SLE or Systemic Lupus Erythematosus or sometime only called Lupus is a chronic systemic autoimmune condition with genetics, nutrition and environment playing a major role in its onset and evolution, its a condition which greatly reduces life expectancy and also causes complications in pregnancy. It falls under disabling disease conditions category though much less than10% cases develops disabilities.

TYPES of SLE

• Acute Cutaneous Lupus
• Sub-Acute Cutaneous Lupus Erthematosus
• Chronic Cutaneous Lupus also called Discoid Lupus Erthematosus
• Neonatal Lupus Erythematosus
• Drug Induced Lupus Erythematosus

EPIDEMIOLOGY of SLE

Lupus was the most google searched topic in healthcare related topics in 2017! Now that is something to be added in Epidemiology section!  😀 hehehe!

Female are affected more with SLE than male, female of child bearing age are affected more with female to male ratio of about 9:1.

African, Caribean and chinese ethnic groups are more prone to this condition.

SIGNS and SYMPTOMS of SLE

GENERAL

Undifferentiating symptoms which are common to other diseases as well.

• Fever
• Fatigue
• Malaise
• Joint pain
• Muscle pain
• Bodyache
• Sleep disturbances
• Psychiatric Disorders
• Poor physical fittness
• Anaemia of chronic disease
• Raynaud’s Phenomenon

SKIN

Majority of cases shows skin manifestation of the condition

• Though the rashes and lesion on skin may vary, the classic sign of SLE on skin is butterfly rashes on face, also called Mallar Rashes and is seen in almost half of the cases with skin lesions.
• If it is Acute type there might not be scaling of skin, not well demarcated distinct edge compared to othe types.
• If it is Subacute type rashes shows scaling of skin with distinct edges.
• And in Chronic type rashes shows thick distinct thick scaling with very well demarcated edges.
• Increased Hairfall is also one of the complaints.
• Ulcers in mucous membranes esp of nose and mouth.

MUSCULOSKELETAL

It affects Small joints especially of fingers and wrist and it very closely mimicks rheumatoid arthritis and psoriatic arthritis making it clinically difficult in making differential diagnosis.

But it is less destructive and disabling compared to other two conditions, only less than 10% cases of SLE will develop deformities and even fewer will have disabilities.

It not only mimicks Rheumatoid Arthritis but it also seems to have very close relation to rheumatoid arthritis.

It significantly increases risks of fractures and also it is associated with facilitation of Osteoarticular Tuberculosis.

HEAMOTOLOGICAL

• Anaemia of chronic disease with low Red Blood cell count
• Low White Blood Cell count
• Anti phospholipid antibody syndrome is a condition where anti-phospholipid antibodies increases Partial Thromboplastin time causing tendency to heamorrhages and it is frequently found positive in patient with SLE and its coexisting is termed as Lupus Anticoagulant Positive.
• Patients with SLE frequently show positive results for Anti Cardiolipin Antibodies as well, and patients with these antibodies sometimes shows false positive results for Syphillis.

CIRCULATORY SYSTEM AND HEART

• Artheroscelerosis – Thickening and deposition of cholestrol plaque in blood-vessel walls which may also give rise to Ischemic Myocardial diseases like Myocardial Infarction.
• Vasculitis – Inflamation of blood-vessels in some cases
• Endocarditis – Inflamation of inner linning of heart, when due to SLE its termed as Libman-Sacks Endocarditis
• Pericarditis – inflamation of outer layers and and surrounding tissues.
• Myocarditis – Inflamation of cardiac muscles.
• It may also cause inflamation of Mitral and Tricuspid valves of heart.

LUNGS

• Pleurisy – Inflamation of pleura.
• Pneumonitis – Inflamation of lungs.
• Interstitial Lung Disease
• Pulmonary Embolism
• Pulmonary Heamorrhage
• All these complications and chronic inflamatory processes causes Shrinking Lung Syndrome where there is reduction in lung volume.

