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Systemic Lupus Erythematosus, ANAs, etc'

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Title: Systemic Lupus Erythematosus, ANAs, etc'


1
Systemic Lupus Erythematosus, ANAs, etc.
  • Hermine Brunner, MD MSc
  • Assistant Professor of Pediatrics
  • Division of Rheumatology
  • Cincinnati Childrens Hospital Medical Center

2
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)-
DEFINITION/DIAGNOSIS
  • Prototype of auto-immune, multi-system disease
  • Onset maybe acute, episodic, or insidious
  • Anything can happen to any organ system
  • Antinuclear antibodies are almost always present
  • Serositis Immune complexes

3
SLE - EPIDEMIOLOGY
  • 20 of all SLE is pediatric age group
  • Incidence 0.6/100,000
  • Prevalence 5-10/100,000
  • Overall 5-10,000 children in U.S.A.
  • Approximately 5 of new diagnoses in Pediatric
    Rheumatology clinics
  • SLE JRA/110 ratio

4
Pediatric SLE versus Adult Onset SLE
  • More severe symptoms at onset
  • More aggressive clinical course than adults
  • Increased need for corticosteroid 77 vs 16
  • Children tend to die during acute SLE phase
  • Adults tend to die secondary to complications
  • African American and Hispanic children have a
    higher incidence of disease
  • African American patients have
  • higher prevalence and severity of renal
  • higher prevalence neuropsychiatric SLE
  • higher titers of anti-DNA and anti-SSA antibodies
    in association with cardiac disease

5
Genetics in SLE
  • Eight of the best supported SLE susceptibility
    loci are the following
  • 1q23
  • 1q25-31
  • 1q41-42
  • 2q35-37
  • 4p16-15.2
  • 6p11-21
  • 12p24
  • 16q12

Tsao, BP, Curr Opinion Rheum, 2004 16 513-521
6
THE 1982 REVISED CRITERIA FOR CLASSIFICATION OF
SLE
  • Malar rash Serositis
  • Discoid rash Renal disorder
  • Photosensitivity Neurologic disorder
  • Oral ulcers Hematologic disorder
  • Arthritis Immunologic disorder
  • Antinuclear antibody

Revised 1997
7
THE 1982 REVISED CRITERIA FOR CLASSIFICATION OF
SLE
  • For the purpose of identifying patients in
    clinical studies, a person shall be said to have
    SLE if any 4 or more of the 11 criteria are
    present, serially or simultaneously, during any
    interval of observation.
  • Sensitivity 96
  • Specificity 96 in adults
  • Similar percentages in pediatric group.

8
MALAR RASH
  • Fixed erythema, flat or raised, over the malar
    eminences
  • tending to spare the nasolabial folds

9
DISCOID RASH
  • Erythematous raised patches with adherent
    keratotic scaling and follicular plugging
  • Atrophic scarring may occur in older lesions

10
PHOTOSENSITIVITY
  • Skin rash as a result of unusual reaction to
    sunlight
  • by patient history or physician observation

11
ORAL ULCERS
  • Oral or nasopharyngeal ulceration
  • Usually painless, observed by a physician

12
ARTHRITIS
  • Nonerosive arthritis involving 2 or more
    peripheral joints
  • Characterized by tenderness, swelling, or joint
    effusion.

13
SEROSITIS
  • A) Pleuritis - convincing history of pleuritic
    pain or rub heard by a physician or evidence of
    pleural effusion
  • OR
  • B) Pericarditis - documented by ECG or rub or
    evidence of pericardial effusion

14
RENAL DISORDER
  • A) Persistent proteinuria greater than 0.5
    grams per day or greater than 3 if
    quantitation not performed
  • OR
  • B) Cellular casts - may be red cell,hemoglobin,
    granular, tubular, or mixed

15
NEUROLOGIC DISORDER
  • A) Seizures - in the absence of offending drugs
    or known metabolic derangements, e.g.,
    uremia, ketoacidosis, or electrolyte imbalance
  • OR
  • B) Psychosis - in the absence of offending drugs
    or known metabolic derangements, e.g. uremia,
    ketoacidosis, or electrolyte imbalance

