SYSTEMIC LUPUS ERYTHEMATOSUS-SLE-

Oral Manifestations and adverse effects of Lupus in oral cavity

Author: Dr. Boban Fidanoski, DMD

Definition

Systemic Lupus Erythematosus is chronic inflammatory multisystem disease of unknown etiology. It is an autoimmune disease where body’s immune system (antibodies in this case referred to as autoantibodies) mistakenly attacks its own tissues, causing multi-organ inflammation and diverse clinical manifestations with domination of peripheral symmetric polyarthritis of small and large joints. SLE is characterized with periods of exacerbation and remission.

Origins of the name: Systemic Lupus Erythematosus

“Lupus” is Latin for wolf, “Erythro” in Greek stands for red, and Systemic is English word meaning that multiple organs are involved. One theory explains that this disease has gotten its name because it is similar to the attacks of a wolf on humans with its severity, random spots of attack and repetitiveness. 

 Pathogenesis:

SLE results in tissue damage caused by attack of autoantibodies and immune complexes. It involves polyclonal and antigen-specific T and B lymphocyte hyperactivity. T cell help in production of autoantibodies is critical for development of full-blown disease.

Proposed Etiology:

Definitive etiology is still unknown. We could only hypothesize what causes this disease is: genetics, environmental factors (sun exposure to UV light), estrogen (prepubertal and postmenopausal women have similar incidence to men; men with SLE have higher concentration of estrogenic metabolites), infection (viral: non-specific stimulant of immune response, medications (Dilantin-anticonvulsant), oral contraceptive pills are associated with exacerbation (they should be avoided in SLE patients). 25% of SLE patients have experienced false-positive tests for syphilis due to circulating lupus anticoagulant in the blood.

 Differential Diagnosis:

Diagnostic criteria updated by American College of Rheumatology in 1997 states that at least 4 or more of 11 (7 clinical and 4 laboratory) criteria must be present serially or simultaneously:

Diagnostic Criteria Description

Clinical

1. Malar rash Classic “butterfly rash”; sparing of nasolabial folds, no scarring2. Discoid rash; May cause scarring since invasion of basement membrane3. Photosensitivity; Skin rush in reaction to sunlight4. Oral/nasal ulcers; Usually painless5. Arthritis; Symmetric, involving 2 or more small or large peripheral joints, non-erosive6. Serositis; Pleuritis or Pericarditis7. Neurologic disorder; Seizures or Psychosis

Laboratory

8. Renal disorder; Proteinuria9. Hematologic disorder; Hemolytic anemia, Leukopenia, Lymphopenia, Thrombocytopenia10. Immunologic disorder; Anti-double stranded DNA Ab (50% of patients), anti-Sm Ab (25-60% of patients), anti-phospholipid Ab.11. Antinuclear antibody –(ANA); Most sensitive test (present in 90%of the patients)

Laboratory tests that will determine diagnosis of Lupus:

• Serologic diagnosis made by high titre of ANA detected by immunofluorescence, but this test doesn’t determine diagnosis because many other autoimmune disease have positive ANA test• Anti-dsDNA antibodies detected by Crithidia test and anti-Sm antibodies are specific for SLE (95-98% of the cases) and these tests determine the diagnosis of Lupus.

Signs and Symptoms:

1. MusculoskeletalThe most common manifestations of SLE are Arthralgias and Nonerosive Arthritis occurs in 95% of patients, it is symmetric and involves small joints of hands, wrists, and feet).There is also avascular necrosis (cause of pain, along with arthritis) and myositis.2. DermatologicAbnormalities of the skin, hair or mucous membranes are second most common manifestation of SLE, occurring in 85% of patients. The most common skin manifestation is the classic malar butterfly rash, an erythematous rash covering both cheeks and the bridge of the nose, with sparing of the nasolabial folds.The second most common skin manifestation is maculopapular rush that can be located anywhere on the body. Also are present: nasal/genital ulcers, panniculitis, alopecia, urticaria and purpura. 

