Lupus in your ED

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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.