Systemic Lupus Erythematosus: Symptoms and Signs at Initial Presentations

Author(s): Abdel Masieh Metry , Issa Al Salmi* , Farida Al Balushi , Mohammed Abdalla Yousef , Faisal Al Ismaili , Alan Hola , Suad Hannawi .

Journal Name: Anti-Inflammatory & Anti-Allergy Agents in Medicinal Chemistry

Volume 18 , Issue 2 , 2019

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Graphical Abstract:


Abstract:

Background: Systemic Lupus Erythematosus (SLE) is an autoimmune multisystem inflammatory condition that causes microvascular inflammation with the production of various auto-antibodies that play a major role in its pathogenesis. SLE can affect both sexes, all ages, and all ethnic groups with widespread geographical and socioeconomic backgrounds. Asia encompasses people of many sociocultural backgrounds with diverse ethnic.

Objective: Due to a lack of national epidemiological research, the incidence and prevalence of SLE in Middle Eastern and Arab countries, have only recently been studied. This article aims to explore the status of SLE in Oman and to record symptoms and signs of SLE at first presentation.

Methodology: Medical records of all patients diagnosed with SLE at the Royal Hospital from 2006 to 2014 were reviewed for information recorded at first visit. SLE diagnosis was based on the American College of Rheumatology classification criteria; ACR97 (which includes the clinical manifestation and laboratory evidence). Patients with SLE disease manifestations extrapolated and analyzed.

There were 966 patients diagnosed with SLE during the period from 2006 to 2014. Mean (SD) age at presentations was 35.5 (11.5) years. Majority of patients were female which constitutes 88.7% of the total SLE patients with mean age 27.6 (1.4) years.

Results: Constitutional symptoms were found in 48.68 of SLE population including fatigue in 35.22%, and weight changes in 13.43%.

The cutaneous manifestations that were present included malar rash 37.69%, photosensitivity 35.10%, discoid lupus 17.63%, and hair loss 39.29%.

Musculoskeletal manifestations were commonly seen among the studied population including arthralgia in 68.75%, myalgia in 55.65%, arthritis in 48.31%, whilst myositis, tendon abnormalities and avascular necrosis were found in only 2.47%, 0.31% and 1.98%. respectively.

Conclusion: This is the first study of the symptoms and signs at initial clinical presentation of SLE patients compared to other studies done regionally where most have focused on clinical manifestations during the progression course of SLE. SLE manifestations may be related to the differences in the genetic make-up of the patients who come from various ethnic groups despite similar geography or sociocultural background, or to referral bias, as some studies were performed in the nephrology units and others in the rheumatology units. There is a pressing need to establish a nationwide and regional collaboration to establish LUPUS and to put forward a strategic planning with each MOH to provide an easy and efficient report of SLE cases and provide various effective management for such a debilitating syndrome.

Keywords: Systemic Lupus Erythematosus (SLE), diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, lung disease, cardiovascular disease (CVD), cerebrovascular accident (CVA), chronic kidney disease (CKD), end-stage kidney disease (ESKD).