 3. Oral Painless, shallow oral ulcers, most often occur on the hard and soft palate. There is also a mild involvement of mucosal ulcers as symptom of this disease. Oral ulcers occur at onset in 11% of patients, while at any time are present in 30% of patients. The lesions appear as maculae (red patches) that will later transform into irregular erosions and ulcers which often heal with scarring. Purpuric lesion such as ecchymoses and petechiae may occur.In 30% of the cases, pathology of major salivary glands may occur leading to secondary Sjogren’s syndrome and severe Xerostomia 

 

 

 4. GastrointestinalRenal involvement occurs in about 50% of patients, with only few % with irreversible changes. Proteinuria is the most common clinical sign. Other signs are: Pancreatitis, Lupus Enteropathy, Hepatitis and Hepatomegaly5. SystemicFever, Malaise/Fatigue, Lymphadenopathy, Weight loss6. Cardio-VascularPericarditis is the most common cardiac manifestation, occurs up to 30% of patients. Raynaud’s phenomenon, Thrombosis, Vasculitis, Livedo reticularis, Hemolytic anemia (most common vascular manifestation, in almost all patients), Leukopenia (50% of patients), Lymphopenia, Thrombocytopenia.7. OphtalmicConjunctivitis, Episcleritis, Keratokonjuctivitis (occurs in 20% of patients)8. PulmonaryInterstitial lung disease, Pulmonary hypertension, Alveolar hemorrhage, and Pleuritis.9. NeurologicalDepression, Personality disorder, Cerebritis, Transverse myelitis, Seizures, Headache and

Peripheral neuropathy

First symptoms to occur: 1. Fatigue 2. Myalgias 3. Arthtritis

Radiographic characteristics:

Radiographically, the arthritis of SLE is non-erosive. This is helpful for differential diagnosis with Rheumatoid Arthritis where there is bone erosion on radiographs. 

 Microscopic features / histoanalysis:

Three histological lesions are most characteristic of SLE:1. Onion-skin lesions – found in arteries of the spleen, which consist of concentric layers of fibrosis surrounding the vessel2. Libman-Sacks verrucous endocarditis: vegetations on heart valves3. Hematoxylin bodies: globular masses of bluish, dense, homogenous material seen on hematoxylin and eosin stain.

Microscopic features of oral lesions:

Histologically, lesions reveal lichenoid mucositis with perivascular exudate and thickening of basement membrane.

Demographics/Epidemiology:

Prevalence: 0.05%, 15 to 50 per 100,000 population in USA.female:male ratio = 10:1 (90% of cases are in women) predominantly in young women due

to higher levels of estrogen, while at premenstrual and postmenopauzal women, ratio with male decreases to 3:1 More common and severe in Blacks and Asians.

Treatment:

Systemic Lupus Erythematosus is a disease without a known cure, so treatment is based on relieving symptoms, suppressing inflammation, and preventing future pathology. Symptomatic treatment is tailored for the organ involved and for severity of the disease: use of topical sunscreen, avoid UV light and estrogens, use of NSAID’s for arthritis, use of antimalarials for dermatologic manifestations, use of topical steroids for rash, use of systemic steroids for prevention of end organ damage. Calcium and Vitamin D to fight osteoporosis, use of Corticosteroids as immunosuppressant drugs for serious organ involvement (e.g. Cerebritis, nephritis). All medications used to treat SLE require periodic monitoring for potential toxicities.

Adverse effects of Lupus therapy in oral cavity:Long term use of medications to control Lupus can induce significant intra-oral pathology.Corticosteroids: can lead to root canal calcification, delay of tooth eruptions and root dilaceration.Steroids: can cause necrotizing ulcerative gingivitis.NSAID’s: can induce gingival bleeding, but because there is a possibility NSAID’s to inhibit alveolar bone resorption, periodontal health in some patients with Lupus has been found improved due to intake of these medications.Cyclosporine: is a common cause of gingival enlargement (hyperplasia).Immunosuppressive treatment: fights against intra-oral infections but promotes Candidiasis and Herpes Simplex Virus infections. 

 

 Treatment of adverse effects of Lupus therapy in oral cavity :Preventive dental hygiene care in Lupus patients is very important. Chlorhexidine mouthwashes could help contain periodontal disease. Mucous membrane ulcers can be treated with hydrogen peroxide gargle, buttermilk gargle, or steroid impregnated gel. Intralesional injection of corticosteroids are also effective. Bacterial, viral and fungal infection should be treated with conventional, proven therapy specific for the infection present. Dental procedures should not be undertaken on patients with active Lupus, or if necessary, antibiotic premedication is advised, due to high incidence of bacterial endocarditis. 

 Lupus prophylaxis before dental hygiene treatment:

Lupus is considered as high-risk category of disease by The American National Guideline Clearinghouse and American Academy of Dermatology so they recommend that patients with this kind of condition require antibiotic premedication before dental treatment.

