erythema nodosum lupus

alright, “systemic lupus erythematosus,”k we totally got this. “systemic” is easy, and refers to affecting multiple organs inthe body. “erythematosus” means reddening of the skin, alright alright. “lupus”is latin for “wolf”. so affects multiple organs wolf...reddening of the skin? not exactly,the modern use of lupus usually refers to a variety of diseases that affect the skin...whichwas possibly originally used since these diseases resemble a wolf bite on the patients’ skin.is that true? who knows. at any rate, systemic lupus erythematosus, or sle, sometimes justlupus, is a disease that’s systemic, and affects a wide variety of organs, but notablyoften causes red lesions on the skin. but how does lupus affect all these organs?well usually the immune system protects the

body’s tissues from invaders, but lupusis an autoimmune disease, which means that immune cells start attacking the very tissuestheir supposed to protect. with lupus, essentially any tissue or organ can be targeted. and justlike a ton of other autoimmune diseases though, it’s not completely clear why it develops,and like most diseases it’s the result of both genetics and the environment. alright so let’s go over a specific scenarioto show how this plays out. let’s say this guy has susceptibility genes—genes thatmake him susceptible to getting lupus, and he’s exposed to uv radiation in sunlight,which we know is an environmental risk factor for lupus. well, given enough uv rays, thinklike sunburn, the cell’s dna can become

so badly damaged, that the cell undergoesprogrammed cell death, or apoptosis, and it dies. this produces all these little apoptoticbodies, and exposes the insides of the cell, including parts of the nucleus, like dna,histones, and other proteins, to the rest of the body. well those susceptibility genesspecifically have an effect on this person’s immune system such that their immune cellsare more likely to think that these are foreign, or antigens, and since they’re from thenucleus, we call them nuclear antigens, and immune cells try to attack them. not onlythat though, susceptibility genes also cause this person to have less effective clearance,essentially they aren’t as good at getting rid of the apoptotic bodies and so they endup having more nuclear antigens floating around.

this means that b cells might swing by, seethem, and start the production of antibodies against these pieces of nucleus, which arecalled antinuclear antibodies, and these guys are present in almost all cases of lupus.alright so those antinuclear antibodies bind to the nuclear antigens, forming antigen-antibodycomplexes. these complexes can get into the blood and then drift away and deposit or stickto the vessel wall in all sorts of different organs and tissues like the kidneys, skin,joints, heart. deposited complexes then initiate a local inflammatory reaction, which causesdamage through the activation of the complement system, which, after a huge cascade of enzymeactivation, leaves cell membranes with channels that let fluid and molecules go in and outall willy nilly, causing the cell to burst

and die, usually though you’d want thisto happen to foreign cell or an infected cell, not healthy cells. when tissues become damagedas a result of these immune complexes, it’s known as a type iii hypersensitivity reaction.uv radiation isn’t the only way to damage cells, though, right? it therefore isn’tthe only trigger that’s thought to be associated with lupus—other potential triggers thathave been associated with sle include cigarette smoking, viruses, bacteria, use of certainmedications like procainamide, hydralazine, and isoniazid, as well as sex hormones, particularlyestrogen, which might be partly why lupus is more common in women, especially consideringit’s about 10 times more common in women than men during reproductive years, but onlyabout 2 or 3 times more common in childhood

or past the age of 65. okay okay, as a quick recap, the model that’sgenerally thought to be what leads to sle starts with some environmental trigger, whichdamages cells, and causes apoptosis and the release of nuclear antigens. at this point,the genetic components come in, and the person likely has certain genes that make them notso good at clearing these apoptotic bodies and nuclear antigens, so you end up with alot of nuclear antigens floating around. in combination, they probably also have genesthat cause their immune cells to recognize these nuclear antigens as foreign, which initiatesan immune response, creates antinuclear antibodies that bind to antigens and then float aroundand deposit in various tissues, which causes

inflammation. these deposits and inflammation seem to bethe cause of most of the symptoms of lupus, which remember is a type iii hypersensitivityreaction. many patients, though, also develop antibodies targeting other cells like redand white blood cells, and molecules like various phospholipids, which can mark themfor phagocytosis and destruction, leading to additional symptoms. this is considereda type ii hypersensitivity reaction, although it isn’t fully understood why some of theseantibodies targeting specific cells and molecules develop. so the classic presentation of lupus is fever,joint pain, and a rash in a woman of childbearing

