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Immune: Systemic lupus erythematosus by Paul Bergner Medical Herbalism 9(4): 1, 3-13 This article is based on a review of the medical literature, both alternative and conventional, and on the histories of five cases treated by the author from 1996-1998. Systemic lupus erythematosus (SLE) is one of the most serious autoimmune diseases. Unlike other autoimmune conditions, SLE attacks a wide variety of tissues, and lupus-induced kidney damage can cause death. See Table 1 at the end of this article, for a list of the symptomatic manifestations of lupus, which may arise as the immune system attacks various tissues. Exacerbations and remissions of symptoms are typical. Conventional medicine lists lupus as a disease of unknown etiology, although a likely genetic component has been identified. If the disease were entirely due to genetics, however, we would expect to find equal rates among primitive people and those living in the developed countries. Incidence is much higher in the developed countries, and systemic lupus and other autoimmune diseases are rare in primitive societies following traditional lifestyle and dietary habits, although they begin to appear in those societies when Western diet and stresses are introduced (Trowell and Burkitt). Thus, natural therapies involving diet and lifestyle may be effective at modifying or removing the cause of SLE. Conventional treatment is symptomatic only, and in clinical practice drug side effects commonly complicate the symptom picture and make natural treatments more difficult. In emergency conditions or SLE complicated with myocarditis, ascites, uremia, or cerebral edema, conventional treatment should be initiated without delay. Natural treatment Natural and herbal treatment of SLE is controversial from a scientific point of view, usually based on empirical approaches, traditional Asian herbalism, or on emerging concepts of pathology which have not been definitively proven in the literature. TCM syndromes The underlying syndromes for systemic lupus in traditional Chinese medicine involve Deficiency patterns and Heat syndromes (especially Deficiency Heat or False Fire). The most important Chinese organ system for therapy is the Kidney, which in Western terms most closely fits the hypothalamic-pituitary-adrenal axis. The therapeutic challenge with herbal medicines (regardless of the medical paradigm) is how to tonify to increase strength in SLE patients without simultaneously increasing heat and inflammation. A window into the therapeutic balance necessary for treating lupus might be seen in the commercial formula Lithospermum 15, produced by the Institute for Traditional Medicine in Portland, OR. Table 1 shows the herbs in Lithospermum 15, and the rationale for their inclusion. Tonics in the formula are mild, and potentially overstimulating tonics such as deer antler or Asian ginseng (Panax ginseng) are avoided. About 20% of the volume of the formula is composed of cooling, heat-clearing herbs. Whatever paradigm of herbalism is used to treat SLE, the principle of using mild tonic herbs combined with cooling herbs is applicable.
Heat-clearing herbs The application of traditional Asian terms such as “heating” and “cooling” to Western herbs is in its infancy, and thus classification may be imprecise or subject to debate. In general, bitter herbs are viewed as “cooling,” and mild bitters may be useful in lupus. During remissions, gentle bitters such as dandelion (taraxacum off.), burdock (Arctium lappa), or agrimony (A. eupatoria, A. pilosa) might be included in formulas. During exacerbations, the stronger artemisia species might be used following the same “heat-clearing” strategy that conventional medicine applies with antimalarial drugs. Sweet Annie (Artemisia annua) is used in China as an antimalarial, and also used for exacerbations of SLE. A dose of 12-24 grams of the dry herb, decocted in a quart of water, and drunk in three doses throughout the day, may be appropriate. American ginseng (Panax quinquefolius) also has cooling properties, as do the leaves of Asian ginseng (Panax ginseng). Asian ginseng leaf costs only a few dollars a pound, whereas American ginseng root may cost several hundred dollars. Immunomodulating herbs Contemporary American herbalists classify a group of herbs, including reishi mushroom (Ganoderma lucidum), shiitake mushroom (Lentinus edodes), maitake mushrooms (xxx), and astragalus root (Astragalus membranaceus) as “immunomodulating.” The term is common is the journal articles of Asian scientists researching traditional Asian herbs and medicinal mushrooms (Chang; He J et al; He Y et al, 1992; Wang and Lin; Yoshida et al.) These herbs have complex actions on the immune system when measured in in-vitro and in-vivo trials. Among herbalists the term is used to indicate herbs that have traditionally been used to restore balance to the immune system rather than to stimulate it. The herbs tend to have a neutral “temperature” or mild action in traditional usage, and are traditionally taken for long periods of time in food quantities, especially as soups or decoctions. The herbs might be administered in a “tonic soup” which the patient can prepare in large quantities every few days. An example might be reishi mushroom, shiitake mushroom, astragalus, and peony root (Paeonia lactiflora), decocted in a nourishing soup with vegetables, grains as tolerated, meat, or meat broth. Peony root is a cooling tonic which can offset the tendency of astragalus to aggravate inflammation. The use of echinacea in lupus is controversial, with differences of opinion among practicing herbalists around the world. One of the five patients in this study reported that taking echinacea would make her lupus symptoms worse. She had tried it several times with rechallenge before stopping its use. Gut-healing herbs The article on the “leaky gut” syndrome [see “Gastrointestinal: Leaky gut, molecular mimicry, microchimerism, and autoimmunity” in this volume] explains the possible connection between loss of efficiency of the gut barrier and autoimmune conditions. Restoration of the integrity of the barrier may be the most important herbal therapy for autoimmune diseases, to modify their course or severity. A gut-healing strategy might include demulcent, antiinflammatory, and carminative herbs. One possible basic formula might include equal parts of chamomile (Matricaria recutita, M. chamomila), peppermint (Mentha piperita), fennel (Foeniculum vulgare), and licorice (Glycyrrhiza glabra). The herbs may be given in decoction or powdered. If powdered, they should be given in warm water. Amounts might be modified and other herbs added to the formula, depending on the presenting picture. Demulcents might best be given separately in order to provide more of the herb than would be available in dose. Slippery elm powder (Ulmus fulva) can be given with applesauce or added to oatmeal. Marshmallow (Althea off), can be given as a simple.
