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Lupus erythematosus

April 29, 2023

Lupus erythematosus is a collection of autoimmune diseases in which the human immune system becomes hyperactive and attacks healthy tissues.[1] Symptoms of these diseases can affect many different body systems, including joints, skin, kidneys, blood cells, heart, and lungs. The most common and most severe form is systemic lupus erythematosus.

Lupus erythematosus
SpecialtyRheumatology, Immunology

Signs and symptoms

Symptoms vary from person to person, and may come and go. Almost everyone with lupus has joint pain and swelling. Some develop arthritis. Frequently affected joints are the fingers, hands, wrists, and knees.[2] Other common symptoms include:

Photosensitivity

Photosensitivity is the amount to which an object reacts upon receiving photons especially in visible light. Photosensitivity is a known symptom of lupus, but its relationship to and influence on other aspects of the disease remain to be defined.[4] Causes of photosensitivity may include:

Genetics

It is typically believed that lupus is influenced by multiple genes. Lupus is usually influenced by gene polymorphisms, 30 of which have now been linked with the disorder. Some of these polymorphisms have been linked very tentatively, however, as the role that they play or the degree to which they influence the disease is unknown. Other genes that are commonly thought to be associated with lupus are those in the human leukocyte antigen (HLA) family. There have been several cases wherein a single gene influence appears to be present, but this is rare. When a single gene deficiency does cause lupus, it is usually attributed to the complement protein genes C1, C2, or C4. The influence of sex chromosomes and environmental factors are also noteworthy. Usually, these factors contribute to lupus by influencing the immune system.[5] Several studies also indicate a potential association of lupus with mutations in DNA repair genes.[6]

Age difference

Lupus can develop in people at any age, but it does most commonly at ages 15 to 44, with varying results. Typically, the manifestation of the disease tends to be more acute in those of younger age. Women are more likely to get it than men. Patients with juvenile-onset lupus are more vulnerable to mucocutaneous manifestations of the disease (alopecia, skin rash, and ulceration of the mucus membranes) than any other age group, and they are also more susceptible to evaluation of pulmonary artery pressure.[7] However, patients with late-onset lupus have a much higher mortality rate. Nearly 50% of those with late-onset lupus die of their condition. Women who are of childbearing age are also particularly at risk.[8]

Differences in ethnicity

Substantial data have been found to indicate that certain ethnic populations could be more at risk for lupus erythematosus and to have a better or worse prognosis. Asian, African, and Native Americans are more likely to get lupus than Caucasians. Caucasians seem generally to have a milder manifestation of the disease. Their survival rates after five years were typically around 94–96%, while patients of African and some Asian ethnicities had survival rates closer to 79–92%. The only documented ethnic group that had a higher survival rate than Caucasians was Koreans, who had survival rates nearer to 98%. Among Caucasians, the most common causes of death were complications involving the cardiovascular system, the respiratory system, and malignancies.[9][10] Atherosclerotic cardiovascular disease is more prevalent in African Americans with lupus than in Caucasians with lupus.[11]

Diagnosis

Diagnosis of lupus will vary from person to person. It is common to be diagnosed with other illnesses before a doctor can finally rule out lupus because a lot of the symptoms overlap with other common illness.[12]

Diagnosis of lupus erythematosus requires a physical examination, blood and urine tests, and a skin or kidney biopsy. Some other tests that may need to be run include:[13]

Classification

Lupus erythematosus may manifest as systemic disease or in a purely cutaneous form also known as incomplete lupus erythematosus. Lupus has four main types:[citation needed]

Of these, systemic lupus erythematosus (also known as SLE) is the most common and serious form.