16
HEMATOLOGIC DISORDER
  • A) Hemolytic anemia - with reticulocytosis
  • OR
  • B) Leukopenia - less than 4,000/mm3 total on 2
    or more occasions
  • OR
  • C) Lymphopenia - less than 1,500/mm3 on 2 or
    more occasions
  • OR
  • D) Thrombocytopenia - less than 100,000/mm3 in
    the absence of offending drugs

17
IMMUNOLOGIC DISORDER
  • A) Anti-dsDNA antibody to native DNA in abnormal
    titer
  • OR
  • B) Anti-Sm presence of antibody to Sm nuclear
    antigen
  • OR
  • C) Antiphospholipid antibodies by positive IgG or
    IgM anticardiolipin antibodies or positive test
    for lupus anticoagulant

18
ANTINUCLEAR ANTIBODY
  • An abnormal titer of antinuclear antibody by
    immunofluorescence or an equivalent assay
  • at any point in time
  • and in the absence of drugs known to be
    associated with
  • drug-induced lupus syndrome

19
Drug-Induced Lupus
  • Minocycline (Minocin)
  • Phenytoin (Dilantin)
  • Carbamazepine (Tegretol)
  • Ethosuximide (Zarontin)

20
ANTINUCLEAR ANTIBODY
  • 120 - 140 Screening titer
  • 1 x titer
  • Pattern
  • speckled - ENAs
  • rim - ds DNA
  • homogeneous - DNA (LE prep)
  • nucleolar - Scl - 70

21
SLE
  • Tissue Specific Nuclear
  • Antibodies Antibodies
  • ATA Ro/SSA
  • Anti ASMA La/SSB
  • Anti-MITO RNP
  • Anti-LKM Sm
  • Anti-PC ds DNA
  • Hep-2 ss DNA

22
Arthralgia and Positive ANA or RF
  • Remember that objective signs of joint
    inflammation substantiate diagnosis of arthritis
  • Comprehensive review of systems may uncover clues
  • Perform a critical, complete physical examination
  • Serial re-evaluations may be necessary
  • Most children do not progress to a C.T.D.
  • Positive serologies may be seen in
  • Normal children - approximately 3-12
  • Response to infection

23
Persistent ANA
  • 24/108 children with musculoskeletal problems had
    positive ANA
  • 21/24 had persistent ANA, mean duration 38 mo
  • No patient developed an overt autoimmune or
    inflammatory disease, mean F/U 61 mo (13-138)
  • Conclusion a child with positive ANA and
    musculoskeletal problems , but with no evidence
    at presentation of AID or inflammatory disease is
    at low risk of developing such a disease.

Cabral, DA, et al Pediatrics 1992, 89(3)441-444
24
Outcome of Children referred to Pediatric
Rheumatology Clinic with a positive ANA but
without AID
  • 500 new patients reviewed, 113 had positive ANA
  • 72 (64) had an autoimmune disease AID,
  • 10 (9) were lost to F/U, 31 (27) had no
    AID,
  • Mean ANA titer 1160, varied pattern
  • Mean clinical F/U 37 mos
  • 25 (81) cleared their symptoms, 5 (16) had
    improvement, 1 developed autoimmune hepatitis
  • Prognosis with ANA is excellent in absence of
    AID at presentation

Deane, PMG, et al, Pediatrics 1995, 95892-895
25
Clinical Utility of Antinuclear ANA Tests in
ChildrenMcGhee JL et al, BMC Pediatrics 2004, 4
13
  • 110 pts referred to Rheum for ANA
  • 80 children with musculoskeletal problems
    syndromes
  • 10 pts subsequently dxd SLE, 1 MCTD, 1 Prim
    Raynauds, 18 with JIA
  • Nonurticarial rash more common in SLE, p0.007
  • Children with SLE were older 14.2 vs 11 yrs,
    p0.001
  • ANA gt 1640 was predictor for SLE while titers
    of lt1360 were negative predictors
  • Conclusion
  • Age and ANA titer assist in Dx SLE, no diagnostic
    value in Dx JRA
  • Remember the AID have objective evidence of
    disease!!!!!!!