A possible complication of “leaky gut” is an overload of gut pathogens on the liver. Nutrients and herbs that support liver detoxification may be appropriate as addition either to a leaky gut formula or to tonic soups. The gentler cleansing herbs, such as dandelion, burdock, or agrimony might be preferred, along with the hepatoprotectant milk thistle seed (Silybum marianum). Nutrients such as magnesium and vitamin B6, essential to the process of liver detoxification, may be helpful, and may also reduce elevated estrogen levels which promote hyperactivity of the immune system. Diet/Supplements/Exercise Food allergies may be either a cause or a consequence of the leaky gut syndrome. The chief offenders appear to be dairy, wheat, and soy.[see “Gastrointestinal: Leaky gut, molecular mimicry, microchimerism, and autoimmunity” in this volume, for a full discussion of possible mechanisms]. All five SLE patients in this demonstrated severe allergies to dairy and/or wheat, confirmed by removal from the diet and rechallenge. Two of the patients could trigger full-blown lupus flareups with joint pain and/or kidney involvement by eating a single cookie made of wheat, with the outbreak following by 12-36 hours. Fasting and reintroduction of suspected foods may dramatically demonstrate to both practitioner and patient the importance of food allergies to the presenting symptom picture. Abandonment of the modern diet in favor of a whole foods diet is essential in the treatment of lupus. The foods most likely implicated in the Western diseases (see introduction) are sugar, refined flour, and refined oils, and margarine. Refined omega-six oils and margarine combined with a relative deficiency of omega-3 oils, such as appear in fish and wild game, can lead to prostaglandin imbalances that favor the inflammatory response. It is the author’s experience that flax oil and other omega-3 oils from vegetable sources are usually ineffective in treating inflammatory conditions, despite their popularity among customers of health foods stores. Wild salmon (not farmed) and/or sardines added to the diet on a regular basis can produce dramatic clinical results with reduced inflammation. Nutrition supplements administered must be selected for easy assimilation, because impaired digestion or intestinal absorption may otherwise render supplementation useless. An easily assimilable form of magnesium is essential. An ionic liquid mineral supplement high in magnesium is available from Trace Minerals Research in Utah. The author has seen dramatic changes in energy-level and/or inflammation in each of the patients above given this supplement.
Homeopathy, flower essences A history of suppression of symptoms with pharmaceutical drugs is the rule in lupus patients, even if they are currently refusing recommended steroids or chemotherapy agents. Underlying emotional complexes either predating the illness or in response to it are also common. These two conditions argue for the value of homeopathic remedies or flower essences, traditionally used to treat deep seated emotional conditions or the ill effects of suppression of symptoms with drugs. Stress management Each of the lupus patients in this review has suffered from mild to severe post-traumatic stress disorder, following major childhood traumas, sexual or physical abuse, or war, according to DSM IV criteria. Each also had unusual stress in their current situation, such as professional lives characterized by deadline pressures or pressure to overwork, abusive marital situations, or poverty. Chronic stress may lead to exhaustion of cortisol secretion by the adrenal glands (which might be measured by a simple salivary cortisol test). The loss of the antiinflammatory effects of the cortisol can exacerbate the autoimmunity. Dihydroepiandrosterone (DHEA) production by the adrenal glands may also be depleted, further contributing to immune imbalances and reduced tissue repair. TCM treatment of the Kidney organ system (see discussion above) is consistent with restoring proper adrenal function. Reducing stress is no simple matter clinically, and the full array of possibilities might be explored, including psychotherapy, group support, prayer, meditation, spa therapy, extended vacations, etc. DHEA supplementation may be helpful in severe cases of lupus, especially with kidney involvement, or to break the cycle of stress and adrenal depletion. In the author’s opinion, DHEA supplementation should be given only in conjunction with treatments that address the cause, and not relied on to “cure” the illness. Dosages of up to 100 mg of DHEA have been reported in the alternative treatment of lupus (Pizzorno), but therapeutic doses should normally be limited to 10-20 mg per day. DHEA does not address the cause of the disease, and will not heal the leaky gut or remove food allergens. Two-phase strategy A dual strategy, with separate treatments for outbreaks and remissions, may be useful. Fasting on water and lemon juice and resting during fever or severe inflammation can reduce the antigenic load on the gut and promote elimination of immune complexes. Mild heat-clearing herbs might also be appropriate, while all tonics should be discontinued during such a period. For milder outbreaks, a light diet or modified fast, especially from potentially allergenic foods, might be useful. Removal of medications The drugs commonly used to treat lupus, including NSAID and steroids, may themselves cause leaky gut syndrome. While they may have their place in treatment, healing is unlikely without their removal. Birth control pills may also induce leaky gut syndrome.