A more thorough categorization of lupus includes the following types:[15][16]

Treatment

There is still no cure for lupus but there are options to help control symptoms. The goal for treatment is to prevent flare ups and reduce organ damage. Doctors may prescribe a handful of different medications to help with their patients’ symptoms.[13]

Some medications are:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Corticosteroids
  • Antimalarial drugs
  • BLyS-specific inhibitors
  • Immunosuppressive agents/chemotherapy

After being diagnosed some treatment options that may be offered are:

See also: Systemic lupus erythematosus § Treatment

Treatment consists primarily of immunosuppressive drugs (e.g., hydroxychloroquine and corticosteroids). A second-line drug is methotrexate in its low-dose schedule.[17] [18] In 2011, the U.S. Food and Drug Administration (FDA) approved the first new drug for lupus in more than 50 years to be used in the US, belimumab.[19] In addition to medical therapy, cognitive behavioral therapy has also been demonstrated to be effective in reducing stress, anxiety, and depression due to the psychological and social impacts that lupus may have.[20]

People with SLE treated with standard care experience a higher risk of opportunistic infections and death than the general population. This risk is higher in men and in African Americans.[21]

Epidemiology

Worldwide

  • An estimated 5 million people worldwide have some form of lupus disease.[22]
  • 70% of lupus cases diagnosed are systemic lupus erythematosus.[22]
  • 20% of people with lupus will have a parent or sibling who already has lupus or may develop lupus.[22]
  • about 5% of the children born to individuals with lupus will develop the illness.[22]

United Kingdom

  • Females in the UK are seven times more likely to be diagnosed with SLE than males.[23]
  • The estimated number of females in the UK with SLE is 21,700, and the number of males is 3000 — a total of 24,700, or 0.041% of the population.[23]
  • SLE is more common amongst certain ethnic groups than others, especially those of African origin.[23]

United States

  • Lupus occurs from infancy to old age, with peak occurrence between ages 15 and 40.[19]
  • Lupus affects females in the US 6 to 10 times more often than males.[19]
  • Prevalence data are limited. Estimates vary and range from 1.8 to 7.6 cases per 100,000 persons per year in parts of the continental United States.[19]

Culture and society

  • In the early seasons of the television show House, members of the eponymous character's medical team often suggested lupus as a diagnosis for their patients, only to be rebuked. The rarity of legitimate lupus diagnoses in the show eventually became described as a running gag.[24][25]