[1]
Askanase, A.; Shum, K.; Mitnick, H. Systemic lupus erythematosus: An overview. Soc. Work Health Care, 2012, 51(7), 576-586.
[2]
Podolska, M.J.; Biermann, M.H.; Maueröder, C.; Hahn, J.; Herrmann, M. Inflammatory etiopathogenesis of systemic lupus erythematosus: An update. J. Inflamm. Res., 2015, 8, 161-171.
[3]
Alarcón, G.S.; McGwin, G., Jr; Bastian, H.M.; Roseman, J.; Lisse, J.; Fessler, B.J.; Friedman, A.W.; Reveille, J.D. Systemic lupus erythematosus in three ethnic groups. VII [correction of VIII]. Predictors of early mortality in the LUMINA cohort. Arthritis Rheum., 2001, 45(2), 191-202.
[4]
Arroyo-Ávila, M.; Santiago-Casas, Y.; McGwin, G., Jr; Cantor, R.S.; Petri, M.; Ramsey-Goldman, R.; Reveille, J.D.; Kimberly, R.P.; Alarcón, G.S.; Vilá, L.M.; Brown, E.E. Clinical associations of anti-Smith antibodies in PROFILE: A multi-ethnic lupus cohort. Clin. Rheumatol., 2015, 34(7), 1217-1223.
[5]
Bruce, I.N.; O’Keeffe, A.G.; Farewell, V.; Hanly, J.G.; Manzi, S.; Su, L.; Gladman, D.D.; Bae, S.C.; Sanchez-Guerrero, J.; Romero-Diaz, J.; Gordon, C.; Wallace, D.J.; Clarke, A.E.; Bernatsky, S.; Ginzler, E.M.; Isenberg, D.A.; Rahman, A.; Merrill, J.T.; Alarcón, G.S.; Fessler, B.J.; Fortin, P.R.; Petri, M.; Steinsson, K.; Dooley, M.A.; Khamashta, M.A.; Ramsey-Goldman, R.; Zoma, A.A.; Sturfelt, G.K.; Nived, O.; Aranow, C.; Mackay, M.; Ramos-Casals, M.; van Vollenhoven, R.F.; Kalunian, K.C.; Ruiz-Irastorza, G.; Lim, S.; Kamen, D.L.; Peschken, C.A.; Inanc, M.; Urowitz, M.B. Factors associated with damage accrual in patients with systemic lupus erythematosus: Results from the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort. Ann. Rheum. Dis., 2015, 74(9), 1706-1713.
[6]
Hiraki, L.T.; Benseler, S.M.; Tyrrell, P.N.; Harvey, E.; Hebert, D.; Silverman, E.D. Ethnic differences in pediatric systemic lupus erythematosus. J. Rheumatol., 2009, 36(11), 2539-2546.
[7]
Murin, S.; Wiedemann, H.P.; Matthay, R.A. Pulmonary manifestations of systemic lupus erythematosus. Clin. Chest Med., 1998, 19(4), 641-665.
[8]
Bertsias, G.K.; Salmon, J.E.; Boumpas, D.T. Therapeutic opportunities in systemic lupus erythematosus: State of the art and prospects for the new decade. Ann. Rheum. Dis., 2010, 69(9), 1603-1611.
[9]
Parker, B.; Urowitz, M.B.; Gladman, D.D.; Lunt, M.; Donn, R.; Bae, S.C.; Sanchez-Guerrero, J.; Romero-Diaz, J.; Gordon, C.; Wallace, D.J.; Clarke, A.E.; Bernatsky, S.; Ginzler, E.M.; Isenberg, D.A.; Rahman, A.; Merrill, J.T.; Alarcón, G.S.; Fessler, B.J.; Fortin, P.R.; Hanly, J.G.; Petri, M.; Steinsson, K.; Dooley, M.A.; Manzi, S.; Khamashta, M.A.; Ramsey-Goldman, R.; Zoma, A.A.; Sturfelt, G.K.; Nived, O.; Aranow, C.; Mackay, M.; Ramos-Casals, M.; van Vollenhoven, R.F.; Kalunian, K.C.; Ruiz-Irastorza, G.; Lim, S.S.; Kamen, D.L.; Peschken, C.A.; Inanc, M.; Bruce, I.N. Impact of early disease factors on metabolic syndrome in systemic lupus erythematosus: Data from an international inception cohort. Ann. Rheum. Dis., 2015, 74(8), 1530-1536.