Prognosis:

Survival in patients with SLE is 90 to 95% at 2 years, 82 to 90% at 5 years, 71 to 80% at 10 years, and 63 to 75% at 20 years. Disability in SLE patients is common. 20% of patients experience remissions. Infections due to immunosuppressive therapy and renal failure are the leading causes of death in the first decade of disease. Thromboembolic events are frequent causes of death in the second decade.

Subsets of Lupus:

1. Idiopathic 2. Discoid 3. Subacute cutaneous (ANA negative)4. Late-onset 5. Neonatal6. Drug-induced

 

Quotes about Lupus:

"Homo homini Lupus est." – Plautus, year 254 before Christ. (Latin phrase meaning: Man is a wolf to his fellow-man)

’It’s never Lupus” – Dr. Gregory House M.D.

______________________________________________________________________

Bibliography:

Written literature:

Andreoli, T.E. et al. (1997): Cecil Essentials of Medicine; (4-th ed.)-W.B.Saunders Company,U.S.A.Fauci, A.S. et al. (1998): Harrison’s principles of internal medicine; (14-th ed.)-The McGraw-Hill Companies INC.,U.S.A.Shiau, C.J., Toren, A.J. (2006): The Toronto Notes 2006: Comprehensive Medical References, 26-nd Ed., Canada.Tierney, L.M. (1997): Pocket guide to the essentials of diagnosis and treatment; (1-th ed.)- Lange medical book, U.S.A. Younger-Lewis,C.; Complete home medical guide;Canadian Medical Association (1-st ed.), Dk Publishing Inc.

Internet resources:

Long, R.G. et al. (1998): Oral manifestations of systemic diseases, The Mount Sinai Journal of Medicine(N.Y.-USA) Vol. 65, No.5-6http://www.mssm.edu/msjournal/65/01_Long.pdfSultan, S.M. et al. (1999): A review of gastrointestinal manifestations of systemic lupus erythematosus, (Oxford Journal of Rheumatology, United Kingdom) Vol. 38, No.10http://rheumatology.oxfordjournals.org/cgi/content/full/38/10/917#SEC1

Photographs:

http://www.merckmedicus.com/ppdocs/us/hcp/content/white/chapters/white-ch-010-s002.htmNorfolk lupus group: www.norfolklupus.co.ukwww.allaboutarthritis.comwww.zhub.com/pathology/listings/16.htmlhttp://dermatlas.med.jhmi.edu 

author: Boban Fidanoski; researched for the purposes of the studies at the CCDH and published on-line in July-August 2007

 

http://www.fidanoski.ca/sle/index.html

manifestasi oral pada penyakit lupus eritematosus

Lupus erithematosus adalah suatu kondisi inflamasi yang berhubungan dengan sistem imunologis yang menyebabkan kerusakan multi organ.. Lupus Eritematosus didefinisikan sebagai gangguan autoimun, dimana sistem tubuh menyerang jaringannya sendiri.

Klasifikasi Menurut Myers SA and Mary HE, (2001) lupus eritematosus dibagi ke dalam 4 bagian besar, yaitu :

1. Chronic Cutaneous Lupus Erythematosus (CCLE)

Dibagi lagi ke dalam 2 subtipe :

a. Discoid Lupus Erythematosus (DLE)

Dibagi juga dalam beberapa subtipe yang jarang terjadi:

1) Palmar-palmar Lupus Erythematosus

2) Oral Discoid lupus Erythematosus

3) Lupus Erythematosus panniculitis

b. Hypertrophic Lupus Erythematosus (HLE)

2. Subacute Cutaneous Lupus Erythematosus (SCLE)

Memiliki subtype yang jarang terjadi yaitu : Neonatal lupus Erythematosus (NLE)

3. Systemic Lupus Erythematosus (SLE)

4. Drug-Induced Lupus Erythematosus (DILE)

Menurut European Assosiation of Oral Medicine (2005) lupus eritematosus diklasifikasikan menjadi :

