SECTION 1. What Is Lupus?
Differentiation from tuberculosis
Recognition of systemic lupus erythematosus
Systemic lupus erythematosus and “collagen disease”
Pathogenesis: Some breakthroughs
Classification criteria and disease indices
Management: Some breakthroughs
Prognosis: Just a few comments
2. Definition and classification of lupus and lupus-related disorders
Systemic lupus erythematosus
Drug-induced lupus erythematosus
Mixed connective tissue disease
Undifferentiated connective tissue disease and overlap syndromes
Antiphospholipid antibody syndrome
3. The epidemiology of lupus
The fundamentals of epidemiology
Pediatric systemic lupus erythematosus
Cutaneous lupus erythematosus
4. Overview of lupus pathogenesis
Phases of SLE: Evolution of disease in susceptible persons
Overview: The major pathways favoring development of SLE
Current approved and investigational therapies for SLE4
SLE susceptibility genes in cell death and clearance of self-antigens
SLE genes in toll-like receptor and IFN-I signaling
B-cell signaling in SLE genetics
SLE genes in T cell signaling
IL12 and JAK/STAT signaling
Transcription factors and epigenetic modifiers in SLE
Applications of the genetic findings
6. Single gene defects and autoinflammation: Relation to Lupus
Type I interfons and their role in autoimmune disease
Interferonopathies and associated molecular defects
Informing monogenic lupus
Therapeutic implications of RNA/DNA sensing in monogenic autoimmune disease and future directions
Histone modification in SLE
Translational application of epigenetics in lupus
8. The role of the environment and microbiome in lupus
Interplay between environmental, genetic, and epigenetic factors
Dietary influences on SLE
Environmental exposures and SLE
Methodologic considerations
9. The innate immune system in SLE
Cellular components of the innate immune system
Extracellular components of the innate immune system
Pattern recognition receptors: Pamps, damps, and pathways of innate immune stimulation in SLE
Innate immune detection of self versus nonself nucleic acid
10. B cells and generation of antibodies
Structure of the antibody molecule
Generation of antibody diversity
Posttranscriptional modifications of antibodies
Pathogenic autoantibodies
Genetic and molecular analysis of anti-DNA antibodies
B-cell subsets: Implications for SLE
Therapeutic interventions
Role of T cells in autoimmunity and inflammation
12. Immunoregulatory cells and networks in lupus
Myeloid-derived suppressor cells
Properties of cytokines and their receptors
Assessment of cytokine production
Use of gene expression to study cytokine effects
Activation of the immune response in systemic lupus erythematosus
Cytokines of the innate immune response
Cytokines of the adaptive immune response
14. Metabolic control of immunopathogenesis in systemic lupus erythematosus
Metabolic pathways regulate proinflammatory immune cell lineage specification via MTOR activation in SLE
Mitochondrial oxidative stress underlie MTOR activation in SLE
Mechanistic checkpoints of metabolic pathways represent targets for treatment in SLE
15. Animal models of systemic lupus erythematosus (SLE)
Multigenic spontaneous SLE
MRL-lpr mice and MRL/Mp (MRL+/+)
Nonfunctional Fas ligand in gld mice
(NZW×BXSB) F1 model of antiphospholipid syndrome and coronary artery disease
BXD2 RI model of spontaneous lupus nephritis and erosive polyarthritis (“rhupus”)
Monogenic spontaneous SLE
Induced lupus-like disease in nonautoimmune strains
Lupus induced by injection of hydrocarbon oil
Therapeutic interventions in mouse models of lupus
Lupus in domestic animals
SECTION 3. Mechanisms of Tissue Injury
16. Abnormalities in clearance of immune complexes and dying cells in lupus
Defective apoptotic cell clearance mechanisms in autoimmunity
Phosphatidylserine receptors
Role of “don’t eat me” receptors in systemic lupus erythematosus
Role of scavenger receptors in apoptotic cell clearance
Role of efferosome maturation in apoptotic cell clearance
Abnormalities in immune complex clearance
Tissue clearance mechanisms
Genetic abnormalities of Fcγ receptors
Other cell types involved in immune complex interactions
Other tissue clearance mechanisms
17. Complement and systemic lupus erythematosus
Biology of the complement system
Complement dysregulation and SLE
Complement defiency and SLE
Soluble complement components as biomarkers for SLE
Cell-bound complements as biomarkers for SLE
Complement-targeted therapeutics for SLE
18. Apoptosis and inflammatory forms of cell death
Introduction and definitions
Biochemistry of apoptosis
Deficiencies in death receptor signaling lead to systemic autoimmunity
Removal of dead and dying cells: Tolerance versus autoimmunity
Cell death abnormalities in human SLE
19. Tissue damage in lupus: Free Radicals and Fibrosis
Overview of reactive oxygen and nitrogen intermediates
Regulation of oxidant stress
Mechanisms through which ROI can modify DNA and change transcription
Association of ROI and RNI with SLE disease activity
T-cell regulation and function
Autophagy regulation and induction