[10]
Appenzeller, S.; Costallat, L.T. Clinical implications of migraine in systemic lupus erythematosus: Relation to cumulative organ damage. Cephalalgia, 2004, 24(12), 1024-1030.
[11]
Costenbader, K.H.; Khamashta, M.; Ruiz-Garcia, S.; Perez-Rodriguez, M.T.; Petri, M.; Elliott, J.; Manzi, S.; Karlson, E.W.; Turner-Stokes, T.; Bermas, B.; Coblyn, J.; Massarotti, E.; Schur, P.; Fraser, P.; Navarro, I.; Hanly, J.G.; Shaver, T.S.; Katz, R.S.; Chakravarty, E.; Fortin, P.R.; Sanchez, M.L.; Liu, J.; Michaud, K.; Alarcón, G.S.; Wolfe, F. Development and initial validation of a self-assessed lupus organ damage instrument. Arthritis Care Res. (Hoboken), 2010, 62(4), 559-568.
[12]
Pego-Reigosa, J.M.; Lois-Iglesias, A.; Rúa-Figueroa, Í.; Galindo, M.; Calvo-Alén, J.; de Uña-Álvarez, J.; Balboa-Barreiro, V.; Ibáñez Ruan, J.; Olivé, A.; Rodríguez-Gómez, M.; Fernández Nebro, A.; Andrés, M.; Erausquin, C.; Tomero, E.; Horcada Rubio, L.; Uriarte Isacelaya, E.; Freire, M.; Montilla, C.; Sánchez-Atrio, A.I.; Santos-Soler, G.; Zea, A.; Díez, E.; Narváez, J.; Blanco-Alonso, R.; Silva-Fernández, L.; Ruiz-Lucea, M.E.; Fernández-Castro, M.; Hernández-Beriain, J.Á.; Gantes-Mora, M.; Hernández-Cruz, B.; Pérez-Venegas, J.; Pecondón-Español, Á.; Marras Fernández-Cid, C.; Ibáñez-Barcelo, M.; Bonilla, G.; Torrente-Segarra, V.; Castellví, I.; Alegre, J.J.; Calvet, J.; Marenco de la Fuente, J.L.; Raya, E.; Vázquez-Rodríguez, T.R.; Quevedo-Vila, V.; Muñoz-Fernández, S.; Otón, T.; Rahman, A.; López-Longo, F.J. Relationship between damage clustering and mortality in systemic lupus erythematosus in early and late stages of the disease: Cluster analyses in a large cohort from the Spanish Society of Rheumatology Lupus Registry. Rheumatology (Oxford), 2016, 55(7), 1243-1250.
[13]
Pineau, C.A.; Bernatsky, S.; Abrahamowicz, M.; Neville, C.; Karp, I.; Clarke, A.E. A comparison of damage accrual across different calendar periods in systemic lupus erythematosus patients. Lupus, 2006, 15(9), 590-594.
[14]
Feng, X.; Zou, Y.; Pan, W.; Wang, X.; Wu, M.; Zhang, M.; Tao, J.; Zhang, Y.; Tan, K.; Li, J.; Chen, Z.; Ding, X.; Qian, X.; Da, Z.; Wang, M.; Sun, L. Associations of clinical features and prognosis with age at disease onset in patients with systemic lupus erythematosus. Lupus, 2014, 23(3), 327-334.
[15]
Kaul, A.; Gordon, C.; Crow, M.K.; Touma, Z.; Urowitz, M.B.; van Vollenhoven, R.; Ruiz-Irastorza, G.; Hughes, G. Systemic lupus erythematosus. Nat. Rev. Dis. Primers, 2016, 2, 16039.
[16]
Rivest, C.; Lew, R.A.; Welsing, P.M.; Sangha, O.; Wright, E.A.; Roberts, W.N.; Liang, M.H.; Karlson, E.W. Association between clinical factors, socioeconomic status, and organ damage in recent onset systemic lupus erythematosus. J. Rheumatol., 2000, 27(3), 680-684.
[17]