REPRODUCTIVE

30 % of pregnancy has comolications like

• Fetal Death
• Spontaneous Abortion
• Still Birth

Prognosis is worse in those who get aggravations in SLE duringbpregnancy.

Neonatal Lupus Erythematosus

Child born to mother with SLE shows symptoms of Discoid Lupus Erythematosus with

• Heart block
• Splenomegaly – Enlargement of Spleen
• Hepatomegaly – Enlargement of Liver
• Neonatal SLE is self limiting condition and in most cases recovers on its own.

RENAL (Kidney)

• Painless Heamaturia – Blood in urine.
• Painless Proteinuria – Protein in urine.
• Lupus Nephritis leading to terminal Renal failure.
• Histologically it shows its classical appearance of Membranous Glomerulonephritis with Wire-Loop  Abnormailities due to deposition of Immune Complexes in Basement Membrane.

NEUROPSYCHIATRIC (NP-SLE)

If any Neuro-Psychiatric is caused dur to SLE its called NPSLE Neuro-Psychiatric Systemic Lupus Erythematosus

There are atleast 12  Central Nervous System related and 7 Peripheral Nervous System relate manifestation of SLE that are being observed in patients with SLE.

Central Nervous System(85-90% of all NPSLE)

1. Headache
2. Anxiety Disorder
3. Mood Disorder
4. Acute Confusional state
5. Psychosis
6. Movement Disorder
7. Cognitive Dysfunction
8. Seizure Disorder
9. Myelopathy
10. Aseptic Meningitis
11. Cerebrovascular diseases
12. Demyelinating Syndrome

Peripheral Nervous System(10-15% of all NPSLE)

1. Acute Inflamatory Demyelinating Polyradiculoneuropathy
2. Autonimic Disorder
3. Mononeuropathy
4. Myasthenia Gravis
5. Cranial Neuropathy
6. Plexopathy
7. Polyneuropathy

DIAGNOSIS of SLE

SLE is considered amongst one of the prototype disease as its very difficult to  differentiate from many other autoimmune conditions as they share in common majority of signs and symptoms making  its diagnosis very difficult, It much depends on clinical picture of the disease and investigations after that there are many criterias based on clinical symptoms coupled with laboratory tests based on which a person can arrive at some conclusion though not absolutely sensitive and specific to confirm diagnosis in every case but fair enough.

LABORATORY TESTS

ANA detection by direct  or indirect immunoflorescence

ANA test detects many different subtypes of ANA related to many other autoimmune conditions as well with many overlapping eachother of which

• Anti- Double Strand DNA Antibodies most specific of all present in almost 70% cases of SLE with only 0.5% non-SLE cases has t in them.
• Anti-Smith DNA Antibodies present in most of the cases of SLE and not frequently found in non-SLE person.
• Anti- Histone Antibodies present in Drug Induced SLE
• Anti- U1 RNP antibodies – non specific also appears in other conditions like Systemic Sclerosis
• Anti- Ro or SS-A and  Anti- La or SS-B – non specific for SLE but more Specific to Sjogrene syndrome, but its present in many of the cases of neonatal lupus with heart involvement in particular.

Other Tests

Anti-ENA Test

Lupus Cell Test – It was used in past as it used to show positive in 50-70% SLE cases but was not specific to SLE and used to be present in many cases of many other conditions like RA Scleroderma etc.

DIAGNOSTIC CRITERIA OF AMERICAN COLLEGE OF RHEUMATOLOGY.

Its a stringent criteria developed by American College of Rheumatology, so that non of non-SLE cases should filter in, so many of the SLE cases are also filtered out.

The criteria is that if any patient shows any of the four symptoms out of eleven simultaneously or serially in more than one occasion than he is considered to be positive for SLE.