age, but the actual diagnosis is difficultbecause it can affect a variety of people of different genders and ages, and there’realso a wide variety of symptoms. there are general symptoms like fever and weight loss,as well as specific symptoms depending on the specific organ system being affected anddamaged. in fact, it’s so unpredictable that a diagnosis is given only when 4 or moreout of eleven diagnostic criteria are met. the first few have to do with the skin andoften happen to sun-exposed areas; the first is a malar rash, meaning a rash over the cheeksthat spares the nasolabial folds, sometimes just called a “butterfly rash” and thisappears after sun exposure. second is a discoid rash, which is chronic rash in sun-exposedareas that are plaque-like or forms a sort

of patchy redness and can scar. finally, ageneral photosensitivity of the skin—essentially a catch-all category for other rashes thathappen to sun-exposed areas—typically only lasting a couple of days. another type of tissue that can be damagedis the mucosa, or the the inner membrane of various tissues can become damaged as well,so the fourth criteria is ulcers in the mucus membrane of the mouth or the nose. lupus canalso affect the serosa, which is like the outer membrane of an organ or tissue, so ifit gets inflamed, people get get serositis, which could manifest as something like pleuritis,which is inflammation of the lining around the lungs and chest cavity, or as pericarditis,inflammation of the lining of the heart. although

this isn’t strictly a criteria, it’s worthnoting that lupus can affect any layer of the heart—meaning in addition to inflammationof the pericardium, they might also have inflammation of the endocardium and myocardium, leadingto endocarditis and myocarditis, of which the former presents as libman-sacks endocarditis,where vegetations form, which are essentially clumps of fibrin, a blood-clotting proteinand immune cells, around the mitral valve. next, if the joints get inflamed, patientsmay also develop arthritis, specifically two or more joints to meet the criteria. if thekidneys are affected, patients might develop renal disorders, like abnormal amounts ofurine protein or diffuse proliferative glomerulonephritis, inflammation of the glomeruli. for reasonsthat aren’t completely understood, some

autoantibodies that target receptors in thebrain have been implicated as well, and this can cause neurologic disorders like seizuresand psychosis. sort of along the same lines, patients can have autoantibodies against componentsof the blood, causing various hematologic disorders, for example they’ll get anemiaif red blood cells are targeted, thrombocytopenia if platelets are targeted, and leukopeniaif white blood cells or immune cells are targeted. that last one is really a mind-bender becauseit means that your immune system is attacking your immune system. alright so the last twohave to do with specific antibodies being found in the blood, the first one being antinuclearantibody, which we already went through. now a large proportion of patients with lupushave these, meaning this test is very sensitive,

but this test isn’t very specific, sincethese are seen in other autoimmune diseases. finally, they can have some other self-directedantibody that isn’t antinuclear antibody, which can be one of three types. it couldbe anti-smith, which is an antibody against small ribonucleoproteins, or it could be anti-dsdnawhich is against double stranded dna and is often seen more during periods of active disease.these two are relatively specific for lupus. a third type of antibody though is anti-phospholipidwhich is actually against proteins that are bound to the phospholipids, and is less specificfor lupus, meaning that it can pop up in other situations. there are three types of antiphospholipidantibodies - anticardiolipin, which can cause a false-positive test for syphilis since anticardiolipinantibodies are also sometimes involved in

syphilis, the other two are lupus anticoagulantalso known as lupus antibody, and anti-beta2 glycoprotein i. sometimes, because of these,patients with lupus develop an antiphospholipid syndrome, where the antiphospholipid antibodiescause a hypercoagulable state, meaning they’re more prone to developing clots and havingcomplications like deep vein thrombosis, hepatic vein thrombosis, and stroke. these patientsoften end up needing lifelong anticoagulation therapy. so lupus is characterized by periods of flare-upsand periods of remittance, so treatment is often aimed at preventing flares or limitinghow severe they are when they do happen. to help prevent flares, some patients may haveto avoid sunlight exposure with hats and long-sleeved

clothes. to reduce severity of flares, corticosteroidsmay be used to help limit the immune response, and finally, if symptoms are really severe,certain immunosuppressive drugs might be used.