El-Miedany, Y. The evolving therapy of rheumatic diseases, the future is now. Curr. Drug Targets Immune Endocr. Metabol. Disord., 2002, 2(1), 1-11.
[18]
Santos, L.L.; Morand, E.F. Macrophage migration inhibitory factor: A key cytokine in RA, SLE and atherosclerosis. Clin. Chim. Acta, 2009, 399(1-2), 1-7.
[19]
Tunnicliffe, D.J.; Singh-Grewal, D.; Craig, J.C.; Howell, M.; Tugwell, P.; Mackie, F.; Lin, M.W.; O’Neill, S.G.; Ralph, A.F.; Tong, A. Healthcare and research priorities of adolescents and young adults with systemic lupus erythematosus: A mixed-methods study. J. Rheumatol., 2017, 44(4), 444-451.
[20]
Ward, M.M. Development and testing of a systemic lupus-specific risk adjustment index for in-hospital mortality. J. Rheumatol., 2000, 27(6), 1408-1413.
[21]
Daleboudt, G.M.; Berger, S.P.; Broadbent, E.; Kaptein, A.A. Health-related quality of life in patients with systemic lupus erythematosus and proliferative lupus nephritis. Psychol. Health Med., 2011, 16(4), 393-404.
[22]
Walsh, S.J.; DeChello, L.M. Geographical variation in mortality from systemic lupus erythematosus in the United States. Lupus, 2001, 10(9), 637-646.
[23]
Rabbani, M.A.; Siddiqui, B.K.; Tahir, M.H.; Ahmad, B.; Shamim, A.; Shah, S.M.; Ahmad, A. Systemic lupus erythematosus in Pakistan. Lupus, 2004, 13(10), 820-825.
[24]
Yang, Y.; Thumboo, J.; Earnest, A.; Yong, S.L.; Fong, K.Y. The effect of comorbidity on hospital mortality in patients with SLE from an Asian tertiary hospital. Lupus, 2014, 23(7), 714-720.
[25]
Zhang, S.; Su, J.; Li, X.; Zhang, X.; Liu, S.; Wu, L.; Ma, L.; Bi, L.; Zuo, X.; Sun, L.; Huang, C.; Zhao, J.; Li, M.; Zeng, X. Chinese SLE Treatment and Research group (CSTAR) registry: V. gender impact on Chinese patients with systemic lupus erythematosus. Lupus, 2015, 24(12), 1267-1275.
[26]
Anderson, E.; Nietert, P.J.; Kamen, D.L.; Gilkeson, G.S. Ethnic disparities among patients with systemic lupus erythematosus in South Carolina. J. Rheumatol., 2008, 35(5), 819-825.
[27]
Al Dhanhani, A.M.; Agarwal, M.; Othman, Y.S.; Bakoush, O. Incidence and prevalence of systemic lupus erythematosus among the native Arab population in UAE. Lupus, 2017, 26(6), 664-669.
[28]
Alballa, S.R. Systemic lupus erythematosus in Saudi patients. Clin. Rheumatol., 1995, 14(3), 342-346.
[29]
AlSaleh, J.; Jassim, V.; ElSayed, M.; Saleh, N.; Harb, D. Clinical and immunological manifestations in 151 SLE patients living in Dubai. Lupus, 2008, 17(1), 62-66.
[30]
Hammoudeh, M.; Al-Momani, A.; Sarakbi, H.; Chandra, P.; Hammoudeh, S. Oral manifestations of systemic lupus erythematosus patients in Qatar: A Pilot Study. Int. J. Rheumatol., 2018, 20186052326
[31]
Petri, M.; Purvey, S.; Fang, H.; Magder, L.S. Predictors of organ damage in systemic lupus erythematosus: The Hopkins Lupus Cohort. Arthritis Rheum., 2012, 64(12), 4021-4028.
[32]