1. Discoid Lupus Erythematosus (DLE)

2. Systemic Lupus Erythematosus (SLE)

3. Bullous form

4. Neonatal form (NLE)

5. Acute Cutaneous form (ACLE)

6. Subacute Cutaneous form (SCLE)

7. Chronic Cutaneous form (CCLE)

8. Childhood onset (CSLE)

9. Drug Induced (DILE)

Epidemiologi

Lupus Erithematosus merupakan penyakit yang jarang terjadi. Di seluruh dunia diperkirakan terdapat 5 juta orang mengidap lupus, sedangkan di Amerika Serikat diperkirakan antara 270.000-1.500.000 orang mengidap lupus. Penyakit lupus ditemukan baik pada wanita maupun pria, tetapi wanita lebih banyak dibanding pria yaitu 9:1, umumnya pada usia 18-65 tahun tetapi paling sering antara usia 25-45 tahun, walaupun dapat juga dijumpai pada anak usia 10 tahun . SLE ditemukan lebih banyak pada wanita keturunan ras Afrika-Amerika, Asia, Hispanik, dan dipengaruhi faktor sosioekonomi. Sebuah penelitian epidemiologi melaporkan insidensi rata-rata pada pria ras kaukasia yaitu 0,3-0,9 (per 100.000 orangper tahun); 0,7-2,5 pada pria keturunan ras Afrika-Amerika; 2,5-3,9 pada wanita ras Kaukasia; 8,1-11,4 pada wanita keturunan ras Afrika-Amerika. Menelusuri epidemiologi SLE merupakan hal yang sulit karena diagnosis dapat menjadi sukar dipahami .

Patogenesis

Etiologi lupus eritematosus, seperti halnya penyakit autoimun lain, adalah tidak diketahui . Terdapat dua teori mengenai etiologi lupus, yaitu teori yang pertama menyebutkan bahwa pada perkembangan penyakit mulai dari gambaran awal sampai timbul kerusakan didasari oleh produksi sirkulasi autoantibodi menjadi suatu nukleoprotein, yaitu antinuclear antibodies (ANA). Proses awal tidak diketahui tetapi kemungkinan terjadi mutasi gen yang berhubungan dengan sel yang mengalami apoptosis yang melibatkan limfosit, kemudian limfosit bereaksi menyerang selnya sendiri. Teori lainnya menyatakan autoantibodi lupus eritematosus merupakan lanjutan dari reaksi silang antigen eksogen seperti retrovirus RNA .

Manifestasi Klinis

Manifestasi klinis lupus eritematosus secara umum penyakit lupus eritematosus sistemik atau lebih dikenal dengan istilah ”lupus”, memiliki manifestasi klinis yang bervariasi, dan melibatkan multiorgan yaitu sekitar 80% melibatkan persendian, kulit, dan darah; sekitar 30-50% melibatkan ginjal, jantung, sistem saraf, sekitar 50 % melibatkan ganguan gastrointestinal, sekitar 20 % melibatkan gangguan optalmik, dan sekitar 10-30% melibatkan trombosis arteri dan vena.

Secara umum tanda dan gejala dari lupus diantaranya adalah :

1. kelelahan (fatigue)

2. demam (fever)

3. penurunan berat badan atau sebaliknya

4. malar-rash (butterfly-shaped rash) pada muka

5. lesi di kulit yang bertambah buruk bila terpapar matahari

6. ganguan mulut

7. alopecia

8. raynaud’s phenomenom

9. nafas yang memendek

10. nyeri dada

11. dry eyes

12. ankietas

13. depresi

14. memory loss

Manifestasi pada kulit dapat berupa lesi ruam diskoid dan ruam malar. Ruam diskoid adalah ruam pada kulit leher, kepala, muka, telinga, dada, punggung, dan ekstremitas yang menimbul dan berbatas tegas, dengan diameter 5-10 mm, tidak gatal maupun nyeri. Pada kepala dapat menyebabkan alopecia yang permanen. Ruam malar adalah ruam yang menyerupai kupu-kupu pada wajah. Ruam-ruam tersebut dipicu oleh paparan cahaya matahari... Lesi-lesi tersebut penyebarannya bersifat sentrifugal dan dapat bersatu sehingga berbentuk ruam yang tidak beraturan. Dapat ditemukan pula berupa lesi kronis malignan, meskipun jarang, tetapi mengarah pada kanker kulit nonmelanoma. Lesi mirip lichen planus (LP) juga dapat ditemukan dan seringkali tumpang tindih antara LE dengan LP atau lesi dapat timbul juga karena penggunaan terapi dengan antimalaria. Penyembuhan dari lesi diskoid akan meninggalkan jaringan yang atropi dan jaringan parut.