1. Mallar Rash/ Butterfly rash on cheeks; Sensitivity of 57% and Specificity of 96%.
2. Discoid Rash; Sensitivity of 18% and Specificity of 99%.
3. Serositis, Inflamation of serous membranes around heart (more specific) and lungs(more sensitive); Sensitivity of 56% and Specificity of 86%.
4. Mucosal Ulcers of oral cavity and nasopharynx; sensitivity of 27% and specificity of 96%.
5. Arthritis, non-erosive with more than two joints involved with tenderness swelling and effusion; Sensitivity of 86% and Specificity of 37%.
6. Photosensitivity, Ligh causes aggravation in skin rashes or other Lupus related complaints; Senitivity of 43%and Specificity of 96%.
7. Non Drug Induce : Hemolytic Anaemia, Leucopenia, Lymphopenia, Thrombocytopenia; Sensitivity of 59% and Specificity of 89%.
8. More than 0.5g of total protein in urine in a day or cellular cast seen in urine under microscope; Sensitivity 51% and Specificity of 94%.
9. Anti- Nuclear Antibody positive; Sensitivity of 99% and specificity of 49%.
10. Positive Anti- Smith, Anti- Double Strand DNA, Positive Anti- Phospholipid Antibody, False Fositive Serological test for Syphillis; Sensitivity 85% and Specificity of 93%; Presence of Anti- ssDNA in 70% of cases.
11. Neurological disorder Seizure or psychosis; Sensitivity of 20% and Specificity of 98%

This is a very stringent criteria used for research purpose if we go through we may falsely conclude negative diagnosis and miss out on diagnosing many patients who are suffering from SLE

Aslo it misses out on certain factors like antiphospholipid anti bodies which has strong association with SLE  there are many cases who are anti phospholipid antibody positive but are not fitting in above ACR criteria but still they are having SLE.

So more practicle approach widely used is through the Recursive Partitioning which has two classification trees

The Simplest Classification Tree – If patient has any immunological disorder with positive anti- Smith antibody, anti- DNA antibody, false positive serology test for Syphillis, presence of Lupus cells or Mallar rash/butterfly rash, then the person is diagnosed as positive for SLE; specificity of 92% and sensitivity of 92%.

Full Classification Tree : It uses six criterias; sensitivity of 97% and specificity of 95%

HOMOEOPATHIC MEDICINES FOR SLE

I have seen homoeopathy work wonders in SLE especially in cases with NPSLE because then the disease becomes very expressive about itself,  it shows itself not only on skin and joints but also on Neuropsychiatric sphere which show various symptoms typically different in each individual and this is what is required in homeopathic medicine selection, that the body is expressing itself in mental sphere which makes remedy selection easier.

Always a proper case taking needs to be done in deep seated chronic autoimmune conditions like this and a deep acting polycrest remedy should be selected after proper repertorisation as per each individual constitution and constitutional treatment is the only permanant solution for such conditions.

Still some theraputic indications are given which can be helpful guide and can be used as per the symptomatology in course of disease if indicated intercurrently or during acute excerbations of disease showing following symptom.

• BELLADONNA

  – Typically suited in Mallar rash or Bitterfly rash of Syetemic Lupus Erythemotosua with symptoms of Neuro-Psychiatric SLE (NPSLE) where CNS involvement is markedly noted also suits in PNS symptoms of NPSLC

• MERCURIOUS SOLUBILIS

  Whenever in case of lupus there are oral and/or naso-pharyngeal ulceration this remedy is very well suited

• BORAX

  Again this is best suited in mucosal ulceration but in this remedy the ulceration are more marked in oral mucosa than in nasopharynx.

• SYPHYLLINUM

  A nosode a dose can be given intercurrent as anti miasmatic of the cases that shows syphillitic miasma in the background also useful in cases showing painless red mallar rash or butterfly rash with much thickening and exfoliation especially like in Chronic Lupus Erythemotosus, also suited well in ulcerations of oral and nasopharyngeal mucosa.

• CINCHONNA OFFICINALIS

  In cases with signs of hemolytic anaemia wether due to disease ot allopathic medicines, it will work wonders in both the cases.

