Differential diagnosis

A doctor who has experience with Lupus / SLE will usually make the correct diagnosis without any uncertainty. However, in special cases, diagnosis can be difficult. The suggestions below can then be considered.

Fever

Infection

Fever that does not respond to prednisolone 30mg / d is not typical of SLE

• Consider opportunistic infections (Pneumocystis jiroveci (PCP) Legionella, Nocardia asteroids, Aspergillosis, Kryptococcus, Mycoplasma pneumoniae, Chlamydia pneuoniae, Listeria, Toksoplasose , Atypical mycobacteria, cytomegalovirus (CMV), BK virus (Similar to JCV), EBV (Ebstein-Barr Virus), Adeno-virus, Hepatitis B, HIV, Hepatitis C. Borrelia miyamoti

Other autoimmune disease

• Adult Stills disease
• ALPS (Autoimmune Lympho-Proliferative Syndrome)
  • Hemolytic anemia
  • Neutropenia
  • Lymph nodes are swollen
  • Splenomegaly (large spleen)
  • Thrombocytopenia
• Periodic Fever Syndrome / Auto-Inflammatory Disease
• Sweet's syndrome

Breathing problem (Dyspnea)

• Alveolitis, lupus pneumonitis
• Antisynthetic Syndrome (ASS)
• Bacterial / viral pneumonia (75% is bacterial)
• Heart failure (myocarditis, valve disease (Libman-Sack's endocarditis), arrhythmia, coronary vasculitis)
• Interstitial Chronic Lung Disease
• Pulmonary haemorrhage (2-4%, often in early disease phase, reference: Ednaldino C, 2015)
• Pulmonary embolism (for example, by APL syndrome)
• Lung cancer
• Drug side effect (cyclophosphamide, methotrexate)
• Pleurisy / pericarditis (Lung / heart bag inflammation)
• Pumonal hypertension (4% by SLE, reference: Parabu A, 2009)
• Shrinking Lung Syndrome

Blood clots / thromboembolism

• Antiphospholipid Syndrome (ApLs) 
  • Lupus anticoagulant, cardiolipin and beta-2 glycoprotein
• Degos disease (Köhlmeier-Degos)
• Cholesterol emboli
• Leiden mutation (factor-5) that 8% has in heterozygous form
• Libman-Sack's endocarditis
• Myxoma
• Nephrotic syndrome
• Protein S og Cdeficiency (values ​​are affected by high inflammation)

Abdominal pain / Abdominal symptoms

• Pancreatitis
•  Peritonitis
  • inflammatory
  • Infectious
• Porphyria
• Thrombosis of the intestinal arteries and organs (APL syndrome)
• Intestinal and intestinal vasculitis
  • Polyarteritis nodosa
  • Behcet's disease
• Ulcer duodeni / ventriculi, abscesses or other infections.

Acute arthritis

• bone necrosis Aseptic (at high doses of steroids, or Antiphospholipid syndrome)
• Crystal arthritis
  • Gout (most often with reduced kidney function)
  • Chondrocalcinosis
• Reactive arthritis
• Rheumatoid Arthritis (Arthritis)
• Septic arthritis (infection)

Thrombocytopenia

• Antifosfolipid syndrome
• Blood disorders
  • Lympho-proliferative disease
    • Investigate: Peripheral cell count, blood pressure, bone marrow
• Evans syndrome (Thrombocytopenia + hemolytic anemia)
• Immunological thrombocytopenic purpura (ITP)
• Infection
  • HIV
  • Hepatitis C
• Macrophage activation syndrome / HLH
• Medication

CNS: Cerebral lupus

• Aicardi-Goutière syndrome (children with significant CNS changes, hepato-splenomegaly, thrombocytopenia
• ApL syndrome
• Borrelia meningitis (infection)
• Dementia
• Depression
• Encephalitis, autoimmune (with differential diagnosis)
• Encephalitis, Infection
• Meningitis (infection)
• Multiple sclerosis
• PRES (Posterior Reversible Encephalopathy Syndrome)
• Primary cerebral vasculitis (with differential diagnosis)
• Progressive Multifocal Leukoencephalopathy (Cause: JC Virus)
• Psychosis of other reasons
• Stroke

Red cheeks

• Dermatomyositis
• Roseacea
• Sarcoidosis
• Butterfly exanthema at systemic lupus erythematosus (SLE)

Eczema

• Dermatomyositis (generalized erythema)
• Degos syndrome (rarely, nodules and wounds in the skin, other organs)
• Discoid lupus
• GVH syndrome after transplantation
• Hypersensitivity reaction / Serum disease
  • Medication
    • DRESS syndrome
• Mastocytosis
• Porphyria (cutaneous)
• Psoriasis
• Sarcoidosis
  • Skin symptoms may be reminiscent of Diskoid lupus
• Seborrhea (In the face at angle of mouth and nose)
• Sweet's syndrome

Mouth ulcers

• Mouth ulcers for other reasons
• Behcet's disease
• Medication
  • Methotrexate
• Mushroom infection (Candida, Mycosis)

Heart disease

• Endocarditis
• Heart attack. SLE women in 35-45's age have 50 x increased risk of myocardial infarction (Reference: Manzi S, 1997).
  • Prevention: Treat cholesterol more than 5,2. Stop smoking, More physical activity. Consider weight reduction. Active SLE treatment but avoid high prednisolone doses (more than 5mg / d) over time
• Libman-Sack's endocarditis
• Pericarditis of other reasons

Cancer (malignancies)

• Cervix uteri cancer (cervical cancer)
  • Possibly slightly increased risk of SLE
• Skin cancer
  • May be increased risk after many years of treatment
•  Lymphoma (lymph node cancer)
  • Probably a little increased risk with SLE
  • Symptoms: tiredness, fever, weight loss,
  • Lymph nodes enlarged,
  • Sweats / New Night Sweats
• Lung cancer risk may be slightly increased (reference: Bin J, 2007)

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