Rúa-Figueroa, I.; López-Longo, F.J.; Calvo-Alén, J.; Galindo-Izquierdo, M.; Loza, E.; García de Yebenes, M.J.; Pego-Reigosa, J.M. National registry of patients with systemic lupus erythematosus of the Spanish Society of Rheumatology: Objectives and methodology. Reumatol. Clin., 2014, 10(1), 17-24.
[33]
Nightingale, A.L.; Davidson, J.E.; Molta, C.T.; Kan, H.J.; McHugh, N.J. Presentation of SLE in UK primary care using the Clinical Practice Research Datalink. Lupus Sci. Med., 2017, 4(1)e000172
[34]
Riveros Frutos, A.; Casas, I.; Rúa-Figueroa, I.; López-Longo, F.J.; Calvo-Alén, J.; Galindo, M.; Fernández-Nebro, A.; Pego-Reigosa, J.M.; Olivé Marqués, A. Systemic lupus erythematosus in Spanish males: A study of the Spanish Rheumatology Society Lupus Registry (RELESSER) cohort. Lupus, 2017, 26(7), 698-706.
[35]
Walsh, S.J.; Algert, C.; Rothfield, N.F. Racial aspects of comorbidity in systemic lupus erythematosus. Arthritis Care Res., 1996, 9(6), 509-516.
[36]
Ahsan, T.; Khowaja, D.; Jabeen, R.; Erum, U.; Ali, H.; Farooq, M.U.; Rehman, U.L. Burden of rheumatological disorders in a tertiary care hospital. J. Pak. Med. Assoc., 2016, 66(5), 563-567.
[37]
Batool, S.; Ahmad, N.M.; Saeed, M.A.; Farman, S. Pattern of initial clinical manifestations of systemic lupus erythematosus in a tertiary care hospital. Pak. J. Med. Sci., 2016, 32(5), 1066-1070.
[38]
Uthman, I.; Nasr, F.; Kassak, K.; Masri, A.F. Systemic lupus erythematosus in Lebanon. Lupus, 1999, 8(9), 713-715.
[39]
Muzaffer, M.A.; Al-Mayouf, S.M. Clinical and laboratory variables of childhood systemic lupus erythematosus in western province of Saudi Arabia. Rheumatol. Int., 2011, 31(1), 23-26.
[40]
Abdwani, R.; Al-Abrawi, S.; Sharef, S.W.; Al-Zakwani, I. Geographical clustering of juvenile onset systemic lupus erythematosus within the Sultanate of Oman. Oman Med. J., 2013, 28(3), 199-203.
[41]
Abid, N.; Khan, A.S.; Al Otaibi, F.H. Systemic lupus erythematosus (SLE) in the eastern region of Saudi Arabia. A comparative study. Lupus, 2013, 22(14), 1529-1533.
[42]
Al-Sobayel, H.I.; Al-Hugail, H.A.; AlSaif, R.M.; Albawardi, N.M.; Alnahdi, A.H.; Daif, A.M.; Al-Arfaj, H.F. Validation of an Arabic version of fatigue severity scale. Saudi Med. J., 2016, 37(1), 73-78.
[43]
Zakeri, Z.; Shakiba, M.; Narouie, B.; Mladkova, N.; Ghasemi-Rad, M.; Khosravi, A. Prevalence of depression and depressive symptoms in patients with systemic lupus erythematosus: Iranian experience. Rheumatol. Int., 2012, 32(5), 1179-1187.
[44]
Al-Shamahy, H.A.; Dhaifallah, N.H.; Al-Ezzy, Y.M. Clinical and laboratory manifestations of yemeni patients with systemic lupus erythematosus. Sultan Qaboos Univ. Med. J., 2014, 14(1), e80-e87.
[45]
Al-Jarallah, K.; Al-Awadi, A.; Siddiqui, H.; Al-Salim, I.; Shehab, D.; Umamaheswaran, I.; Gaurer, S.; Al-Saied, K.; Kumar, R.; Malaviya, A.N. Systemic lupus erythematosus in Kuwait-hospital based study. Lupus, 1998, 7(7), 434-438.
[46]