Podocyte dysfunction induced by RNI
The role of NO• in vascular homeostasis
Renal anatomy and physiology
Histologic classification of lupus nephritis
Genetic risk for lupus nephritis
Mouse models of lupus nephritis
Mechanisms for immune complex deposition in the kidneys
Pauci-immune glomerulonephritis
Dissociation of immune complex deposition and/or glomerular injury from end-stage renal disease
Effector mechanisms in the kidney
Progression to fibrosis and sclerosis
Systems biology of lupus nephritis
Future directions in lupus nephritis
21. Pathogenesis of accelerated atherosclerosis and vascular injury in systemic lupus erythematosus
Epidemology of cardiovascular disease in systemic lupus erythematosus
Pathogenesis of premature atherosclerosis in SLE
The role of inflammatory lipids
Other factors associated with cardiovascular disease in SLE
22. Pathogenesis of cutaneous lupus
How understanding pathogenesis is changing treatment
23. Pathogenesis of neuropsychiatric lupus
Cell-mediated inflammation
Complement-mediated immunity
24. Pathogenesis of Sjögren syndrome
From a gland disease to a systemic disease
From pathogenesis to targeted treatment
SECTION 4. Autoantibodies
25. Antinuclear antibodies, antibodies to DNA, histones, and nucleosomes
Antinuclear antibody overview
Antibodies to DNA, histones, and nucleosomes
26. Antibodies against extractable nuclear antige ns (RNP, Sm, SS-A/RO, and SS-B/La)
Structure of the antigens
Assays for measuring anti-ENA antibodies
Prevalence and clinical associations in SLE
Origins of anti-ENA autoimmunity
Genetic risks and anti-ENA antibodies
Pathogenic importance of anti-RNP and anti-Sm antibodies
Pathogenic role of anti–SS-A/Ro and anti–SS-B/La antibodies
Autoantibodies against other ENA
27. Other autoantibodies: Antibodies to C1q, Lipoprotein, and Endothelial Cells
Antilipoprotein antibodies
Antiendothelial cell antibodies
28. Pathogenesis of antiphospholipid antibody syndrome
The clinical importance of antiphospholipid antibodies
Epidemiology of aPL and APS
Which aPL tests should be done and how should they be interpreted?
Antiphospholipid antibody–induced mechanisms of disease
Coronavirus disease 2019 and antiphospholipid antibodies
Role of cytokines—evidence from biologic agents
SECTION 5. Clinical Aspects of Lupus Erythematosus
30. Overview and clinical presentation
Clinical manifestations and racial disparities
Chief complaint, autoantibody development, and immunologic changes
Variations in clinical presentation
Categorization of lupus symptoms
31. Skin disease in cutaneous lupus erythematosus
Triggers of cutaneous lupus erythematosus
Relationship with systemic disease features
Lupus-nonspecific skin lesions
32. The musculoskeletal system and bone metabolism
Soft tissue disorders and other pain syndromes
Musculoskeletal infections
Musculoskeletal features in outcome measures
33. Lupus and the cardiovascular system
34. Pulmonary manifestations of systemic lupus erythematosus
Diseases of the mediastinum and musculature
Uncommon pulmonary involvement in SLE
Lung transplantation in SLE
35. Lupus and the nervous system: Clinical Presentation, Diagnosis, and Treatment
Clinical presentation of NPSLE
Neuroimaging studies in NPSLE
36. Gastrointestinal and hepatic manifestations
Gastrointestinal involvement
Liver manifestations of systemic lupus erythematosus
Biliary abnormalities: Cholecystitis, cholangitis, and biliary cirrhosis
Hepatobiliary and pancreatic malignancies
37. The gut microbiome and lupus pathogenesis
Microbiome dysbiosis and the etiopathogenesis of systemic lupus disease
Limitations of current approaches and future considerations
Key points and conclusions
38. Hematologic and lymphoid abnormalities in SLE
Immune-mediated hemolytic anemias
Thrombocytopenia and qualitative platelet disorders
White blood cell disorders
Bonus content for this chapter can be found online at
39. Neonatal lupus: Pathogenesis and Clinical Approaches
Candidate biomarkers and new theories relating to pathogenesis
40. Pregnancy and reproductive health issues in systemic lupus erythematosus
Hormones and reproductive immunology
Infertility and protection against premature ovarian failure
Antiphospholipid syndrome and pregnancy
Medications in SLE pregnancy
Bone health and osteoporosis
Reproductive health care and screening
41. Systemic lupus erythemato sus in childhood and adolescence
Diagnosis of SLE in children
Common medications in cSLE therapy
42. Clinical aspects of antiphospholipid syndrome
Risk factors for thrombosis in those with antiphospholipid antibodies
Diagnosis and laboratory testing
Management strategies in antiphospholipid syndrome
Other therapies in antiphospholipid syndrome
Prevalence of infections in SLE
Infections as a cause of morbidity and mortality in SLE
Risk factors for infections and serious infections in SLE
Protean spectrum of infection in SLE
Intrinsic immune dysfunction increasing infection susceptibility in SLE
Select genetic defects and risk of infection
Can biomarkers be used to differentiate between infection and disease flare?
