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9/26/2018 0 Comments

Lupus in your ED


Background:
  • Lupus is more common than you think – 1/2000 people have it
  • We will rarely diagnose lupus in ED – diagnostic criteria is intense and involves a blood test that takes days to come back.
  • Must have 4/11 of the following
    • Malar rash, discoid rash, photosensitivity, oral ulcers, serositis, arthritis, renal involvement, neurological findings, hematological abnormality, AND at least one of the 4/11 must be a positive autoantibody.
  • Lupus can affect every organ system in your body
 
Understanding Lupus – The Big Picture:
  • People are constantly between Lupus flairs and remission
  • Lupus medications have a ton of side effects
    • Steroids and Immunomodulators
  • People are very pro-coagulableand immunocompromised
  • Benign presentations may be more serious in patients with Lupus, even if they are taking their medications
 
Organ specific problems: Cardiac
  • Patients with Lupus are 10x more likely to have ACS. Can present at younger ages too.
  • Libman Sachs endocarditis gives you an increased risk of acute valve rupture
  • Increased risk cardiac effusion, pericarditis, CHF, RHF
 
Organ specific problems: Respiratory
  • Diffuse alveolar hemorrhage – very rare. 
  • Increased risk pleural effusions, PE, PNA, pulmonary HTN, interstitial lung disease
 
Organ specific problems: Neuro
  • Stroke, dural venous sinus thrombosis
  • Seizure that may not respond to benzos – intubate and paralyze
  • PRES - posterior reversible encephalopathy syndrome from immunomodulators
  • Peripheral neuropathy with strange distributions – not a stocking glove presentation
 
Organ specific problems: Vasculitis
– resuscitate and give 1g methylprednisone, and suggest to the admitted team they should consider IVIG and/or plasmapheresis!
  • Can cause any vessels to be inflamed/bleed
  • Mesenteric = hematemesis, hematochezia, bowel necrosis, perforation 
  • Lung = hemoptysis 
  • Catastrophic antiphospholipid syndrome (CAPS) – presents with multiple arterial occlusions, cold clammy body parts. Do same as above plus add heparin.
 
Organ specific problems: Many others random presentations
​
– if someone has Lupus and a weird problem it can likely be attributed to Lupus, but rule out other causes first.
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