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Lupus Diagnosis

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease, where different organs and tissues can be affected due to attacks by the immune system, resulting in various clinical manifestations. Some manifestations are typical and characteristic of SLE, such as a butterfly-shaped rash on the face or photosensitivity. However, some manifestations are not specific and can resemble symptoms of other diseases, such as hair loss, fever, and joint pain. To reach an accurate diagnosis, patients must undergo clinical examinations and laboratory tests. 


Whether it is the early American College of Rheumatology (ACR 1982, revised 1997) criteria or the more recent Systemic Lupus International Collaborating Clinics (SLICC, 2012) criteria, the classification of SLE is determined based on the classification criteria. These criteria involve evaluating clinical manifestations from different organs, combined with serological or immunological tests, to make a diagnosis. This emphasizes that we cannot rely solely on individual symptoms or blood test results to confirm or exclude a diagnosis of SLE. 


These classification criteria were initially developed for medical research and patient recruitment purposes but also hold value in everyday clinical diagnosis. The SLICC criteria, published in 2012, present 17 criteria for diagnosing SLE, including clinical examinations (11 criteria) and immunological tests (6 criteria). If a patient meets four or more criteria, with at least one criterion from each category, a diagnosis of SLE can be made. 

Clinical Criteria: 


(1) Acute cutaneous lupus: Butterfly rash on cheeks, photosensitive lupus rash, subacute lupus skin lesions, etc. 


(2) Chronic cutaneous lupus: Discoid lupus, and other chronic skin lesions. 


(3) Non-scarring alopecia. 


(4) Oral or nasal ulcers. 


(5) Arthritis: Swelling or effusion in two or more joints, pain in two or more joints with morning stiffness lasting at least 30 minutes. 


(6) Pleuritis or pericarditis: Pleurisy or pleural effusion, pericarditis or pericardial effusion. 


(7) Renal disorder: Proteinuria exceeding 0.5 grams per day or red blood cell casts. 


(8) Neurologic disorder: Seizures, psychosis, myelitis, peripheral neuropathy, acute confusional state. 


(9) Hemolytic anemia. 


(10) Leukopenia: Total white blood cell count less than 4,000/mm3 or lymphocyte count less than 1,000/mm3. 


(11) Thrombocytopenia: Platelet count less than 100,000/mm3. 

Immunological Criteria: 


(1) Anti-nuclear antibody (ANA) test. 


(2) Anti-dsDNA antibody test (positive if using ELISA and exceeds the normal upper limit by at least double). 


(3) Anti-Smith (anti-Sm) antibody test. 


(4) Antiphospholipid antibody testing: Lupus anticoagulant, moderate to high levels of anticardiolipin antibodies (IgA, IgG, IgM), or anti-beta2-glycoprotein 1 antibodies (IgA, IgG, IgM). 


(5) Complement levels: C3, C4, or CH50. 


(6) Direct Coombs test. 


A typical lupus nephritis finding on kidney biopsy, combined with a positive ANA or anti-dsDNA antibody test, can also confirm the diagnosis of systemic lupus erythematosus. 


It is worth noting that lupus symptoms may not appear simultaneously, so healthcare professionals may need to follow up with suspected cases for an extended period. If new symptoms arise, patients should undergo immediate testing and diagnosis to initiate treatment promptly. 


Additionally, some patients may also have other autoimmune diseases, such as Sjögren's syndrome or overlap syndromes, requiring cautious management. 


1. Hong Kong Rheumatism Foundation: Dancing with the Wolf: Nursing and Treatment of Lupus Erythematosus. Heaven and Earth Publishing Co., Ltd., 2017. 

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