26
SLE - CLINICAL MANIFESTATIONS
  • Most common signs/symptoms
  • Unexplained fever, any pattern
  • Malaise
  • Weight Loss
  • Arthralgia

27
SLE - MUCOCUTANEOUS INVOLVEMENT
  • Butterfly Rash - 1/3 at onset
  • Angiitic papules
  • Periungual erythema
  • Urticaria / angioedema
  • Palatal ulcer / aphthous ulcer
  • Alopecia

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30
SLE - MUCOCUTANEOUS INVOLVEMENT
  • Discoid lupus
  • Subacute cutaneous lupus
  • Livedo reticularis
  • Nailfold capillary changes
  • Vasculitic ulceration
  • Panniculitis
  • Nasal septal perforation

31
  • Ulcerated
  • leukocytoclastic
  • vasculitis in SLE

32
SLE - MUSCULOSKELETAL DISEASE
  • Arthralgia / Arthritis
  • Myalgia / Myositis
  • Ischemic necrosis of bone - AVN

33
SLE - VASCULOPATHY
  • Small vessel vasculitis
  • Palpable purpura
  • Raynauds phenomenon
  • Antiphospholipid antibody syndrome

34
SLE - CARDIAC INVOLVEMENT
  • Pericarditis
  • Myocarditis
  • Endocarditis, Libman-Sacks
  • Accelerated atherosclerosis

35
SLE - PLEUROPULMONARY DISEASE
  • Pleuritis/Pleural effusion
  • Infiltrates/Atelectasis
  • Acute lupus pneumonitis
  • Pulmonary hemorrhage
  • Shrinking lung - diaphragm dysfunction
  • Subclinical restrictive disease

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37
SLE - GASTROINTESTINAL MANIFESTATIONS
  • Anorexia, weight loss, nonspecific abdominal pain
  • Pancreatitis
  • Mesenteric arteritis
  • Esophageal dysmotility

38
SLE LIVER , SPLEEN LYMPH NODE
  • Generalized lymphadenopathy
  • Lupoid hepatitis vs SLE hepatic involvement
  • Functional asplenia

39
SLE - NEUROPSYCHIATRIC MANIFESTATIONS
  • Must be differentiated from infection or
    hypertensive or metabolic complications
  • Any level of the CNS/PNS can be affected
  • Thorough evaluation necessary - CSF, EEG, CT,
    MRI, EMG / NCV, NP testing

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SLE - NEUROPSYCHIATRIC INVOLVEMENT
  • Behavior/Personality changes, depression
  • Cognitive dysfunction
  • Psychosis
  • Seizures
  • Stroke
  • Chorea
  • Pseudotumor cerebri
  • Transverse myelitis
  • Peripheral neuropathy
  • Total of 19 manifestations described

42
SLE - RENAL INVOLVEMENT
  • Usually asymptomatic
  • Gross hematuria
  • Nephrotic syndrome
  • Acute renal failure
  • Hypertension
  • End stage renal failure

43
SLE - NEPHRITIS
  • Nephritis remains the most frequent cause of
    disease-related death.

44
WORLD HEALTH ORGANIZATION CLASSIFICATION OF LUPUS
NEPHRITIS
  • Class I Normal
  • Class II Mesangial
  • IIA Minimal alteration
  • IIB Mesangial glomerulitis
  • Class III Focal and segmental proliferative
    glomerulonephritis
  • Class IV Diffuse proliferative
    glomerulonephritis
  • Class V Membranous glomerulonephritis
  • Class VI Glomerular sclerosis

45
SLE - LABORATORY EVALUATION
  • Antinuclear antibody profile
  • Anti dsDNA abs, Sm abs
  • C3, C4, IgA, IgG, IgM
  • Direct Coombs, DAT
  • Antiphospholipid antibodies
  • ACLA - Anticardiolipin antibodies
  • LAC - Lupus anticoagulant
  • CBC with Diff, U/A, CMP, TSH, ESR

46
Comprehensive Evaluation of a Child with SLE
  • Cumulative medication burden
  • Serial DEXA while on corticosteroids
  • Lipid panels
  • Repeat APA profile, ? Frequency
  • HRQL and damage indices, SLEDAI, SDI
  • Neuropsychiatric testing ?
  • ECHO
  • Complement factor deficiency (C1q)

47
Long-term Management Issues
  • Long term morbidity of corticosteroids
  • short stature, cataracts, osteoporosis
  • How to manage ongoing active disease after
    multiple medications during childhood
  • Long term morbidity of immunosuppressive agents
  • Non-sustained durable disease ? remission
  • Cumulative risk re malignancy and premature
    ovarian failure