pictures of lupus

hey this is dr k from imedicalschool and todaywe are going to talk about systemic lupus erythematosis otherwise known as sle. so as the name suggests sle is a systemicautoimmune disorder that causes inflammation and affects all the major organs of the body.if you are interested in learning what you can do to help further lupus research or supportadvocacy for lupus patients make sure to check out the lupus foundation of america at lupus.org. since lupus is a systemic inflammatory disorderwhat are the symptoms of lupus? well lupus commonly presents with a multitude of generalizedsymptoms making the differential diagnoses quite broad. some common general symptomsinclude fever, fatigue, myalgias, arthritis,

and weight loss. there are additional symptomsand signs associated with lupus and we will talk about them next as we discuss how todiagnoses lupus. the most important step in understanding anydisease is grasping how to diagnose the disease. lets talk about how to diagnose lupus. thereare many pneumonics that can aid in remembering all the diagnostic criteria. the one i rememberis called dopamine rash. you need to have at least 4 criteria met to diagnose lupus. lets go through each one. the d representsdiscoid rash. a discoid rash is a disc shaped rash that is flat but has pronounced rednessat the borders. here we have a picture that demonstrates a discoid rash.

next we have oral ulcers. generally patientswill have ulcers that you find incidentally on exam. the way to differentiate these ulcersfrom infectious ulcers is that infectious ulcers are usually painful while ulcers fromlupus are generally painless. other skin findings include a photosensitiverash. photosensitive means that sun exposure triggers and can worsen the skin rash. patientsdo not need much sun exposure to really develop these rashes. in addition patients may experience jointpain otherwise known as arthralgia or joint inflammation known as arthritis. a classic physical exam finding for a lupuspatient is the malar rash. the malar rash

affects the cheeks and the bridge of the nose.in a truly classic rash it appears in the shape of a butterfly covering the nasal bridgeand both cheeks. in addition to rashes another criteria isimmunologic phenomenon. immunologic phenomenon include detection of anti-smooth muscle antibody,anti-double stranded dna, ant-ro and anti-la (otherwise known as ssa and ssb.) finallyif the lupus is drug induced you may see anti-histone antibodies. the next criteria are neurologic phenomenon.patient can develop altered mental status, seizures, stroke and headache. in additionto mental status changes lupus can damage the kidneys causing either a nephritic ora nephrotic disorder. nephritic disorder is

when the kidney is damaged causing proteinuriawith less than 3.5 g/day in the urine. in addition in a nephritic disorder a patientmay have high blood pressure and rbc casts. nephrotic disorder is when there is significantprotein loss of greater than 3.5 g/day in the urine. in addition patients have elevatedcholesterol levels, low albumin levels, and edema. one of the classical tests for lupusis ana or antinuclear antibody. ana is sensitive but not specific so a positive ana alone doesnot indicate lupus and you need to look for other criteria described by dopamine rashto make the diagnosis. other symptoms are characterized as serositis.this includes pleuritis, pericarditis, and peritonitis. finally patient can have hematologicalphenomenon. these include anemia, thrombocytopenia,

and hemolytic anemia. now that we have talkedabout the diagnostic criteria for lupus lets talk about how to monitor disease activity. lupus patient will need frequent routine labsto monitor disease activity. key labs include c3, c4, and ch50. these labs test the complementsystem. when lupus is highly active it leads to consumption of complement factors. in additiona rise in the igg anti-double stranded dna indicates an increase in disease activity.in addition to monitoring disease activity, as we know, lupus can cause kidney damage.one indicator of proliferative glomerulonephritis is a drop in c1q complement. the next importantstep is treatment of lupus one of the most important factors in decreasingdisease activity is to stop smoking. smoking

has been linked to worsening disease activityand worse outcomes. like i mentioned before lupus patients should be monitored with frequentlabs. these labs include cbc, esr, crp, urinalysis, spot urine and creatinine, ch50, c3, c4, andanti double stranded dna. in terms of actual therapy the first step is to begin with nsaids.if nsaids do not control symptoms, and they rarely do, hydroxychloroquine can be used.hydroxychloroquine is an antimalarial medication and has been shown to prevent damage to thecentral nervous system and kidneys. if symptoms continue to persist and major organs are beingaffected systemic corticosteroids should be administered. finally if these therapies donot work the patient needs to be escalated to methotrexate, cyclophosphamide, and azathioprinefor better system control.

