🦋 Systemic Lupus Erythematosus (SLE) CPSP Short Case

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Pre‑exam protocol · Locomotor

Wash hands (sterilizing solution) Warm hands Introduce & rapport Position: standing / sitting / lying Exposure (shirt off, trousers rolled) Approach from right side

“Kissi jorr main dard tuu nahi?” “Bachaa Chal saktaa hai?” “Muh kholo, ungli rakho” “Pair se khara ho jao” “Zara uth kar dekho”

STEP 1 Inspection (General & Joints)

Malar / butterfly rash (33%), discoid rash, photosensitive rash
Alopecia, oral/nasal ulcers, cutaneous vasculitis (purpura, ulcers)
Joints: symmetry, swelling, redness, deformity (Jaccoud), muscle wasting
Nails: pitting, periungual telangiectasia, Raynaud phenomenon
Growth parameters: weight loss, short stature

STEP 2 Palpation

Joint warmth (compare bilaterally)
Tenderness (examine affected joint last, look at child’s face)
Effusion (patellar tap, bulge sign)
Lymphadenopathy, hepatosplenomegaly
Pulses, BP (hypertension if renal involvement)

STEP 3 Gait & Back

Ask: “Bachaa Chal saktaa hai?” → antalgic / waddling gait
Back: spinal tenderness, deformity, scoliosis
ROM spine: flexion (touch toes), extension, lateral bending
Squat (proximal weakness), stand on one leg (Trendelenburg)

STEP 4 Range of Motion

Upper limb

Fingers: make fist, prayer sign, reverse prayer, radial/ulnar deviation
Elbow: flexion, extension, supination, pronation
Shoulder: abduction, adduction, rotation, circumduction

Lower limb & spine

Hip: flexion, extension, abduction, adduction, rotation
Knee: flexion, extension, internal/external rotation
Ankle/foot: dorsi/plantar flexion, inversion, eversion
TMJ: open mouth (3 fingers), neck movements

Always stabilise pelvis / shoulder girdle; do passive movements only in affected joints.

STEP 5 Relevant GPE (multi-system)

Face: malar rash, discoid rash, alopecia, oral/nasal ulcers
Eyes: slit lamp (uveitis, keratoconjunctivitis sicca), retinal vasculitis
CVS: pericardial rub, murmur (Libman-Sacks), hypertension
Chest: pleuritic rub, effusion, tachypnoea
Abdomen: hepatosplenomegaly, ascites, tenderness (serositis)
Hands: Raynaud, digital ulcers, nailfold capillary changes
Genitalia: Tanner staging, contraception counselling

STEP 6 Functional & Dev Assessment

Comb hair, dress/undress (functional ability)
School performance, mood, depression screening
Measurements: true leg length (ASIS to medial malleolus), apparent (umbilicus to malleolus)
Anthropometry: height, weight, BMI (growth failure, steroid effects)
CNS: seizures, psychosis, cognitive dysfunction

Description template

“Thank you sir. I would like to complete my examination by doing [missed steps: vitals / anthropometry / slit lamp]. This is a [age]-year-old child, conscious, cooperative. No acute distress. Gait is [normal / antalgic]. Back examination unremarkable. He has [number] swollen joints, [symmetrical / asymmetrical], with/without active inflammation. Range of motion is reduced at [joints]. No fixed flexion deformity. Skin: [malar rash / discoid / alopecia / oral ulcers]. BCG scar present. No steroid toxicity, purpura, visceromegaly, or pericardial rub. He can dress/undress himself and is able/not able to walk. True leg length: [R] cm, [L] cm. Apparent leg length: [R] cm, [L] cm. I would like to do a slit lamp exam and check urine for protein.”

Differentials

Infections

Sepsis, EBV, parvovirus B19
Endocarditis
Post-streptococcal GN
Tuberculosis

Rheumatologic

JIA, JDM, vasculitides
Mixed connective tissue disease

Malignancy

Leukemia, lymphoma

Drug-induced lupus

Minocycline, hydralazine, procainamide
Isoniazid, penicillamine, diltiazem
Anti-TNF agents, interferon-α
Anticonvulsants (phenytoin, carbamazepine)

Investigations

DIAGNOSIS	ANA (95-99% sensitive), Anti-dsDNA, Anti-Smith, Hypocomplementemia (C3/C4), Antiphospholipid Ab, CBC (anaemia, leukopenia, thrombocytopenia), Coomb's test
SUPPORTIVE	ESR, CRP, Hypergammaglobulinemia, Anti-RNP (Raynaud, pulmonary HTN), Anti-Ro/La (neonatal lupus, sicca), Antihistone (drug-induced lupus)
EXCLUDE OTHERS	Blood cultures, TB workup, bone marrow biopsy, viral serology (EBV, parvovirus), complement levels
RULE OUT COMPLICATIONS	RFTs & electrolytes, Urine RE (protein, casts), Chest X-ray, ECG, 2D-Echo, slit lamp (uveitis), DEXA scan

SLICC criteria: ≥4 criteria (≥1 clinical + ≥1 immunologic) or biopsy-proven lupus nephritis + ANA/dsDNA.

MDT Management

Pharmacological

NSAIDs (arthralgia), Hydroxychloroquine (5-7 mg/kg/day), Corticosteroids (oral/IV pulse), Steroid-sparing: Methotrexate, Mycophenolate mofetil, Cyclophosphamide, Rituximab, Belimumab

Supportive

Sunscreen (SPF 50+), Calcium & Vitamin D, Statins (if elevated CRP), Immunisations (influenza, pneumococcal), Anticoagulation (if antiphospholipid)

Ophthalmology

Regular slit-lamp (hydroxychloroquine retinal toxicity every 6-12 months), uveitis management

Cardiology / Nephrology

BP monitoring, ACE inhibitors (proteinuria), 2D-Echo (pericarditis, myocarditis), RFT monitoring

Psychology & Counselling

Mental health support, contraception counselling (teratogenic drugs), pregnancy risks, school support

Nutrition & Growth

Monitor growth, bone health (DEXA), avoid weight gain from steroids, dietitian input

Prognosis & Counseling

5-year survival (paediatric)	~95%
10-year survival	~80-90%
Leading causes of death	Atherosclerosis, malignancy, infection, renal failure
Renal involvement	Major predictor of morbidity; diffuse proliferative GN (class IV) highest risk
Pregnancy risks	Can worsen SLE; teratogenic drugs; spontaneous abortion, neonatal lupus

Support: Lupus Foundation of America (www.lupus.org) · Arthritis Foundation

Tips & Tricks

Time taking exam – practice systematically; offer missed steps at the end.

Never inflict pain – examine tender joints last, look at child’s face.

Expose properly – check for purpura, rashes, alopecia, oral/nasal ulcers.

Always check for uveitis – slit lamp essential, even if joint disease is quiescent.

Don't forget CVS – pericarditis, myocarditis, Libman-Sacks endocarditis.

Renal involvement – urine RE for protein and RBC casts is critical.

Drug-induced lupus – antihistone antibodies, equal M:F, resolves after stopping drug.

Nelson textbook of Pediatrics · CPSP short case · Systemic Lupus Erythematosus (SLE)