48
Therapeutic Goals in SLE Still Unmet Expectations
  • Rate of renal remission after first line therapy
    still 81 at best
  • Renal relapse in 1/3 pts mostly still
    immunosuppressed
  • 5- 20 experience ESRD 5-10 yrs after disease
    onset
  • Treatment related toxicity remains a concern
    osteoporosis, premature ovarian failure, severe
    infections, etc.
  • Prognostic factors have been identified but are
    difficult to modify in order to improve outcomes

49
Treatment Regimens for LN
  • Glucocorticoids plus cyclophosphamideinduction
    maintenance for 3 years
  • NIH protocol
  • Glucocorticoids plus low dose cyclophosphamide
    with maintenance with MMF or AZA
  • Immunoablative doses of cyclophosphamide
  • Autologous stem cell transplantation
  • Plasmapharesis is not recommended
  • Reviewed Houssian FA, J Am Soc Nephrol 2004 15
    2694

50
Sequential Therapies for WHO III- V
  • 60 adult SLE pts randomized 3 groups
  • 12 Class III, 46 Class IV and 1 Class Vb
  • All received initial therapy with
    Cyclophosphamide 0.5-1.0 gm/m² up to 7 pulses
  • Contd on 1) cyclophosphamide, 2) azathioprine
    1-3mg/kg, or 3)M ycophenolate mofetil (Cellcept,
    MMF) 0.5-3.0 gm/d for 1-3 years
  • 5 pts died- 4CYC, 1 MMF 5 CRF- 3 CYC,1 AZA, 1
    MMF
  • 72 month event free survival rate higher in MMF
    and AZA than in CYC (P0.05 and P0.009,
    respectively)
  • Incidence of hosp, amenorrhea, infections, nausea
    and vomiting lower in the MMF and AZA groups than
    in the CYC group

Contreras, G et al NEJM 350(10) 971-980, 2004
51
Targeted Immune Intervention
  • Directed against B Cells Rituximab, anti-CD20 B
    cell depleting monoclonal antibody
  • LJP 394, anti-dsDNA-producing B cells
  • Co-stimulatory signals CD40-CD40L (CD154)
    blockade CTLA41g, abatacept binding to CD80
    and CD86 prevents engagement to CD28 to T
    cells thereby prevents co-stimulation
  • Cytokine blockade IL10, INF-a

Houssian FA, J Am Soc Neprol, 2004 15 2694-2704
52
Major Clinical Syndromes in SLE Requiring
Vigilance
  • Antiphospholipid Antibody Syndrome with
    thrombosis
  • Premature atherosclerosis and marked risk of
    myocardial infarction
  • Neurocognitive dysfunction with deterioration of
    mental capacity
  • Iatrogenic syndromes of osteoporosis and
    premature ovarian failure 2 therapy

53
Case 1 9 yo AAF with SLE
  • Fever T 101-102?, 3-4 x/week
  • Weight loss
  • Swollen fingers
  • Facial, malar, and eyelid rash
  • Weakness
  • Gradual decline in school performance
  • Family history positive for arthritis in mother
    maternal aunt

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Case 1 Physical Examination
  • T 101.8?, Wt 27.1 kg (30), Ht 130.6 (40)
  • BP 90/50
  • Scleral/conjunctival injection
  • Nasal and oral ulcerations
  • Patchy parietal alopecia
  • Shoddy lymphadenopathy
  • Symmetric PIP swelling
  • Depressed affect

56
Case 1 Laboratory Investigation
  • Hgb 9.5 gm, WBC 4.05, 55 PMN
  • platelets 257,000
  • U/A essentially negative
  • RF negative
  • ANA 15120, diffuse, membranous
  • Ro (SSA) ?, La (SSB) ?, RNP ?, Sm ?,
  • ds DNA 15120, APA negative
  • ?C3-55 (83-177),?C4-4 (21-75),?IgG 3260
    (608-1572)
  • DAT ?