• FERRUM PHOSPHORICUM

  Where the patient has febrile condition due to disease with malaise, fatigue, Hairloss and aneamia duw to lupus or its medicines, can also be givem in low potencies in biochemic form along with other medicines

• FERRUM METALLICUM

  Red acute rash typically in acute lupus erythematosus with involvement of oral mucosa, also in later chronic stages when there is are signs of anaemia of chronic disease of hemolytic anaemia

• RHUS TOXICODENDRON 

  Works wonders in cases of lupus where it not only acts on skin but also wonderfully acts on the joints and musculoskelwtal complaints the disease shows.

• HYOCYAMUS 

  In patients with symptoms of NPSLE.

• ACONITE NAPELLUS

  in acute violent spells of relaopse and aggravations with symptoms of NPSLE like mental restlessness and has fear fright and anxiety in general and fear of death in particular.

• RHUS VENENTA

Psoriatic Arthritis is a condition found in patient suffering from autoimmune disease called Psoriasis where in there is involvement of joints as well, along with skin and nail. It is classified as Seronegative Arthropathy and individuals with HLA B27 genotype shows more susceptibility towards this condition with genetic and environmental factors playing a major role in precipitation of the condition.

It presents itself as Chronic Inflamatory Arthritis involving one or more joints which accompanies or alternates with acute of spells of Psoriasis or has relation with the cyclic pattern of Psoriasis.

Signs and Symptoms of Psoriatic Arthritis

If a person is suffering from Psoriasis doesnt mean he will develop psoriatic Arthritis, regardless of severity of psoriasis he is suffering from. But its observed that person having Psoriatic Arthritis shows some relation between skin complaints and joint complaints either they aggravate together or alternate each other in their spells of aggravation but not in every case and always.

70% of Psoriatic Arthritis cases presents first sign of disease as psoriasis lesion on skin, in majority cases it usually develop almost 10yrs after onset of appearance of skin psoriasis. majority of them are adults between 35-55yrs.

15% first develops joint complaints then skin psoriasis develops later. and majority of them are children.

15% presents both skin and joint complaints originating simultaneously at the onset of disease.

SKIN and NAIL

Typical features of Psoriasis on Skin and Nail

• Silverish scaly skin exfoliating cyclically leaving behind clear red base on extensor surface of skin and typically on scalp, around umbilicus.
• Exudation and cuts may also be seen in severe cases.
• Onycholysis, Ridges on nail, Pitting on nail, Hyperkeratosis of skin below nails of fingers and toes.

MUSCULOSKELETAL

It more frequently involves small joints of hand and feets especially of Fingers and Toes frequently wrist and spine are also involved, There is morning stifness pain and swelling of joints. Almost 20% cases shows symetry in joints involved.

• Swelling of fingers, Dactilitis, giving sausage like appearance to fingers.
• Sacroilitis, Lumbar spondylitis, pain in lower back
• Cervical Spondylitis, pain in cervical region.
• Enthesitis of Tendo-Achilles causing severe pain in ankle.
• Plantar Fascitis causing pain and stiffness in soles.

GENERAL

When the disease progresses or aggravates patient may show signs of

• Malaise, Fatigue Weakness and Exhaustion.
• Deformities, Disfigurement and Disabilities.
• Anaemia of Chronic Disease.

Psoriatic Arthritis presents itself in one of the following five patterns.

1) Oligoarticular

Its the most common type affecting almost 70% of all the cases where in ther is involvement of less than 3 joints and lacks symetry.

2) Polyarticular

Its comparatively severe type and accounts for almost 25% of all the cases of which 50% develops disability and deformities. It typically involves more than 4-5 joints and shows somewhat symetrical pattern. It resembles much to Rheumatoid Arthritis and need to differentially diagnosed which becomes difficult in sero-negative Rheumatoid Arthritis cases.

3) Arthritis Mutilans

Also called Chronic Absorptive arthritis ans is found in almost 5% of all the cases and is the most severe and destructive form of arthritis presented due to psoriasis and in many other conditions like Rheumatoid Arthritis and it shows severe disfigurement and deformities.

4) Spondyloarthritis

Typically affects spine especially the cervical spine and sacro-illiac joint. may also affect other joints as well in a symetric fashion.

