CURRENT Essentials of Critical Care.pdf

Chapter 15 Rheumatology 221■■■Systemic Lupus Erythematosus (SLE)Essentials of Diagnosis• Symptoms depend on organ system involved and include dyspnea,hemoptysis, altered mental status, cerebral dysfunction,chest pain, fever• Systemic autoimmune disorder that can affect multiple organsystems• Complications requiring ICU care: acute lupus pneumonitis,alveolar hemorrhage, lupus cerebritis, seizures, premature atheroscleroticcoronary artery disease, pericarditis, myocarditis,bowel perforation, pancreatitis• Infection important cause of ICU admission: bacteria accountfor 90% including Streptococcus pneumoniae, Staphylococcusaureus, Enterobacteriaceae, nonfermentative gram-negativerods, Salmonella• Chronic steroid use increases risk of lung and brain infectionwith NocardiaDifferential Diagnosis• Lung: pleuritis, alveolar hemorrhage, community-acquiredpneumonia, ARDS• CNS: seizure, stroke, meningitis• Cardiovascular: pericarditis, pericardial effusion, myocarditis,myocardial infarction, vasculitis• Gastrointestinal: mesenteric thrombosis, ischemic bowel, rupturedhepatic aneurysm, cholecystitis, pancreatitisTreatment• Empiric broad-spectrum antibiotics until infection excluded; ifroutine cultures nonrevealing, bronchoscopy or open-lung biopsymay be necessary if lungs involved• Severe noninfectious complications typically treated with corticosteroids• Adjunctive immunosuppressive therapy with cyclophosphamide,azathioprine can be considered in conjunction withplasmapheresis in certain patients■ PearlInfections are the leading cause of morbidity and mortality in patientswith SLE and can be difficult to discern from an exacerbation of thisautoimmune disease.ReferenceRaj R et al: Systemic lupus erythematosus in the intensive care unit. Crit CareClin 2002;18:781. [PMID: 12418441]