well that was a brief review of systemic lupuserythematoisis. i hope you liked the video. if you did please share this video with yourfriends on facebook and twitter. give this video a like, place any comments or suggestionsdown below and most importantly subscribe. you can follow us on our facebook page imedicalschoolor twitter at imedschool finally check out our podcast on itunes under imedicalschool.this is dr k from imedicalschool and i will see you next time.

erythema nodosum and lupus

with vasculitis, you have “inflammation”,of the “blood vessels”, and even though this can happen in arteries or veins, we’regoing to focus on vasculitis in arteries because it’s way more common. vasculitides are categorizedby the size of the blood vessels they affect, so we have small-vessel, medium-vessel, andlarge-vessel vasculitis. typically vasculitis is due to an autoimmune disease, where theimmune system confuses a part of normal body as a foreign invader, and there are a coupleof ways this might happen. sometimes the body confuses the innermostlayer of the blood vessel, which is the endothelial layer, with a foreign pathogen and directlyattacks it. to be a little more specific, the white blood cells of the immune systemmix up the normal antigens on the endothelial

cells with the antigens of foreign invaderslike bacteria simply because they look similar - this is called molecular mimicry. this autoimmuneconfusion is thought to be the cause several types of medium-vessel and large-vessel vasculitides. other times the immune system attacks healthycells that are near the vascular endothelium, and the endothelial cells are only gettingindirectly damaged. this is the situation in many small-vessel vasculitides, where theimmune system attacks white blood cell enzymes or other non-endothelial cell targets. once the endothelium is damaged either directlyor indirectly, almost all vasculitis diseases progress in a similar way. the damaged endotheliumexposes the underlying collagen and tissue

factor, and these exposed materials increasethe chance of blood coagulation. the blood vessel walls themselves get weaker as theyare damaged, making aneurysms more likely. and finally as the vessel wall heals, it becomesharder and stiffer because fibrin is deposited into the blood vessel walls as part of thehealing process. and actually, that’s vasculitis in a nutshell.the different types of vasculitis for the most part only vary depending on how theyare triggered and where in the body they cause problems. people with vasculitis have generalized symptomscaused by the inflammatory response of the immune system. symptoms like fever, weightloss, fatigue, etc. more specific symptoms

occur usually based off where in body thevasculitis is occurring, and which organ is supplied by that blood vessel. reduced bloodflow caused by vasculitis can cause organ ischemia which can happen in two ways. first,blood cells clump onto the exposed tissue factor and collagen on the inside of bloodvessels forming blood clots that and can restrict blood flow. the second way is caused by thehealing process of the blood vessel. as fibrin is deposited in the vessel wall, the wallsbecome thicker and bulge into the vessel, reducing the diameter of the vessel lumen. alright, now that we have the general ideaof vasculitis covered, let’s take a look at some specific conditions, starting withthe large-vessel vasculitides.

giant cell arteritis is a vasculitis thataffects branches of the carotid arteries. vasculitis in the temporal branch of the carotidartery is the most common location and causes headaches. vasculitis in the ophthalmic arterycan cause visual disturbances, and vasculitis in any of the arteries that supply the jawmuscles can cause pain when someone chews food - called claudication. giant cell arteritisaffects older individuals (typically more than 50 years old) and women more than men,so a grandmother would be in a high-risk group. classically, this type of vasculitis causeslots of inflammation and it results in a really high erythrocyte sedimentation rate (or esrfor short) - sometimes over 100! in giant cell arteritis, a biopsy of the affected arterywill show giant cells embedded in the internal

elastic lamina, which is a thin layer of elastictissue that separates the tunica intima and the tunica media. to be clear, these giantcells are actually not individual cells at all, but rather granulomas - a group of monocytesthat are packed tightly together, and look like one giant cell. now giant cell arteritisis segmental, which means that if you look at the entirety of an affected artery, you’llsee only sections of the artery are actually affected. this means that when biopsies aredone, you have to take a long section of the artery and examine it under a microscope.it also means that, if you don’t see any affected tissue, you can’t for sure ruleout the disease because it’s possible you took an unaffected section of the blood vessel.you can treat people with giant cell artertitis