5) Distal Interphalangeal

Typically involves distal small joints of fingers and toes with involvement of nails.

Diagnosis of Psoriatic Arthritis

There is no Specific Test Available For Psoriatic Arthritis. It cant be predicited based either only on joint or only on skin complaints that the person is developing Psoriatic Arthritis and its only after both skin and musculoskeletal complaints presents itself the diagnosis can be established. So, early diagnosis is not possible and its usually established only after the disease has progressed enough to show itself on both the spectrums.

The diagnosis of Psoriatic Arthritis depends upon clinical features and host of investigative tests that collectively exclude probability of other conditions and indicate towards Psoriatic Arthritis.

• Psoriasis with chronic inflamatory arthritis of which the aggravation pattern can be related to cyclic process of psoriasis but not necessarily in all cases. Especially showing features like
• Distal interphalangeal arthritis
• 80% of patients presents nail complaints Onycholysis – ridging pitting and hyperkerotosis of skin under nail
• Dactilitis, sausage like appearance of fingers.
• 30-50% patients show Enthesitis, involving Tendo-Achilles, Plantar fascia,
• Pain around Patella, illiac crest, epicondyles, supraspinatus insertions, sacroillitis.
• X ray shows degenerative changes
• Family history of psoriasis or psoriatic arthritis
• Subjects with HLA B27 genotype.
• Negative Serological tests like RA factor and ACCP of Rheumatoid Arthristis.

For Differential Diagnosis of Psoriatic Arthritis Read

• Rheumatoid Arthritis
• Gouty Arthritis
• Ankylosing Spondylosis
• Osteoarthritis
• Inflamatory Bowel Disease related Arthritis
• Systemic Lupus Erythematousus

Homoeopathic Treatment For Psoriatic Arthritis

As mentioned above its an autoimmune condition chronic in nature. So its important to treat the cause first and the symptoms will be relieved on its own. For that a proper homoeopathic case taking and constitutional approach is necessary as its deep seated genetic complaint and only a deep seated constitutional remedial force can bring about change for better. But in many severe cases where there are gross degenerative changes or the disease has progressed much further or the pain is severe we need to treat theraputically initially to get the acute exacerbations in check and later we can find out constitutional remedy based on Miasmatic background and totality of symptoms of Mind and Body. Also There arise much need for anti-miasmatic nosode administeration in the course of treatment if the case is improving but improvement is soon regressing or case has hit a stand still and ia not reaponding further in such case we need to consider a nosode.

Homoeopathic Medicines for Psoriatic Arthritis

RHUS TOX

Rhus tox is usually adapted or well suited to a person of rheumatic diathesis. Rhus tox is very well indicated in psoriatic arthritis. The effects on the skin, rheumatic pains, mucus memmbrane affections makes this remedy frequently indicated. Rhus tox affects the fibrous tissue of the joints, ligaments causing rheumatic symptoms. Patient presents with burning eczematous erruptions with tendency to scale formation. Skin is red swollen with intense itching. Hot painfull swelling of joints. Rheumatic pains spread over a large surface area at nape of neck, loins, and extremities which is relieved by motion. The cold fresh air is intolerable makes the skin painful.

URTICA URENS

Urtica urens is one of the indicated remedy for psoriatic arthritis. Rheumatism is usually associated with skin complaints. As its common name stinging nettle implies it produces stinging and burning pain. Skin complaints alternate with rheumatism with severe pain in joints. Itching and swelling all over body resembling hives. Heat in skin of face arms shoulderand chest with formication numbness and itching. Psoriatic errruptions with scales, skin looks wrinkled. Intense burning of skin. Patient is worse from exposure to cold moist air.

RHUS VENETA

In case of Rhus veneta, the skin symptoms of this species of rhus are most severe. Rhus veneta is one of the most actively poisonous remedy among the family. Presents with great restlessness.,numbness and lameness of joints. Bruised feeling in the limbs. Pains as if sprained or dislocated. Presents with trembling of limbs with twitching of muscles. Rashes under the skin with severe nightly itching. Fine psoriatic erruptions on forearm, wrist, back of hands between and on fingers. Severe desquamation with severe itching. Complaints are usually aggravated by warmth.