Penyakit lupus pada sistem saraf pusat (SSP) berhubungan dengan beberapa sindrom neurologik yang berbeda. Manifestasi neuropsikiatrik lupus bervariasi dari ringan (seperti sakit kepala) sampai berat (seperti stroke). Spektrum manifestasi klinis lupus SSP sangat luas sehingga merupakan suatu sindrom klinis utama pada lupus SSP yaitu berupa vaskulitis SSP yang merupakan inflamasi pada pembuluh darah otak karena aktivitas lupus, dan merupakan satu dari dua sindrom spesifik lupus SSP yang dibuat oleh American College of Rheumatology.Manifestasi utama dari Lupus SSP :

1. Disfungsi kognitif ( tidak dapat berpikir jernih, defisit memori)

2. Sakit kepala

3. Seizure

4. berubahnya kewaspadaan mental (stupor atau koma)

5. Meningitis aseptik

6. Stroke (gangguan suplai darah pada bagian – bagian otak yang berbeda)

7. Periperal neuropathy ( contoh : hilang rasa,rasa geli, rasa terbakar pada tangan dan kaki)

8. Gangguan pergerakan

9. Myelitis (gangguan pada spinal cord)

10. visual alternation

11. Autonomic neuropathy (contoh: reaksi flushing atau mottled skin)

Diagnosis

Diagnosis lupus sulit ditegakan karena gejala dan tanda tiap individu bisa berbeda, bisa berubah dari seiring berjalanya waktu dan overlap dengan penyakit lain yang memiliki gejala yang sama. Alsan inilah yang sangat dipertimbangkan oleh para klinisi untuk benar-benar mendiagnosa lupus, bila tanda dan gejala sudah jelas mengarah ke lupus. Untuk membedakan lupus dengan penyakit lain, ahli medis dariAmerican Rheumatism Association (ACR) telah nenetapkan 11 kriteria kelainan yang terjadi dalam mendiagnosis lupus eritematosus yaitu

bila ada 4 poin dari 11 manifestasi kelainan. Kriteria ini dikemukan oleh Dr Graham Hughes pada tahun 1982 yaitu :

1. ruam malar

2. ruam diskoid

3. fotosensitifitas

4. ulser pada rongga mulut

5. artritis

6. serositis

7. gangguan pada ginjal

8. gangguan pada sistem saraf

9. gangguan perdarahan

10. gangguan imunologis

11. antibodi antinuklear

Pemeriksaan penunjang dilakukan untuk menyingkirkan diagnosa penyakit lain, mengetahui fungsi organ yang menjadi predileksi serangan lupus (tes fungsi ginjal) atau memantau perjalanan penyakit. Pemeriksaan laboratorium yang berguna diantaranya adalah hematologi lengkap, tes fungsi ginjal dan hati, urinalisis, dan pemeriksaan serologi.

Antibodi Signifikansi

Antinuclear Antibodi (ANA) Diindikasikan untuk Reumatoid

Tidak spesifik untuk SLE

Antibody t double-stranded DNA

Disarankan untuk sistemik lupus Eritromatosus (SLE)

Prediktif bila ginjal terlibat

Anti-Smith antibody Prediktif bila ginjal terlibat

Anti-Ro antibody Disarankan bila ada sekunder sindroma Sjögren’s

Antiphospolipid antibody Meningkatkan resiko tromboembolisme

Tabel. Tes serologi untuk penyakit lupus eritromatosus

Tujuan penatalaksanaan pada penderita lupus adalah untuk mencegah dan melawan proses inflamasi yang terjadi, meningkatkan keadaan umum penderita, mengontrol lesi kulit yang ada, mengurangi bekas luka, dan untuk mencegah pertumbuhan lesi lebih lanjut. Penderita lupus juga perlu mengetahui kemungkinan adanya manifestasi sistemik yang beresiko serius, sehingga perlu dilakukan pemeriksaan klinis dan pemeriksaan laboratorium secara reguler Pengobatan sesuai standar medis meliputi pemberian kortikosteroid (topikal atau intralesi) dan antimalaria (hydroxychloroquine), Diantara agen imunosupresif (cyclophosphamide, azathioprine dan mycophenolet) dapat digunakan pada kasus lupus yang berat, namun juga memiliki efek samping yang berat .diantaranya adalah resiko rentan terkena infeksi, kerusakan hati, infertilitas dan kanker Pasien lupus yang memiliki lesi di kulit harus memakai pelindung kulit dari paparan sinar ultraviolet dengan menggunakan sun-block (SPF) minimal SPF 15 agar melindungi dan mencegah lesi tidak bertambah parah. Pengobatan lainya pada penyakit lupus eritromatosus adalah simptomatik sesuai dengan gejala yang muncul.