See also

References

  1. ^ Fitzpatrick, Thomas B.; Klauss Wolff; Wolff, Klaus Dieter; Johnson, Richard R.; Suurmond, Dick; Richard Suurmond (2005). Fitzpatrick's color atlas and synopsis of clinical dermatology. New York: McGraw-Hill Medical Pub. Division. ISBN 978-0-07-144019-6.[page needed]
  2. ^ "Lupus - Symptoms and causes". Mayo Clinic. Retrieved 2022-02-12.
  3. ^ "Systemic Lupus Erythematosus (Lupus, SLE)". PubMed Health. National Library of Medicine.
  4. ^ Scheinfeld, Noah; Deleo, Vincent A (2004). "Photosensitivity in lupus erythematosus". Photodermatology, Photoimmunology and Photomedicine. 20 (5): 272–9. doi:10.1111/j.1600-0781.2004.00094.x. PMID 15379880. S2CID 25740605.
  5. ^ Kiriakidou, Marianthi; Cotton, D; Taichman, D; Williams, S (2013). "Systemic Lupus Erythematosus". Annals of Internal Medicine. 159 (7): ITC4–1. CiteSeerX 10.1.1.1008.5428. doi:10.7326/0003-4819-159-7-201310010-01004. PMID 24081299. S2CID 39068728.
  6. ^ Meas R, Burak MJ, Sweasy JB (August 2017). "DNA repair and systemic lupus erythematosus". DNA Repair (Amst.). 56: 174–182. doi:10.1016/j.dnarep.2017.06.020. PMC 5543809. PMID 28623091.
  7. ^ Adrovic, Amra; Dedeoglu, Reyhan; Sahin, Sezgin; Barut, Kenan; Koka, Aida; Cengiz, Dicle; Oztunc, Funda; Kasapcopur, Ozgur (2018-02-20). "Evaluation of pulmonary artery pressure in patients with juvenile systemic lupus erythematosus (jSLE)". Bosnian Journal of Basic Medical Sciences. 18 (1): 66–71. doi:10.17305/bjbms.2017.2178. ISSN 1840-4812. PMC 5826676. PMID 28704174.
  8. ^ 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. (2013). "Associations of clinical features and prognosis with age at disease onset in patients with systemic lupus erythematosus". Lupus. 23 (3): 327–34. doi:10.1177/0961203313513508. PMID 24297642. S2CID 11694732.
  9. ^ Voss, A.; Laustrup, H.; Hjelmborg, J.; Junker, P. (2013). "Survival in systemic lupus erythematosus, 1995–2010. A prospective study in a Danish community". Lupus. 22 (11): 1185–91. doi:10.1177/0961203313498796. PMID 23873432. S2CID 46247629.
  10. ^ "Lupus Facts, Symptoms, Rash, Effects, Complications, and More." WebMD, n.d. Web. 6 October 2014. http://www.webmd.com/lupus/arthritis-lupus.
  11. ^ Alenghat, Francis J (2016). "The Prevalence of Atherosclerosis in Those with Inflammatory Connective Tissue Disease by Race, Age, and Traditional Risk Factors". Scientific Reports. 6: 20303. Bibcode:2016NatSR...620303A. doi:10.1038/srep20303. PMC 4740809. PMID 26842423.
  12. ^ "Lupus - Diagnosis and treatment - Mayo Clinic". www.mayoclinic.org. Retrieved 2022-04-20.
  13. ^ a b "Diagnosing and Treating Lupus | CDC". www.cdc.gov. 2018-10-18. Retrieved 2022-02-12.
  14. ^ "Systemic lupus erythematosus: MedlinePlus Medical Encyclopedia". Medline Plus. US National Library of Medicine.
  15. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Disease of the Skin: Clinical Dermatology. (10th ed.). Saunders. Chapter 8. ISBN 0-7216-2921-0.[page needed]
  16. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1.[page needed]
  17. ^ Böhm I (2004). "Increased peripheral blood B-cells expressing the CD5 molecules in association to autoantibodies in patients with lupus erythematosus and evidence to selectively down-modulate them". Biomed Pharmacother. 58 (5): 338–43. doi:10.1016/j.biopha.2004.04.010. PMID 15194170.
  18. ^ Boehm IB, Boehm GA, Bauer R (1998). "Management of cutaneous lupus erythematosus with low-dose methotrexate: indication for modulation of inflammatory mechanisms". Rheumatol Int. 18 (2): 59–62. doi:10.1515/cclm.1993.31.10.667. PMID 9782534.
  19. ^ a b c d "Lupus - Arthritis". CDC. 2018-10-18.
  20. ^ Greco, Carol M; Rudy, Thomas E; Manzi, Susan (2004). "Effects of a stress-reduction program on psychological function, pain, and physical function of systemic lupus erythematosus patients: A randomized controlled trial". Arthritis Care & Research. 51 (4): 625–34. doi:10.1002/art.20533. PMID 15334437.
  21. ^ Dospinescu, Paula; Shamliyan, Tatyana A. (2017-07-01). "Additional Improvements in Clinical Response From Adjuvant Biologic Response Modifiers in Adults With Moderate to Severe Systemic Lupus Erythematosus Despite Immunosuppressive Agents: A Systematic Review and Meta-analysis". Clinical Therapeutics. 39 (7): 1479–1506.e45. doi:10.1016/j.clinthera.2017.05.359. ISSN 0149-2918. PMID 28673504.
  22. ^ a b c d . Archived from the original on June 29, 2013. Retrieved August 24, 2013.
  23. ^ a b c . Arthritis Research UK. Archived from the original on February 1, 2014. Retrieved August 24, 2013.
  24. ^ Kandell, Zachary (10 April 2020). "House MD: Why It's Never Lupus (And the One Time It Was)". ScreenRant. Retrieved 29 April 2022.
  25. ^ Vincent, Fabien B.; Mackay, Fabienne. "Why 'It's never lupus' - television, illness and the making of a meme". The Conversation.