Al-Mosawi, Z.; Al-Hermi, B.E.; Al-Saad, K.K.; Farid, E.M.; Makki, H.A. Juvenile systemic lupus erythematosus in Bahrain. A tertiary referral center experience. Saudi Med. J., 2009, 30(5), 667-672.
[47]
Jakati, S.; Rajasekhar, L.; Uppin, M.; Challa, S. SLE myopathy: A clinicopathological study. Int. J. Rheum. Dis., 2015, 18(8), 886-891.
[48]
Lim, K.L.; Abdul-Wahab, R.; Lowe, J.; Powell, R.J. Muscle biopsy abnormalities in systemic lupus erythematosus: Correlation with clinical and laboratory parameters. Ann. Rheum. Dis., 1994, 53(3), 178-182.
[49]
Leuchten, N.; Milke, B.; Winkler-Rohlfing, B.; Daikh, D.; Dörner, T.; Johnson, S.R.; Aringer, M. Early symptoms of systemic lupus erythematosus (SLE) recalled by 339 SLE patients. Lupus, 2018, 27(9), 1431-1436.
[50]
Evans, S.A.; Hopkinson, N.D.; Kinnear, W.J.; Watson, L.; Powell, R.J.; Johnston, I.D. Respiratory disease in systemic lupus erythematosus: Correlation with results of laboratory tests and histological appearance of muscle biopsy specimens. Thorax, 1992, 47(11), 957-960.
[51]
Al Rasbi, A.; Abdalla, E.; Sultan, R.; Abdullah, N.; Al Kaabi, J.; Al-Zakwani, I.; Abdwani, R. Spectrum of systemic lupus erythematosus in Oman: From childhood to adulthood. Rheumatol. Int., 2018, 38(9), 1691-1698.
[52]
Wu, C.Y.; Li, C.F.; Wu, Q.J.; Xu, J.H.; Jiang, L.D.; Gong, L.; Wu, F.Q.; Gu, J.R.; Zhao, J.L.; Li, M.T.; Zhao, Y.; Zeng, X.F. Chinese systemic lupus erythematosus treatment and research group registry IX: Clinical features and survival of childhood-onset systemic lupus erythematosus in China. Chin. Med. J. (Engl.), 2017, 130(11), 1276-1282.
[53]
Gedalia, A.; Molina, J.F.; Molina, J.; Uribe, O.; Malagon, C.; Espinoza, L.R. Childhood-onset systemic lupus erythematosus: A comparative study of African Americans and Latin Americans. J. Natl. Med. Assoc., 1999, 91(9), 497-501.
[54]
Andreoli, L.; Bertsias, G.K.; Agmon-Levin, N.; Brown, S.; Cervera, R.; Costedoat-Chalumeau, N.; Doria, A.; Fischer-Betz, R.; Forger, F.; Moraes-Fontes, M.F.; Khamashta, M.; King, J.; Lojacono, A.; Marchiori, F.; Meroni, P.L.; Mosca, M.; Motta, M.; Ostensen, M.; Pamfil, C.; Raio, L.; Schneider, M.; Svenungsson, E.; Tektonidou, M.; Yavuz, S.; Boumpas, D.; Tincani, A. EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann. Rheum. Dis., 2017, 76(3), 476-485.
[55]
Rúa-Figueroa, I.; Fernández Castro, M.; Andreu, J.L.; Sanchez-Piedra, C.; Martínez-Taboada, V.; Olivé, A.; López-Longo, J.; Rosas, J.; Galindo, M.; Calvo-Alén, J.; Fernández-Nebro, A.; Alonso, F.; Rodríguez-Lozano, B.; Alberto García Vadillo, J.; Menor, R.; Narváez, F.J.; Erausquin, C.; García-Aparicio, Á.; Tomero, E.; Manrique-Arija, S.; Horcada, L.; Uriarte, E.; Gil, S.; Blanco, R.; López-González, R.; Boteanu, A.; Freire, M.; Galisteo, C.; Rodríguez-Gómez, M.; Díez-Álvarez, E.; Pego-Reigosa, J.M. Comorbidities in patients with primary Sjögren’s syndrome and systemic lupus erythematosus: A comparative registries-based study. Arthritis Care Res. (Hoboken), 2017, 69(1), 38-45.
