Systemic Lupus Erythematosus (SLE)

Systemic Lupus Erythematosus (SLE)

1. Definition
   Systemic Lupus Erythematosus is a chronic multisystem autoimmune disease in which the body’s immune system produces antibodies that attack its own tissues. It may involve skin, joints, kidneys, brain, blood cells and many other organs.

2. Synonyms (if any)
   Lupus erythematosus, simply called lupus, is often used as a synonym for SLE. The term “lupus” can also refer to cutaneous forms that are limited to the skin.

3. Causes / Etiology
   Genetic predisposition – a family history of SLE or other autoimmune disorders increases susceptibility.
   Environmental triggers – ultraviolet light, certain infections (for example Epstein‑Barr virus) and drugs such as procainamide, hydralazine or isoniazid can precipitate disease in a genetically susceptible person.
   Hormonal influence – the higher prevalence in women of child‑bearing age suggests that estrogen may enhance auto‑antibody production.
   Immune dysregulation – defective clearance of apoptotic cells leads to exposure of nuclear antigens and formation of auto‑antibodies.

4. Types / Classification
   SLE is not divided into separate “types” but is classified according to organ involvement and disease severity.
   Mild disease – limited to skin and joints, intermittent flares, good response to NSAIDs and low‑dose steroids.
   Moderate disease – involvement of kidneys (class II–III lupus nephritis) or central nervous system, requires higher dose steroids and an immunosuppressant.
   Severe disease – diffuse proliferative nephritis (class IV), neuro‑psychiatric lupus, pulmonary hemorrhage; needs aggressive therapy with high‑dose steroids, cyclophosphamide or biologics.
   Acute versus chronic forms – an acute flare presents with sudden onset of fever, rash and arthritis, while chronic disease shows persistent organ damage such as chronic kidney disease or arthropathy.

5. Pathophysiology / Pathology – step by step
   First, genetic and hormonal factors cause loss of tolerance to nuclear antigens.
   Second, autoreactive B‑cells produce antinuclear antibodies (ANA) and anti‑double‑stranded DNA antibodies.
   Third, these antibodies bind to self‑antigens forming immune complexes.
   Fourth, immune complexes deposit in small vessels of skin, kidney, brain and other tissues.
   Fifth, complement activation follows, attracting neutrophils and macrophages that release inflammatory mediators.
   Sixth, ongoing inflammation leads to tissue injury, fibrosis and loss of organ function.

6. Clinical Features – general and specific
   General features – persistent fatigue, low‑grade fever, weight loss, arthralgia and myalgia.
   Cutaneous – malar (“butterfly”) rash over the cheeks, discoid plaques, photosensitivity, alopecia.
   Articular – non‑erosive symmetric polyarthritis, usually sparing the distal interphalangeal joints.
   Renal – proteinuria, hematuria, edema; may progress to lupus nephritis and renal failure.
   Neuro‑psychiatric – seizures, psychosis, mood disorders, peripheral neuropathy.
   Hematologic – anemia of chronic disease, leukopenia, thrombocytopenia.
   Serosal – pleuritis, pericarditis causing chest pain that improves on leaning forward.

7. Complications – acute and chronic
   Acute complications – lupus nephritis with rapid loss of renal function, central nervous system involvement, severe thrombocytopenia leading to bleeding, opportunistic infections due to immunosuppression.
   Chronic complications – chronic kidney disease or end‑stage renal disease, accelerated atherosclerosis causing premature cardiovascular disease, osteoporosis from long‑term steroid use, cataracts, avascular necrosis of bone.
   Early detection and appropriate therapy are essential to prevent irreversible organ damage.

8. Investigations / Diagnosis – routine, specific and confirmatory
   Complete blood count – looks for anemia, leukopenia or thrombocytopenia.
   Urinalysis – detects protein, red cells or cellular casts suggestive of nephritis.
   Serum chemistry – assesses renal function, electrolytes and liver enzymes.
   Antinuclear antibody (ANA) – screening test; a positive result is present in >95 % of patients.
   Anti‑double‑stranded DNA (anti‑dsDNA) – highly specific; titres often correlate with disease activity, especially renal involvement.
   Anti‑Smith (anti‑Sm) antibodies – specific but less sensitive.
   Complement levels (C3, C4) – low levels indicate active consumption during flares.
   Renal biopsy – gold standard for classifying lupus nephritis and guiding therapy.