Clinical approach to SLE patients with a suspected infection
44. Ocular, aural, and oral manifestations of lupus
Systemic lupus erythematosus and the eye
45. Clinical aspects of Sjögren’s disease
Introduction and epidemiology
Classification and diagnosis of Sjögren’s
46. Clinical presentations of lupus in the kidney and urogenital system
Lupus nephritis epidemiology and risk factors
Clinical presentation and diagnosis of lupus nephritis
Differential diagnosis of lupus nephritis
Histopathologic classification of lupus nephritis
Lupus nephritis biomarkers
Lupus nephritis during pregnancy
47. The endocrine system and hormones in lupus
Role of the hypothalamic-pituitary-adrenal axis in the pathogenesis of SLE
Does prolactin function as an inflammatory cytokine?
Sex hormones and their role in SLE
Specific endocrine disorders in SLE
Diabetes mellitus and SLE
Parathyroid disease in SLE
SECTION 6. Assessment of Lupus
48. Clinical application of serologic tests, serum protein abnormalities, and other laboratory tests in systemic lupus erythematosus
Monitoring disease activity in SLE
Clinical significance of anti-dsDNA antibodies
Anti–U1 ribonucleoprotein
Antinucleosome antibodies in SLE
Anti–ribosomal P antibodies
Anti-centromere and anti–SCL-70 antibodies
Other serologic abnormalities in SLE
Clustering of autoantibodies
49. Differential diagnosis and disease associations
Laboratory evaluation of suspected systemic lupus erythematosus
50. Incomplete lupus, undifferentiated connective tissue disease, and mixed connective tissue disease
Introduction and historical background
Undifferentiated connective tissue disease and incomplete lupus syndromes
Clinical findings in incomplete lupus erythematosus and undifferentiated connective tissue disease
Autoantibodies and immunologic findings
Mixed connective tissue disease
51. Clinical markers, metrics, indices, and clinical trials
Principles and approaches for assessing patients with lupus
Health-related quality of life
SECTION 7. Management of Lupus
52. Principles of therapy, local measures, and NSAIDs
General therapeutic considerations
Nonsteroidal antiinflammatory drugs for the treatment of SLE
53. Antimalarial medications
Efficacy of antimalarials
Adverse effects of antimalarials
54. Systemic glucocorticoid therapy for SLE
Therapeutic use of glucocorticoids in SLE
Molecular mechanisms of glucocorticoid action
Adverse effects of glucocorticoids
Conclusions and the future of glucocorticoid therapy in SLE
55. Immunosuppressive drug therapy
56. Complementary and integrative health approaches
57. Specialized and niche therapies
Treatment of patients with SLE and end-stage renal disease
Apheresis and related technologies
Should radiation therapy be avoided?
Niche therapies for lupus subsets
58. Adjunctive and preventive measures
Infection prevention in lupus
Antibiotic prophylaxis in lupus
Drug allergies in patients with lupus
Vitamin D supplementation in lupus
Adherence issues in lupus
59. Management of cutaneous lupus erythematosus
Oral/intravenous corticosteroids
Intravenous immunoglobulin
60. Targeted therapies in SLE
B cell directed therapies
T cell directed therapeutic approaches
61. Management of lupus nephritis
Clinical manifestations of lupus nephritis
Laboratory assessment of lupus nephritis
Kidney biopsy in the management of lupus nephritis
Histopathologic classification of lupus nephritis
Management of lupus nephritis
Renoprotective nonimmunosuppressive interventions
Antimalarial drugs in lupus nephritis
Expected results of the initial therapy
Nonimmune complex-mediated kidney injury in SLE
Long-term monitoring of lupus nephritis patients
Pregnancy in lupus nephritis
Progression to end-stage kidney disease
62. Management of Sjögren disease syndrome
Nonmedical therapy of dryness
Treatment of symptoms of mild-to-moderate dry eye
Treatment of moderate-to-severe dry eye
Overview of treatment of dry mouth
Treatment of systemic and extraglandular manifestations of Sjögren disease
Emerging therapies for the management of Sjögren disease
63. Socioeconomics, disparities, and disability
Physical health and quality of life
Mental health and well-being
Effect of illness on school and social support systems
Employment and long-term disability
Economic costs of systemic lupus erythematosus
Effects of adverse social determinants of health
64. Prognosis and mortality of systemic lupus erythematosus
Mortality in pediatric-onset SLE
Strategies for improved mortality outcomes in SLE
65. Future directions: Therapeutics
Innate immune system targets
Adaptive immune system targets
66. Expanding the opportunities to effectively treat patients: Clinical Considerations
Classification criteria and treatment guidance documents
The relevance of lupus subsets
Identifying relevant biomarkers and clinical determinants for precision medicine
Role of lupus advocacy groups