External links

April 29, 2023
lupus, erythematosus, collection, autoimmune, diseases, which, human, immune, system, becomes, hyperactive, attacks, healthy, tissues, symptoms, these, diseases, affect, many, different, body, systems, including, joints, skin, kidneys, blood, cells, heart, lun. Lupus erythematosus is a collection of autoimmune diseases in which the human immune system becomes hyperactive and attacks healthy tissues 1 Symptoms of these diseases can affect many different body systems including joints skin kidneys blood cells heart and lungs The most common and most severe form is systemic lupus erythematosus Lupus erythematosusSpecialtyRheumatology Immunology Contents 1 Signs and symptoms 1 1 Photosensitivity 2 Genetics 2 1 Age difference 2 2 Differences in ethnicity 3 Diagnosis 3 1 Classification 4 Treatment 5 Epidemiology 5 1 Worldwide 5 2 United Kingdom 5 3 United States 6 Culture and society 7 See also 8 References 9 External linksSigns and symptoms EditSymptoms vary from person to person and may come and go Almost everyone with lupus has joint pain and swelling Some develop arthritis Frequently affected joints are the fingers hands wrists and knees 2 Other common symptoms include chest pain during respiration joint pain stiffness and swelling painless oral ulcer fatigue weight loss headaches fever with no other cause Skin lesions that appear worse after sun exposure general discomfort uneasiness or ill feeling malaise hair loss sensitivity to sunlight a butterfly facial rash seen in about half of people with SLE swollen lymph nodes 3 Photosensitivity Edit Photosensitivity is the amount to which an object reacts upon receiving photons especially in visible light Photosensitivity is a known symptom of lupus but its relationship to and influence on other aspects of the disease remain to be defined 4 Causes of photosensitivity may include change in autoantibody location cytotoxicity induction of apoptosis with autoantigens in apoptotic blebs upregulation of adhesion molecules and cytokines induction of nitric oxide synthase expression ultraviolet generated antigenic DNAGenetics EditIt is typically believed that lupus is influenced by multiple genes Lupus is usually influenced by gene polymorphisms 30 of which have now been linked with the disorder Some of these polymorphisms have been linked very tentatively however as the role that they play or the degree to which they influence the disease is unknown Other genes that are commonly thought to be associated with lupus are those in the human leukocyte antigen HLA family There have been several cases wherein a single gene influence appears to be present but this is rare When a single gene deficiency does cause lupus it is usually attributed to the complement protein genes C1 C2 or C4 The influence of sex chromosomes and environmental factors are also noteworthy Usually these factors contribute to lupus by influencing the immune system 5 Several studies also indicate a potential association of lupus with mutations in DNA repair genes 6 Age difference Edit Lupus can develop in people at any age but it does most commonly at ages 15 to 44 with varying results Typically the manifestation of the disease tends to be more acute in those of younger age Women are more likely to get it than men Patients with juvenile onset lupus are more vulnerable to mucocutaneous manifestations of the disease alopecia skin rash and ulceration of the mucus membranes than any other age group and they are also more susceptible to evaluation of pulmonary artery pressure 7 However patients with late onset lupus have a much higher mortality rate Nearly 50 of those with late onset lupus die of their condition Women who are of childbearing age are also particularly at risk 8 Differences in ethnicity Edit Substantial data have been found to indicate that certain ethnic populations could be more at risk for lupus erythematosus and to have a better or worse prognosis Asian African and Native Americans are more likely to get lupus than Caucasians Caucasians seem generally to have a milder manifestation of the disease Their survival rates after five years were typically around 94 96 while patients of African and some Asian ethnicities had survival rates closer to 79 92 The only documented ethnic group that had a higher survival rate than Caucasians was Koreans who had survival rates nearer to 98 Among Caucasians the most common causes of death were complications involving the cardiovascular system the respiratory system and