by giving them corticosteroids, which weakensthe immune response. people whose ophthalmic artery is affected and don’t receive treatmentare at a high risk of blindness, again because poor blood flow to the eyes causes ischemiaand irreversible blindness. alright, so another large-cell vasculitisis called takayasu arteritis, and it’s very similar to giant cell arteritis except fortwo key differences. one is that it usually affects asian women that are under 40 yearsold where giant cell arteritis usually affects people over the age of 60. and two, it affectsthe arteries that branch off from the aortic arch, particularly around the branch points.if the inflammation occurs around aortic branches that serve the upper extremities, it causesa weak or nonexistent pulse. if the inflammation

occurs around the aortic branch that servesthe head, then it causes visual and neurological symptoms. histopathologically it’s quitesimilar to giant cell arteritis because in takayasu arteritis you still see giant cellsand granulomatous inflammation in the internal elastic lamina of the blood vessel. in addition,the erythrocyte sedimentation rate will be elevated, and takayasu arteritis is treatedwith corticosteroids. let’s move onto medium-vessel vasculitisdiseases. these vasculitis diseases typically affect a wide range of muscular arteries thatsupply organs, which gives the conditions a wide range of possible symptoms. the mostcommon type of all vasculitides is kawasaki disease, and we’ve got a separate videoon kawasaki disease, but for now it’s important

to note that it affects the coronary arteries,the muscular arteries serving the heart. next there’s polyarteritis nodosa, whichis thought to occur when the immune cells directly attack the endothelium, confusingit with hepatitis b virus. now, polyarteritis nodosa causes transmural inflammation, whichmeans the entire wall, the tunica intima, media, and adventitia are all affected. thisinflammation causes the vascular wall to die through all three layers of the artery andfibrosis occurs as the vascular wall heals, this process is called fibrinoid necrosis.the fibrosed vessel wall is left weak and prone to aneurysms, so some areas start tobulge out through the weakened walls. so if you step back and look at the artery you seethese fibrotic aneurysms which are hard bulges

down the length of the artery, and they looklike a “string of beads” on angiogram. this pattern is quite unique among the variousvasculitides. organ ischemia in the distribution of affected arteries is the main complication.if the renal arteries are affected, then a person will have hypertension (remember kidneysregulate blood volume). if the mesenteric artery is affected, a person can have mesentericischemia and severe abdominal pain and gastrointestinal bleeding. if the arteries affecting the brainare affected it can cause neurological symptoms, and if arteries supply the skin are affectedthen it can lead to skin lesions. treatment is aimed at reducing the vessel inflammationand generally includes corticosteroids. another medium-vessel vasculitis is buerger’sdisease, named for a nyc pathologist not a

hamburger. it’s other name is thromboangiitisobliterans, which literally translates to clot vessel inflammation blockage, and asthe name suggests this vasculitis is notoriously for causing blood clots in tiny arteries inthe fingers and toes, which leads to ulcers and eventually dead tissue in these digitsand eventual autoamputation. not fun. buerger’s disease typically affects men between theages of 20-40 years and the biggest risk factor for this vasculitis is the use of tobaccoproducts. in fact, the thought is that tobacco might be the trigger for the autoimmune responseagainst blood vessel. stopping the use of tobacco actually slows down (but doesn’tnecessarily stop) the disease and need for amputations in most patients.

alright onto small-vessel vasculitis. small-vesselvasculitis affects small vessels like arterioles, capillaries, and venules. in the diseases,b-cells mistakenly target their antibodies to granules made by a person’s own neutrophils.in a sense, one immune cell attacking another. the antibodies are called “anti-neutrophiliccytoplasmic antibodies” or ancas for short and they are mainly of the igg type. the disease granulomatosis with polyangiitis(gpa) which used to be called wegener’s granulomatosis, is one of these small vesselvasculitides. the b-cells release an autoantibody called cytoplasmic antineutrophil cytoplasmicantibody or c-anca. yep, the name is hilariously redundant - with cytoplasmic included twiceto drive home the point. c-anca targets and