LEDUM PAL

Ledum pal usually affects the fibrous tissue of joints especially small joints. Hence it can be called as a rheumatic remedy where rheumatism begins in the feet and travels upwards. Ledum pal is very valuable remedy in psoriatic arthritis. There is weakness and numbness of affected parts. Painful cold oedematous joints. Presents with erruptions only on the covered parts of the body. Affecting the skin ledum produces reddish spots with scaly erruptions. Gouty pains shoot all thrkugh the foot and limbs. Cracking in joints worse from warmth of bed. Aggravation from warmth is so severe that the patient can only get relief from rheumatism is by putting his feet in cold water.

BELLADONA

Belladona has marked sphere of action on the skin, bones, glands and nervous system. Useful in case of psoriatic arthritis. Pains are usually throbbing, sharp, cutting, shooting which come and go in repeated attacks. Joints are swollen, red hot with severe throbbing sensation and extreme sensitiveness. The heat, redness and burning characterise most of the skin complaints, and presnts with alternate redness and paleness of skin with scaly erruptions and severe itching. The complaints of belladona come on suddenly, eun a regular course and subside suddenly.

SILICEA

Silicea too can be considered one of the efficient remedy in psoriatic arthritis. Silicea produces inflammation of skin. It acts upon the constitution that are sluggish. There is i.perfect assimilation and defective nutrition. Presents with neurasthenic states and increased susceptibility to nervous stimuli. Presents with moist erruptiions on skin with fomation of scales. Usually patient presents with weak spine, susceptible to draught on back. Pain in coccyx. Diseases of bones of spine.

MEDORRHINUM

Medorrhinum is a nosode prepared from gonorrhoeal virus. It is a powerful deep acting remedy indicated for most of the cgronic complaints. Medorrhinum is a very valuable remedy for arthritic and rheumatic pains , loss of power in joints, joints feel loose. Useful in chronic psoriatic arthritis wuth great disturbance and irritabilty of nervous system. Pain in back with burning heat. Legs feel heavy and ache all night. Acting on skin medorrhinum causes intense itching worse at night. Yellowish copper coloured spots remain after erruptions.

ACTEA SPICATA

Actea spicata is a rheumatic remedy especially affecting the smaller joints, tearing tingling pain. Presents with wrist rheumatism. Though wrist is affected prominently other joints are too equally affected. Slight fatigue causes swelling of joints. Psoriatic erruptions on skin which are dry scaly and with intense itching.

SYPHILLINUM

Syphilinum is another nosode prepared from syphilitic virus. Acts on the bone, nerves, mucus membrane. Indicated in psoriatic arthritis. Presents with rheumatic stiffness and lameness in back. Aching in the whole spine. Inflammation of joints. Pains are usually aggravated by warmth of bed. Indiacted in shifting rheumatic pains and chronic eruptions like psoriasis, presents with dry scaly or pustular erruptions on different parts of the body in patches. Presents with great weakness with very few symptoms, utter prostration and debility in morning or on walking.

THUJA OCCIDENTALIS

Thuja has main action on the skin, bones. Useful in case of psoriatic arthritis. Thuja chiefly acts on the mucus membrane of skin, nerves, glands. Presents with cracking in joints when stretching them. Limbs feel as uf made of wood or glass and would break easily. Psoriatic erruptions itch or burn violently. Erruptions on covered parts of the body. Worse from scratching. Dry skin with brownish spots and scales with severe itching.

ALSO READ

Psoriasis

PSORIASIS

ARTHRITIS (GENERAL)

ARTHRITIS

Rheumatoid Arthritis

RHEUMATOID ARTHRITIS

ANKYLOSING SPONDYLOSIS

ANKYLOSING SPONDYLITIS

GOUT

GOUT