malignancies 9 10 Atherosclerotic cardiovascular disease is more prevalent in African Americans with lupus than in Caucasians with lupus 11 Diagnosis EditDiagnosis of lupus will vary from person to person It is common to be diagnosed with other illnesses before a doctor can finally rule out lupus because a lot of the symptoms overlap with other common illness 12 Diagnosis of lupus erythematosus requires a physical examination blood and urine tests and a skin or kidney biopsy Some other tests that may need to be run include 13 Antinuclear antibody ANA CBC with differential Chest X ray Serum creatinine Urinalysis 14 Classification Edit Lupus erythematosus may manifest as systemic disease or in a purely cutaneous form also known as incomplete lupus erythematosus Lupus has four main types citation needed systemic discoid drug induced neonatalOf these systemic lupus erythematosus also known as SLE is the most common and serious form A more thorough categorization of lupus includes the following types 15 16 acute cutaneous lupus erythematosus subacute cutaneous lupus erythematosus discoid lupus erythematosus chronic cutaneous childhood discoid lupus erythematosus generalized discoid lupus erythematosus localized discoid lupus erythematosus chilblain lupus erythematosus Hutchinson lupus erythematosus lichen planus overlap syndrome lupus erythematosus panniculitis lupus erythematosus profundus tumid lupus erythematosus verrucous lupus erythematosus hypertrophic lupus erythematosus cutaneous lupus mucinosis complement deficiency syndromes drug induced lupus erythematosus neonatal lupus erythematosus systemic lupus erythematosusTreatment EditThere is still no cure for lupus but there are options to help control symptoms The goal for treatment is to prevent flare ups and reduce organ damage Doctors may prescribe a handful of different medications to help with their patients symptoms 13 Some medications are Nonsteroidal anti inflammatory drugs NSAIDs Corticosteroids Antimalarial drugs BLyS specific inhibitors Immunosuppressive agents chemotherapyAfter being diagnosed some treatment options that may be offered are See also Systemic lupus erythematosus Treatment Treatment consists primarily of immunosuppressive drugs e g hydroxychloroquine and corticosteroids A second line drug is methotrexate in its low dose schedule 17 18 In 2011 the U S Food and Drug Administration FDA approved the first new drug for lupus in more than 50 years to be used in the US belimumab 19 In addition to medical therapy cognitive behavioral therapy has also been demonstrated to be effective in reducing stress anxiety and depression due to the psychological and social impacts that lupus may have 20 People with SLE treated with standard care experience a higher risk of opportunistic infections and death than the general population This risk is higher in men and in African Americans 21 Epidemiology EditWorldwide Edit An estimated 5 million people worldwide have some form of lupus disease 22 70 of lupus cases diagnosed are systemic lupus erythematosus 22 20 of people with lupus will have a parent or sibling who already has lupus or may develop lupus 22 about 5 of the children born to individuals with lupus will develop the illness 22 United Kingdom Edit Females in the UK are seven times more likely to be diagnosed with SLE than males 23 The estimated number of females in the UK with SLE is 21 700 and the number of males is 3000 a total of 24 700 or 0 041 of the population 23 SLE is more common amongst certain ethnic groups than others especially those of African origin 23 United States Edit Lupus occurs from infancy to old age with peak occurrence between ages 15 and 40 19 Lupus affects females in the US 6 to 10 times more often than males 19 Prevalence data are limited Estimates vary and range from 1 8 to 7 6 cases per 100 000 persons per year in parts of the continental United States 19 Culture and society EditIn the early seasons of the television show House members of the eponymous character s medical team often suggested lupus as a diagnosis for their patients only to be rebuked The rarity of legitimate lupus diagnoses in the show eventually became described as a running gag 24 25 See also EditList of cutaneous conditions List of target antigens in pemphigoid List of immunofluorescence findings for autoimmune bullous conditions List of human leukocyte antigen alleles associated with cutaneous conditions List of people with lupusReferences Edit Fitzpatrick Thomas B Klauss Wolff Wolff