9. Differential Diagnosis – key points for distinction
   Rheumatoid arthritis – symmetric polyarthritis but lacks the characteristic malar rash, renal involvement and positive ANA.
   Sjögren’s syndrome – prominent dry eyes and mouth, anti‑Ro/La antibodies, minimal skin rash.
   Systemic sclerosis – skin tightening and Raynaud’s phenomenon dominate; ANA pattern is usually centromere, not speckled.
   Dermatomyositis – heliotrope rash and muscle weakness are prominent; CK levels are markedly raised.

10. Management / Treatment

General management – educate the patient about disease nature, importance of regular follow‑up and avoidance of triggers such as excessive sunlight. Encourage vaccination against influenza and pneumococcus to reduce infection risk.

Modern medicine treatment –
Non‑steroidal anti‑inflammatory drugs for mild arthritis and serositis.
Antimalarial drug hydroxychloroquine for skin and joint disease; it also reduces flares and improves survival.
Corticosteroids – low dose for maintenance, high dose for severe flares; taper slowly to avoid adrenal suppression.
Immunosuppressants – azathioprine, mycophenolate mofetil or cyclophosphamide for moderate to severe organ involvement, especially lupus nephritis.
Biologic agents – belimumab (anti‑BLyS) for refractory disease; rituximab may be used in selected cases.

Diet and lifestyle advice –
Avoid prolonged sun exposure; use sunscreen with high SPF and protective clothing.
Adopt a balanced diet rich in fruits, vegetables, whole grains and omega‑3 fatty acids to modulate inflammation.
Limit salt intake to control blood pressure and reduce renal stress.
Quit smoking because it worsens cardiovascular risk and interferes with medication efficacy.
Engage in regular low‑impact exercise to maintain bone health and cardiovascular fitness.

11. Homeopathic Therapeutics – eight remedies with detailed points

12. Natrum Muriaticum
    Causation – emotional grief, prolonged disappointment.
    Characteristic symptoms – dry, scaly facial rash, joint pains that improve with rest.
    Modalities – worse from sun, better from cool sea air or fresh water.
    Mental state – melancholy, feels misunderstood, often keeps feelings inside.
    Thirst and appetite – thirst for small sips of cold water; appetite is moderate but may be reduced during flare.
    Discharges – scanty, thin nasal discharge; occasional watery eyes.
    Physical generals – tendency to anemia, low vitality, cold extremities.
    Suitable constitution – people who are introverted, sensitive, often artists or scholars.
    How it helps – addresses the underlying emotional trigger and the photosensitive rash typical of SLE.

13. Apis Mellifica
    Causation – insect stings, allergic reactions, exposure to venom.
    Characteristic symptoms – red, swollen, burning skin lesions that are relieved by cold applications.
    Modalities – worse from heat, better from cold compresses.
    Mental state – irritable, impatient, may feel “buzzed” like a bee.
    Thirst and appetite – thirst for cold water; appetite may be increased after meals.
    Discharges – thin, watery stool; occasional mild diarrhea.
    Physical generals – marked edema of hands and feet, especially after standing.
    Suitable constitution – individuals who are quick‑tempered, love sweet foods, and have a history of allergic tendencies.
    How it helps – reduces the inflammatory swelling and burning sensation of lupus skin lesions.

14. Urtica Urens
    Causation – contact with stinging nettles, exposure to irritant plants.
    Characteristic symptoms – intensely itching, prickly rash that becomes urticarial.
    Modalities – worse from warmth, better from cool fresh air.
    Mental state – restless, anxious, feels “on edge”.
    Thirst and appetite – prefers cold drinks; appetite may be irregular.
    Discharges – occasional clear, watery urine; no significant secretions.
    Physical generals – generalized itching, especially at night, with occasional hives.
    Suitable constitution – people who are sensitive to environmental changes, often live in rural areas.
    How it helps – controls the pruritic, urticarial component of cutaneous lupus.

15. Rhus Toxicodendron
    Causation – contact with poison ivy, poison oak or other irritating plants.
    Characteristic symptoms – stiff, aching joints that improve with continued motion.
    Modalities – worse from rest and cold, better from warmth and movement.
    Mental state – impatient, eager to move, dislikes being still.
    Thirst and appetite – thirst for warm drinks; appetite is good.
    Discharges – occasional sticky mucus from the throat during flare.
    Physical generals – swelling of joints, especially knees and wrists, with a feeling of “tightness”.
    Suitable constitution – active individuals who enjoy physical work but become sore after over‑exertion.
    How it helps – relieves the migratory arthritic pain that is common in SLE.

