

Cardiopulmonary Manifestations

Cardiopulmonary symptoms commonly include recurrent pleurisy, with or without pleural effusion. Cardiac complications include pericarditis (most commonly), pericardial effusion, and myocarditis. 

Vasculitis (inflammation of the blood vessels) and serositis (inflammation of serous membranes) are frequently part of the autoimmune pathology of SLE. These conditions report well to corticosteroids. Vasculitis may cause many different symptoms, depending on the system(s) most affected. Serositis most commonly presents as pleurisy or pericarditis. Pleuritic chest pain is common. Pleurisy is the most common respiratory manifestation in SLE. Attacks of pleuritic pain can also be associated with pleural effusions. 

Obstetric Manifestations

Obstetric manifestations include early and late fetal loss. SLE may first appear during pregnancy; women who have had an unexplained 2nd-trimester stillbirth, a fetus with growth restriction, preterm delivery, or recurrent spontaneous abortions are often later diagnosed with SLE. In patients with antiphospholipid antibodies, the risk of recurrent miscarriages is increased. The course of preexisting SLE during pregnancy cannot be predicted, but SLE may worsen, particularly immediately postpartum. Pregnancy can be successful particularly after 6 to 12 mo of remission, but SLE flares are common during pregnancy. Pregnancy should be timed when disease is in remission. During pregnancy, the patient should be monitored closely for any disease flare or thrombotic events. 

Renal Manifestations

Renal damage is one of the most serious complications of SLE. The majority of Lupus people have some degree of asymptomatic microscopic kidney damage. Renal lesions can range in severity from a focal, usually benign, glomerulitis to a diffuse, potentially fatal, membranoproliferative glomerulonephritis. Common manifestations include proteinuria (most often), an abnormal urinary sediment manifested by RBC casts and leukocytes, hypertension, and edema. 


Gastrointestinal Manifestations

Gastrointestinal (GI) problems are common for SLE. Anorexia, nausea, vomiting, and diarrhea may be related to the use of NSAIDs, antimalarials, corticosteroids, and cytotoxic drugs. Abnormal liver enzyme levels are also found in about one-half of SLE people (usually secondary to medications). Active liver disease is rarely found. 

 

Ophthalmologic Manifestations

Visual impairment may be due to SLE or to drug treatment (corticosteroids or antimalarials) or it may be a separate problem (glaucoma or retinal detachment). Blindness due to SLE occurs, but is rare. Other visual problems may occur: 

  • A Lupus rash may develop on the eyelids.

  • Glaucoma and cataracts may be caused by corticosteroids.

  • Conjunctivitis occurs in 10 percent of SLE people and is usually infectious. Kerato-conjunctivitis is usually mild.

  • Sjogren’s syndrome is an autoimmune condition manifest as excessive dryness of mucous membranes. Lupus persons with these symptoms require artificial tears to relieve dry eyes.

  • Antimalarials can damage the retina, which can impair vision (particularly color vision) or, in rare instances, cause blindness.

Neurologic Manifestations

Neurologic symptoms can result from involvement of any part of the central or peripheral nervous system or meninges. Mild cognitive impairment is common. There may also be headaches, personality changes, ischemic stroke, subarachnoid hemorrhage, seizures, psychoses, organic brain syndrome, aseptic meningitis, peripheral neuropathies, transverse myelitis, or cerebellar dysfunction. 
 

Advantages of Integrated Medicine in treating SLE

Currently, Western medicine used for SLE includes prednisone, and immunosuppressant such as cyclophosphamide, azathioprine, and mycophenolate mofetil. They can contain the symptom, but long-term use will produce adverse reactions that upset patients, such as obesity, diabetes, hypertension, hyperlipidemia, leukopenia, osteoporosis, alopecia, Cushing’s Syndrome, increased risk of infections, accelerated atherosclerosis, avascular necrosis, and glucoma.

I (Dr. Chi) find immunosuppressant to consume Qi and damage Blood.  I also view prednisone as a Yang-only substance, long-term use of which will hurt Yin and consume Qi. Furthermore, large dosages of these drugs over an extended period of time will cause symptoms to mutate. We should therefore observe the mutations and incorporate Chinese medicine into the treatment to minimize poisonous adverse reactions and maximize the effect of the treatment.

Principals we need to know with Integrated Medicine

 

Patients with large dosage of prednisone

When the patient receives a full dosage or large dosage of prednisone, there will be Yin deficiency and internal Heat. We should use the toxin cleaning, stasis removing and yin nourishing approach.

 

Patients with dosage reducing

When the dosage is reduced, the patient may have Qi and Yin deficiency or Yin and Yang deficiency. We should nourish Yin, benefit Qi and warm Yang to help prednisone reduction take effect.

When the dosage of prednisone is steady, the patient often has Spleen and Kidney deficiency. We should warm the Kidneys and nourish the Spleen to ensure the treatment effect, and prevent the rebound and recurrence of symptoms.

In the meantime we should look at the amount of stasis and poison to determine the herbs we use. However, we recognize that Chinese medicine may not be able to treat acute and severe symptoms, in which case we should use Western medicine and have Chinese medicine complement it. In order to treat the symptoms in a timely manner. That will be the most appropriate approach. 

 

Research proves that integrated medicine can counter-balance and assist on one another

Dr Fang Yong Shen has compared 212 SLE patients who received Chinese medicine in addition to prednisone and 89 who only used prednisone.The study discovered the integrative medicine group had 11.38% complete recovery, 30.08% remarkable improvement and an overall success rate of 92.68%, all the percentages higher than the 5.62%, 22.47% and 86.52% of the Western medicine group. In clinical observation, the integrative medicine group had a higher rate of recovery from mouth sores, joint pains, over-sensitivity to sunlight, kidney damage, abnormal nerve system, fever, rashes, hair loss, Raynaud’s phenomenon, and irregular menstruation. In lab test results, the integrative medicine group showed superior numbers in ESR, hemoglobin, anti-ds-DNA, white blood cells, platelets, IgG, and C3. In conclusion, the integrative approach is more effective than Western medicine in relieving symptoms and achieving desirable lab test results. A further study has found the dosage of prednisone for each patient on day 180 and the total amount of prednisone used over six months for each patient were both lower in the integrative medicine group than in the Western medicine group. In terms of adverse reactions and complications, the integrative medicine group had fewer cases of hypertension, hyperglycemia, hyperlipidemia, Cushing syndrome, osteoporosis, acne, hirsutism, insomnia, depression, fungal and viral infection. Follow-up observations found more patients with abilities in housework and occupation regained in the integrative medicine group. Based on the studies depicted above, it can be conclude that the integrative approach works more effectively in treating SLE than Western medicine only. The integrative approach can maximize the curing effect and reduce adverse reactions. The longer it is used, the more helpful it proves to be. We highly recommend worldwide applications of the integrative approach.

 

[1]Wen Cheng Ping, Fang Yong shenh, Chengx Xue Qi at el.Study on the Adjustable Effect of toxin cleaning, yin nourishing, stasis removing on the Expression of Fas in T Lymphocyte Subsets in Systemic Lupus Erythematosus, Chinese Journal of Integrated Traditional and Western Nephrology,1999,6:57-5

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