[56]
Al-Omairi, O.A. Clinical presentation and management outcome of childhood-onset systemic lupus erythamatosus in Baghdad. Arab J. Nephrol. Transplant., 2014, 7(2), 125-127.
[57]
Yun, S.J.; Lee, J.W.; Yoon, H.J.; Lee, S.S.; Kim, S.Y.; Lee, J.B.; Lee, S.C.; Won, Y.H.; Kim, S.J. Cross-sectional study of hair loss patterns in 122 Korean systemic lupus erythematosus patients: A frequent finding of non-scarring patch alopecia. J. Dermatol., 2007, 34(7), 451-455.
[58]
Al Arfaj, A.S.; Khalil, N. Clinical and immunological manifestations in 624 SLE patients in Saudi Arabia. Lupus, 2009, 18(5), 465-473.
[59]
Al Arfaj, A.S.; Khalil, N.; Al Saleh, S. Lupus nephritis among 624 cases of systemic lupus erythematosus in Riyadh, Saudi Arabia. Rheumatol. Int., 2009, 29(9), 1057-1067.
[60]
Nazarinia, M.A.; Ghaffarpasand, F.; Shamsdin, A.; Karimi, A.A.; Abbasi, N.; Amiri, A. Systemic lupus erythematosus in the Fars Province of Iran. Lupus, 2008, 17(3), 221-227.
[61]
Bakr, A. Epidemiology treatment and outcome of childhood systemic lupus erythematosus in Egypt. Pediatr. Nephrol., 2005, 20(8), 1081-1086.
[62]
Salah, S.; Lotfy, H.M.; Sabry, S.M.; El Hamshary, A.; Taher, H. Systemic lupus erythematosus in Egyptian children. Rheumatol. Int., 2009, 29(12), 1463-1468.
[63]
Abdel-Hafez, M.A.; Abdel-Nabi, H. Juvenile systemic lupus erythematosus: Onset patterns and short-term outcome in Egyptian children, a single-center experience. Lupus, 2015, 24(13), 1455-1461.
[64]
Bachen, E.A.; Chesney, M.A.; Criswell, L.A. Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus. Arthritis Rheum., 2009, 61(6), 822-829.
[65]
Fawzy, M.; Edrees, A.; Okasha, H.; El Ashmaui, A.; Ragab, G. Gastrointestinal manifestations in systemic lupus erythematosus. Lupus, 2016, 25(13), 1456-1462.
[66]
Al-Rawi, Z.; Al-Shaarbaf, H.; Al-Raheem, E.; Khalifa, S.J. Clinical features of early cases of systemic lupus erythematosus in Iraqui patients. Br. J. Rheumatol., 1983, 22(3), 165-171.
[67]
Alamoudi, O.S.; Attar, S.M. Pulmonary manifestations in systemic lupus erythematosus: Association with disease activity. Respirology, 2015, 20(3), 474-480.
[68]
Al-Rayes, H.; Al-Swailem, R.; Arfin, M.; Sobki, S.; Rizvi, S.; Tariq, M. Systemic lupus erythematosus and infections: A retrospective study in Saudis. Lupus, 2007, 16(9), 755-763.
[69]
Beça, S.; Rodríguez-Pintó, I.; Alba, M.A.; Cervera, R.; Espinosa, G. Development and validation of a risk calculator to differentiate flares from infections in systemic lupus erythematosus patients with fever. Autoimmun. Rev., 2015, 14(7), 586-593.


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VOLUME: 18
ISSUE: 2
Year: 2019
Page: [142 - 150]
Pages: 9
DOI: 10.2174/1871523018666181128161828
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