57
Case 1 Course
  • Within 6 months
  • pleural effusion, pulmonary infiltrates
    (prednisone)
  • Episodic photosensitive cutaneous flares
    (Plaquenil)
  • Digital angiitis
  • DPGN (WHO IV) ? progressive renal involvement ?
    HBP (cyclophosphamide, prednisone)
  • School failure, psychosocial disruption
  • Marked non-adherence to medication regimen
  • ESRD, TTP, cerebritis, hemodialysis, depression
  • Shunt infections, on/off transplantation registry

58
Cognitive Dysfunction in SLE
  • Variable between pts with overt NPSLE and nSLE
  • 52-80 NPSLE vs 27-40 nSLE
  • Verbal and non-verbal long-term memory, and
    visuospatial memory in both groups and
    visuoconstructional abilities in NPSLE
  • Coexistent depression amplifies the deficits
  • Maybe present without overt active SLE sxs

Monastero R, et al, J of the Neurological Sci
2001 18433-39
59
Case 2 Learn from old experience
  • 17 yo WF initially evaluated for rheumatoid
    arthritis with polyarthritis and ANA
  • History of photosensitive rash and subsequent
    development of pericarditis led to dx of SLE
  • Renal biopsy done WHO class II
  • Off/on low C3 and C4 and elevated dsDNA abs
  • Notable elevated cholesterol, LDL and
    triglycerides PLUS tobacco smoking for gt10 years

60
Case 2 continued
  • Had a full term normal pregnancy with healthy
    infant followed by a Bacteroides sepsis 5 days
    postpartum
  • Approximately 1 year later developed chest pain
  • Several ED visits later at adult EDs she was
    dxd with MI unable to stent 2º distal disease
  • Now cardiac invalid, continues to smoke tobacco
    and has active SLE
  • Multiple cholesterol lowering agents, Plaquenil

61
Risk Factors of Premature CVD in cSLE
  • Elevated levels of homocysteine
  • Metabolic syndrome with hyperinsulinemia
  • Hypertension
  • Nephrotic range proteinuria
  • Dyslipoproteinemia/hyperlipidemia
  • Arterial vasculitis
  • Antiphospholipid antibodies
  • Increased oxidative state, anti-Ox-LDL IgG ab
  • Steroid induced obesity and hyperlipidemia, etc.
  • Sustained SLE disease activity, ? SDI

Stichweh, D , Curr Opin Rheumatol 16577-587,
2004
Schanberg LE, Sandborg C, Current Rheum Reports
20046425-433
62
Case 3 Clinical Presentation
  • Patient is a 10 yo WF who was admitted to
    inpatient psychiatric team for treatment of
    PTSD/depression
  • Due to worsening abdominal pain, decreased oral
    intake, and peripheral edema she was evaluated by
    abd U/S which showed clot in IVC as well as
    edematous/ enlarged kidneys.
  • Further evaluation by CT scan of her
    abdomen/thorax showed the clot went from her
    right atrium to her infrarenal IVC there was
    extension of clot into renal veins bilaterally.

63
Ultrasound Results
IVC
Clot
64
Clinical Presentation
  • Anticoagulation with heparin.
  • Laboratory evaluation to help determine the
    etiology of her clot was undertaken.
    Rheumatology service consulted.
  • HPI abd pain since beginning of June no fevers,
    skin rashes, mucosal changes, joint
    pain/swelling.
  • PMH no h/o thrombotic events depression, PTSD
    thought to be secondary to alleged abuse and
    diagnosed during this admission.
  • Family Hx Maternal grandmother diagnosed with
    lupus at 23 years of age.

65
Laboratory Evaluation
  • 9.3 U/A 1.015, pH 6.0,
  • 9.7 137 gt300 mg protein,
  • moderate blood
  • 30.7
  • ALC 1360
  • ESR - gt140 CRP 5.26
  • C3 153 C4 - 21.2
  • Thrombotic Profile normal
  • DAT positive
  • ANA positive at 12560 other autoantibodies
    all negative
  • APA Profile positive

66
Pathology Findings Class V
Light Microscopy with Silver Stain showing
epimembranous deposits.
Electron Microscopy showing epimembranous
deposits.
Light Microscopy showing increased mesangial
cells.
67
Antiphospholipid Antibodies in cSLE
  • Associated with venous and arterial thrombosis,
    thrombocytopenia, neurologic disorders and fetal
    loss
  • Found in 65 of children with SLE
  • LAC, ACLA and false positive VDRL
  • Prolonged partial thromboplastin time
  • All are associated with thrombosis esp LAC and
    ACLA
  • Anticoagulation required if a patient has a
    thrombotic event
  • Aspirin in everybody else