16. Lupus (homeopathic)
    Causation – constitutional predisposition to autoimmune reaction, often after severe infection.
    Characteristic symptoms – ulcerating skin lesions, especially on the scalp, with a tendency to bleed.
    Modalities – worse from heat, better from cool, moist environments.
    Mental state – despondent, feels a sense of impending doom.
    Thirst and appetite – thirst for cold water; appetite is poor during active disease.
    Discharges – bloody or purulent discharge from ulcerated lesions.
    Physical generals – marked weakness, low blood pressure, tendency to faint.
    Suitable constitution – patients with a family history of autoimmune disease, often thin and frail.
    How it helps – directly targets the ulcerative, bleeding skin lesions seen in severe lupus.

17. Calcarea Carbonica
    Causation – constitutional weakness, prolonged exposure to cold and damp.
    Characteristic symptoms – sluggish joints, easy bruising, slow healing of skin lesions.
    Modalities – worse from cold, damp, and mental over‑exertion; better from warm, dry environments.
    Mental state – feels insecure, worries about health, lacks confidence.
    Thirst and appetite – thirst for warm drinks; appetite is moderate but may be reduced when ill.
    Discharges – scanty, thick mucus when respiratory involvement occurs.
    Physical generals – low stamina, tendency to obesity in the abdomen, cold hands and feet.
    Suitable constitution – individuals who are diligent, often teachers or clerks, who become ill in cold weather.
    How it helps – strengthens the constitutional resistance and improves bone health compromised by long‑term steroids.

18. Sulphur
    Causation – chronic irritation of the skin, often after exposure to chemicals or heat.
    Characteristic symptoms – burning, itching rash that worsens at night, with a tendency to develop crusts.
    Modalities – worse from warmth and tight clothing, better from cool fresh air.
    Mental state – restless, philosophical, often feels “different” from others.
    Thirst and appetite – thirst for cold water; appetite is good but may be irregular.
    Discharges – oily, foul‑smelling sweat from affected areas.
    Physical generals – tendency to eczema‑like eruptions, especially on the scalp and trunk.
    Suitable constitution – creative, often artists or writers, who are sensitive to odors and heat.
    How it helps – alleviates the chronic, burning skin eruptions that accompany lupus.

19. Arnica Montana
    Causation – physical trauma, over‑exertion, or surgical procedures.
    Characteristic symptoms – bruised, sore muscles and joints, with a feeling of heaviness.
    Modalities – worse from motion, better from rest and cold applications.
    Mental state – feels “knocked‑out”, wishes to lie down, may be irritable.
    Thirst and appetite – thirst for cold water; appetite is usually normal.
    Discharges – no specific discharge; may have mild swelling of the affected area.
    Physical generals – marked tenderness on pressure, especially after a flare of arthritis.
    Suitable constitution – individuals who engage in heavy physical work or sports, prone to injuries.
    How it helps – reduces the muscular and joint soreness that often accompany lupus flares.

20. Prognosis
    The outcome of SLE ranges from mild disease with normal life expectancy to severe, organ‑threatening disease. Early recognition, regular monitoring of renal function and appropriate use of immunosuppressive therapy improve survival. Factors that worsen prognosis include early onset of renal involvement, high anti‑dsDNA titres, low complement levels and non‑adherence to treatment.

21. Prevention
    Primary prevention focuses on avoiding known triggers: diligent sun protection, avoidance of photosensitizing drugs and prompt treatment of infections. Secondary prevention involves regular screening for renal, cardiovascular and bone complications, vaccination, and maintaining a healthy lifestyle to reduce disease activity.

22. Diet – recommended and avoided foods
    Recommended – fresh fruits and vegetables for antioxidant protection, oily fish rich in omega‑3 fatty acids to dampen inflammation, whole grains for stable blood sugar, low‑salt diet to protect kidney function, adequate calcium and vitamin D to counter steroid‑induced bone loss.
    Avoided – excessive saturated fats and trans‑fats that accelerate atherosclerosis, high‑salt foods that raise blood pressure, processed sugars that may trigger flares, alcohol in large amounts because it can worsen liver function and interact with medications.