MBBS viva · Rheumatology / General Medicine
Systemic lupus erythematosus — viva (serology, nephritis, HCQ)
Final-prof viva on SLE: clinical pattern, ANA/dsDNA/Smith/complements, ACR/EULAR 2019, lupus nephritis classes, hydroxychloroquine and flare vs infection.
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"A young woman has a malar rash, oral ulcers, arthritis and proteinuria. Discuss SLE."
Q1: Clinical diagnosis (2 min)
- Multisystem pattern: cutaneous (malar spares nasolabial folds; discoid; photosensitivity), oral ulcers, non-erosive arthritis, serositis, cytopenias, renal, neuropsychiatric.
- Differentials: RA (erosive, anti-CCP), MCTD (anti-RNP), dermatomyositis, adult Still's, drug-induced lupus (anti-histone; hydralazine, procainamide, isoniazid, minocycline, anti-TNF), infection.
- ACR/EULAR 2019: ANA ≥1:80 entry, weighted score ≥10.[1]
Q2: Investigations and serology (2 min)
- ANA sensitive; anti-Smith most specific; anti-dsDNA tracks activity/nephritis; low C3/C4 in flare.
- Anti-Ro/La, APL antibodies (lupus anticoagulant, anticardiolipin, anti-β2GP1).
- FBC, renal, urine PCR, Coombs if haemolysis; biopsy if renal involvement.
Q3: Management (3 min)
- Universal: photoprotection, vaccines, hydroxychloroquine 200–400 mg/day (≤5 mg/kg/day), retinal screen.[2]
- Mild disease: HCQ ± short steroid.
- Organ-threatening: high-dose steroid + MMF or cyclophosphamide induction; maintenance MMF/azathioprine.
- Flare vs infection: cultures first; CRP more often rises with infection than pure lupus flare.
- APS overlap: antiplatelet/anticoagulation decisions; pregnancy needs specialist care.
Q4: Special populations and pitfalls (1–2 min)
- Pregnancy: continue HCQ; stop MMF/MTX/CYC; aspirin; anti-Ro monitoring for neonatal lupus/heart block.
- Drug-induced lupus: usually skin/joint, anti-histone+, renal/CNS rare; stop culprit drug.
- Pitfalls: ANA = diagnosis; missing silent nephritis; immunosuppression without infection screen; no retinal monitoring on HCQ.
Key phrases examiners want
- "ANA is entry; anti-Smith is specific; dsDNA and complements track activity."
- "Hydroxychloroquine for nearly every patient."
- "Proteinuria needs biopsy to class nephritis."
- "Infection before escalation of immunosuppression."
References2ShowHide
- [1]Aringer M, et al. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol, 2019.PMID 31385462
- [2]Fanouriakis A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis, 2019.PMID 30926722