Seaman DE, et al, Pediatrics. 1995 96 1040-5
68
Management Goals for cSLE
  • Counseling, education
  • Recommend adequate rest and activity
  • Decrease inflammation prevent end-organ injury
    failure
  • Preserve renal function provide HBP Rx prevent
    flare
  • Provide photo protection
  • Maintain up-to-date immunizations
  • Management of infection
  • Minimize osteoporosis
  • Identify patients at risk of thrombo-occlusive
    events
  • Evaluate and treat ASHD risk dyslipoproteinemia,
    etc.
  • Family planning/contraceptive issues

69
Combined Oral Contraceptives Are Not Associated
with an Increased Rate of Flare in SLE Patients
in SELENA
  • SELENA- Safety of Estrogen in Lupus
    Erythematosus-National Assessment
  • 183 premenapausal pts, mean age 30 y
  • Inactive 76, stable/active 24
  • Randomized, double blind OC vs placebo for 12
    28-day OC cycles
  • Primary end point, severe flare, rare 7/91
    (7.7) OC vs 7/92 (7.6) placebo
  • Mild/moderate flares 1.41 vs 1.40
    flares/person-year (OC vs P) RR 1.01, P 0.96
  • 3 or more mild/moderate flares 15 vs 16
  • OC does not increase rate of severe or
    mild/moderate flare in SLE

Petri,M, Arthritis Rheum 2004, 50(9) S239,
abstract 523
70
Adjunct Therapy for SLE
  • Antimalarials hydroxychloroquine
  • Nonsteroidal anti-inflammatory drugs
  • ASA
  • Folic Acid
  • ACE Inhibitors
  • Glucocorticoids variable dose ranges
  • Immunosuppressives non CYC, azathioprine,
    mycophenalate mofetil MMF, cyclosporin,
    methotrexate
  • Herpes Zoster prophylaxis
  • Vaccinations
  • Organ specific medications e.g. anti-HTN,
    osteoporosis, infection, etc.

71
Risk Factors for Damage in Childhood-Onset SLE
  • Disease activity and damage in 66 pts
  • SLICC/ACR Damage Index 1.76 (mean FU 3.3 y)
  • Cumulative disease activity single best predictor
    of damage (R2 0.30)
  • Corticosteroid treatment, APA, acute
    thrombocytopenia
  • Immunosuppressive agents protective

Brunner, HI, et al. Arthritis and
Rheumat.200246436-44.

72
Long-term Followup ofSLE Nephritis Toronto
  • 67 pt, MF 13.8, FU mean 11 y
  • 15 Class II, 8 Class III, 32 Class IV, 11 Class V
  • 4/67 died, 6/67 ESRD, 94 survival rate
  • Non-Caucasian pts may be at increased risk for
    renal failure
  • Azathioprine most commonly employed
    immunosuppressive agent

Hagelberg, S. J Rheumatol. 2002292635-42.
73
Long-Term Outcomes of Childhood-Onset SLE
  • 77 pts (prev 9.6/100,000 FM 101), 39
    interviewed
  • Mean age at dx 14.6 yrs, 57 Cauc, 40 AA and 3
    Asian
  • 8 pts died (86.9 survival) mean F/U 7.6 yrs
  • Mean SLEDAI score 6.2 (range 0-26),
  • 42 SDIgt0, mean 1.4 (0-10)
  • NPL, renal, ocular, and MS accounted for 79 of
    damage
  • AA had higher SLEDAI and SDI scores
  • cSLE pts develop 2 times damage of adults and
    continue to have active disease
  • CYC used in 39,
  • higher rate of ovarian damage (36) dose related
  • HRQL compared to healthy controls much lower
    mental and physical component

Brunner et al, Lupus 2006, in press
74
Conclusion(s)
  • SLE in children has the same clinical expression
    as in adults but a more aggressive disease
    course.
  • Numerous potential complications loom behind the
    scenes and must be anticipated and monitored.
  • Better understanding of the pathogenesis will
    enable better targeted and safer therapy.
  • Multiple trials are ongoing at CCHMC to
    investigate better health outcomes for cSLE.

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