Manifestasi Oral Pada Penyakit Lupus EritromatosusLesi pada mukosa mulut merupakan yang tersering menjadi target pada lupus eritematosus, seperti pada diskoid lupus eritematosus dan lupus eritematosus sistemik. Lesi terlihat sebagai daerah eritematous yang berpusat dan dikelilingi oleh tepi putih yang meninggi. Lesi sering ditemukan pada palatum, mukosa bukal, dan palatum, dapat tidak spesifik dan terlihat seperti ulser tanpa rasa sakit. Ulserasi yang terdapat pada rongga mulut pada penyakit lupus menjadi tanda akibat vaskulitis.Sekitar 75% penderita lupus mengeluhkan gejala pada rongga mulut seperti rasa kering, rasa sakit, dan rasa terbakar terutama ketika makan makanan panas dan pedas. Infiltrasi limfosit kelenjar saliva minor ditemukan pada 50-75% pasien, baik mereka mengeluhkan adanya rasa kering pada mulut ataupun tidak.Salivary flow rate yang tidak terstimulasi menurun pada banyak penderita lupus eritematosus sistemik. Lupus eritematosus sistemik juga menjadi komponendiferensial diagnosis dari Sjogren’s Syndrome

Lesi spesifik pada rongga mulut penderita lupus eritematosus dapat berupa aphtae ( canker sores). Pada literatur, aphtae sering disebut juga sebagai stomatitis aphtous rekuren. Lesi ini mengenai 15% pada populasi normal. Lesi aphtae seringnya berukuran kecil ( kurang dari 1 cm), terasa sakit, dapat ditemukan pada mukosa bukal. Lesi pada lupus eritematosus cenderung lebih lama, lebih besar, dan terlihat pada palatum. Lesi oral pada penderita lupus diskoid menyerupai plak berwarna merah yang dikelilingi oleh daerah putih. Lesi ini mirip dengan lichen planus.

http://mixmedic.blogspot.com/2010/10/manifestasi-oral-pada-penyakit-lupus.html

Video latihan SLE

http://voices.yahoo.com/lupus-periodontal-disease-oral-hygiene-tmj-risks-695600.html

Facts About Systemic Lupus

John Mallozzi, Yahoo! Contributor Network

Jun 4, 2010 "Share your voice on Yahoo! websites. Start Here."

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Systemic lupus is an auto-immune disease with no known cause or cure. A

person is naturally equipped with anti-bodies that attack harmful intrusions

within the body. Within the body of a person who has Systemic lupus the

anti-bodies for unknown reasons also attack and damage healthy productive

cells and tissue. More women are diagnosed with Systemic lupus than men

with symptoms that affect a wide range of a person's body including organs,

joints, and skin.

Flare-up

Symptoms often come and go with no predictable pattern, which are

referred to as a 'flare-up'. A 'flare-up' may be ignited by numerous factors

but a common factor among many people includes direct sun light exposure.

Diagnosis

Systemic lupus is considered one of the most difficult disorders to diagnose,

and people with Systemic lupus often suffer for several years experiencing

numerous misdiagnoses including severe fatigue or stress.

Skin rash

A skin rash often appears on a person's face consisting of tiny painless red

dots that spread along the nose, cheeks, and around the eyes forming the

pattern of a butterfly or a wolf's face.

Joint pain

A person with Systemic lupus experiences arthritis type pain in their joints,

fingers, knees, feet, arms, wrists, and hands which often become completely

stiff and swollen. Fingertips often lack cold temperature sensitivity and may

even appear pale or purple.

Organ damage

Several organs are often attacked during a 'flare-up' increasing the

possibility of causing irreversible damage even death. The kidneys become

damaged in a way that they are unable to process and remove excess waste.

Damage to the lungs lead to severe chest pain while breathing. People with

Systemic lupus are also at a high risk of developing heart conditions that

may lead to a heart attack.

Treatment

Once a person is diagnosed with Systemic lupus treatment is designed to

reduce or prevent 'flare-up's' and organ and tissue damage.

http://voices.yahoo.com/facts-systemic-lupus-6160664.html?cat=70

MAYOCLINIC

http://www.mayoclinic.com/health/lupus/DS00115/DSECTION=risk-factors