Klaus Dieter Johnson Richard R Suurmond Dick Richard Suurmond 2005 Fitzpatrick s color atlas and synopsis of clinical dermatology New York McGraw Hill Medical Pub Division ISBN 978 0 07 144019 6 page needed Lupus Symptoms and causes Mayo Clinic Retrieved 2022 02 12 Systemic Lupus Erythematosus Lupus SLE PubMed Health National Library of Medicine Scheinfeld Noah Deleo Vincent A 2004 Photosensitivity in lupus erythematosus Photodermatology Photoimmunology and Photomedicine 20 5 272 9 doi 10 1111 j 1600 0781 2004 00094 x PMID 15379880 S2CID 25740605 Kiriakidou Marianthi Cotton D Taichman D Williams S 2013 Systemic Lupus Erythematosus Annals of Internal Medicine 159 7 ITC4 1 CiteSeerX 10 1 1 1008 5428 doi 10 7326 0003 4819 159 7 201310010 01004 PMID 24081299 S2CID 39068728 Meas R Burak MJ Sweasy JB August 2017 DNA repair and systemic lupus erythematosus DNA Repair Amst 56 174 182 doi 10 1016 j dnarep 2017 06 020 PMC 5543809 PMID 28623091 Adrovic Amra Dedeoglu Reyhan Sahin Sezgin Barut Kenan Koka Aida Cengiz Dicle Oztunc Funda Kasapcopur Ozgur 2018 02 20 Evaluation of pulmonary artery pressure in patients with juvenile systemic lupus erythematosus jSLE Bosnian Journal of Basic Medical Sciences 18 1 66 71 doi 10 17305 bjbms 2017 2178 ISSN 1840 4812 PMC 5826676 PMID 28704174 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 2013 Associations of clinical features and prognosis with age at disease onset in patients with systemic lupus erythematosus Lupus 23 3 327 34 doi 10 1177 0961203313513508 PMID 24297642 S2CID 11694732 Voss A Laustrup H Hjelmborg J Junker P 2013 Survival in systemic lupus erythematosus 1995 2010 A prospective study in a Danish community Lupus 22 11 1185 91 doi 10 1177 0961203313498796 PMID 23873432 S2CID 46247629 Lupus Facts Symptoms Rash Effects Complications and More WebMD n d Web 6 October 2014 http www webmd com lupus arthritis lupus Alenghat Francis J 2016 The Prevalence of Atherosclerosis in Those with Inflammatory Connective Tissue Disease by Race Age and Traditional Risk Factors Scientific Reports 6 20303 Bibcode 2016NatSR 620303A doi 10 1038 srep20303 PMC 4740809 PMID 26842423 Lupus Diagnosis and treatment Mayo Clinic www mayoclinic org Retrieved 2022 04 20 a b Diagnosing and Treating Lupus CDC www cdc gov 2018 10 18 Retrieved 2022 02 12 Systemic lupus erythematosus MedlinePlus Medical Encyclopedia Medline Plus US National Library of Medicine James William Berger Timothy Elston Dirk 2005 Andrews Disease of the Skin Clinical Dermatology 10th ed Saunders Chapter 8 ISBN 0 7216 2921 0 page needed Rapini Ronald P Bolognia Jean L Jorizzo Joseph L 2007 Dermatology 2 Volume Set St Louis Mosby ISBN 978 1 4160 2999 1 page needed Bohm I 2004 Increased peripheral blood B cells expressing the CD5 molecules in association to autoantibodies in patients with lupus erythematosus and evidence to selectively down modulate them Biomed Pharmacother 58 5 338 43 doi 10 1016 j biopha 2004 04 010 PMID 15194170 Boehm IB Boehm GA Bauer R 1998 Management of cutaneous lupus erythematosus with low dose methotrexate indication for modulation of inflammatory mechanisms Rheumatol Int 18 2 59 62 doi 10 1515 cclm 1993 31 10 667 PMID 9782534 a b c d Lupus Arthritis CDC 2018 10 18 Greco Carol M Rudy Thomas E Manzi Susan 2004 Effects of a stress reduction program on psychological function pain and physical function of systemic lupus erythematosus patients A randomized controlled trial Arthritis Care amp Research 51 4 625 34 doi 10 1002 art 20533 PMID 15334437 Dospinescu Paula Shamliyan Tatyana A 2017 07 01 Additional Improvements in Clinical Response From Adjuvant Biologic Response Modifiers in Adults With Moderate to Severe Systemic Lupus Erythematosus Despite Immunosuppressive Agents A Systematic Review and Meta analysis Clinical Therapeutics 39 7 1479 1506 e45 doi 10 1016 j clinthera 2017 05 359 ISSN 0149 2918 PMID 28673504 a b c d Media Relations Archived from the original on June 29 2013 Retrieved August 24 2013 a b c Lupus Arthritis Research UK Archived from the original on February 1 2014 Retrieved August 24 2013 Kandell Zachary 10 April 2020 House MD Why It s Never Lupus And the One Time It Was ScreenRant Retrieved 29 April 2022 Vincent Fabien B Mackay Fabienne Why It s never lupus television illness and the making of a meme The Conversation External links Edit Retrieved from https en wikipedia org w index php title Lupus erythematosus amp oldid 1150814450, wikipedia, wiki, book, books, library,

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