bind to a specific neutrophil granule calledproteinase 3 which is embedded in the membrane of some neutrophils. once c-anca binds tothe neutrophil, it causes the neutrophil to release oxygen free radicals, which enterthe nearby endothelial cells damaging them indirectly and causing vasculitis. on a biopsy,you can see evidence of inflammation and granulomas in the blood vessel wall. gpa affects thenasopharynx, lungs, and kidneys and usually occurs in middle-aged males. people with thedisease can have chronic pain caused by sinusitis or bloody mucus from ulcers within the nose.over time, the nose itself may even cave in or curl, a condition called a saddle nosedeformity. blood vessel inflammation in the lungs and air passages can also make breathingmore difficult causing air passages to constrict,

and ulcers can form causing bloody coughing.in the kidneys, the inflammation restricts blood flow to the glomeruli, causing themto die and leading to decreased urine production and an increase in blood pressure since thekidneys are no longer as efficient at regulating blood volume. gpa is typically treated withcorticosteroids and cyclophosphamide, but relapses in the disease are common, and thatmakes sense. the presence of c-anca is the main cause of the disease, and if it keepsattacking the granules from within neutrophils, there is a good chance the disease will return. another small-vessel vasculitis that is verysimilar to granulomatosis with polyangiitis is microscopic polyangiitis. it’s so similarin fact, that you need to rely on some clues

to help distinguish them. microscopic polyangiitisdoes not affect the blood vessels of the nose/sinuses, only the kidneys and lungs. you also won’tsee the granulomas in the blood vessel walls like you would in granulomatosis with polyangiitis.the third difference is you won’t find c-anca antibodies. instead you’ll find p-anca antibodies(the p stand for perinuclear), which is just a different type of anti-neutrophilic cytoplasmicantibody reacting with the neutrophil granule myeloperoxidase instead of proteinase 3. youtreat microscopic polyangiitis the same way you treat granulomatosis with polyangiitis,corticosteroids and cyclophosphamide, and it’s also common for it to relapse. churg-strauss syndrome is very similar toboth granulomatosis with polyangiitis and

microscopic polyangiitis. it too is causedby p-anca antibodies and it causes similar symptoms such as sinusitis, lung damage, andkidney damage, but it also causes gastrointestinal, skin, nerve, and heart damage like some medium-vesselvasculitis diseases. a lot of the time churg-strauss syndrome ismistaken as allergies and asthma because they all have similar symptoms. that, and likeallergies and asthma, churg-strauss causes a lot of eosinophils to float around in theblood. actually people who have asthma and peripheral eosinophilia are more likely todevelop churg-strauss syndrome because they both have elevated eosinophils. also justlike granulomatosis with polyangiiti, granulomas can form.

next up, henoch-schonlein purpura. now unlikethe other small vessel vasculitis diseases we’ve talked about henoch-schonlein purpura(abbreviated at hsp) doesn’t involve anca antibodies. instead, we find elevated levelsof the iga antibodies floating around in the blood. now iga is an awesome antibody thatis found in our mucosal cells, which are cells that are in some way exposed to the outsideworld, for example cells in our lungs and our gastrointestinal tract. in hsp, the person starts making iga thatis directly targeted at their own endothelial cells because of molecular mimicry. this goesagainst the general trend of small-vessel vasculitides being the result of indirectdamage. symptoms depend on where the iga-mediated

attack on small blood vessels happens. sometypical places is the skin blood vessels around the buttocks and legs, which leads to significantskin discolouration that looks like blood is pooling under the skin surface - calledpurpura. one indication that the disease is henoch-schonlein is that the skin discolorationis palpable, as in you can feel it raise above the normal skin. remember the fibrosis ofthe blood vessel walls hardens and makes it palpable, just like in polyarteritis nodosa.if the iga attacks the blood vessels in the gastrointestinal tract it can cause abdominalpain, and if it attacks the blood vessels in the kidneys, it can lead to hematuria (bloodin the urine) and eventually affect the kidney’s function which is called iga nephropathy.

just like the other small-vessel vasculitisdiseases, henoch-schonlein purpurpa resolves on its own but it can reoccur. generally itis only treated with steroids if the symptoms are severe. and there you go! that’s vasculitis!