Case 1: Early Stage Lupus Patient: 25 y.o. female, 5’5" 120 lbs. Overall health self-assessment: 7 of 10 Chief complaint: Lupus-like autoimmune outbreaks. The patient was told she had “pre-lupus” by her physician. Raynauds phenomenon. Painful swelling of all the lymph glands in the body during attacks. Joint inflammation. Possible kidney pain. Low grade fever. About four outbreaks a year, spaced at regular three-month intervals. “Could set the calendar by them” Mild hair loss. Most recent outbreak three weeks prior. Daily meds: 1000 mg Vitamin C. Discontinued all conventional meds eight months prior. Lifestyle: 6-8 beers per week, in two sittings. 2-3 cups coffee per week Exercise (walk, jog, bike, etc) 60 minutes per day seven days a week. Sleeps 6-9 hours per night. Meditates regularly, especially past 3-6 months. High stress job. Ending long-term relationship. Diet: Diet diary revealed possible dairy allergy, with dairy binges. Drinks 2-3 quarts water a day. Family History: Father: Stomach ulcer, liver damage secondary to alcoholism. Deceased Paternal grandfather: allergy; heart disease Paternal grandmother: enlarged heart; allergies Great aunts and uncles: heart disease, allergy Great grandparents: Emphysema, arthritis Mother: symptoms of lupus without clear diagnosis; hair loss, Raynauds; easy bruising. Minor symptoms. One positive “anti-DNA antibody” test. Maternal grandfather: stomach ulcer, goiter, M.I., bone cancer, esophageal cancer. Maternal grandmother: allergy; headaches; arthritis; angina; osteoporosis.
Great aunts and uncles: enlarged thyroid; hypothyroid; stomach “upsets” Great grandparents: arthritis; prostate cancer; hypertension; osteoporosis; thyroid problems in extended family. Client History Fungal infection on bottom shortly after birth. Treated with “mycolog cream” — combination of nyastatin and corticosteroid. Breast fed for two weeks, but then put on soy formula. 2 months: first DPT shot, oral polio vaccine. Fungal infection cleared. No obvious adverse reactions to any immunizations. Introduced solid baby food. 3 months (Feb 8) Put on cow’s milk. Doctor says “may eat anything”. Second DPT shot 4 months (March 8) 3rd DPT shot, 2nd oral polio vaccine. (March 29) fungus on 3 fingers of each hand — index, middle, thumb — in symmetrical pattern. Tongue developed “raw spots” Unspecified medication. 6 months, Fungus infection still present 9 months (August 6). Eczema on scalp, head cold, diaper rash. Sulfur-salicylic acid shampoo prescribed for eczema. Meds for cold. 13 months. Corticosteroid cream for scalp eczema. Tegopen (cloxacillin) for recurrence of infection on finger. Age 6-12 Recurrent strep throat infections. Treated with repeated antibiotics. Age 12: Tonsillectomy for recurrent strep Teens: sulfa allergy; developed seasonal allergies to grasses; Mother says developed Raynauds phenomenon in teens. Age 13: Menarche. ovarian cysts. “bad” periods. Put on bc pills. Continuous until Norplant at age 23 Age 12-17: Repeated urinary tract infections; repeated antibiotics, with yeast infections as side effect. Received multiple prescriptions and antibiotics with simultaneous antifungals. Hospitalized with pyelonephritis. Eventual surgery to “stretch tubes” Doctor says ureters were congenitally too narrow — i.e. incomplete and slow draining of bladder. Age 22: January. Client says first Raynauds symptoms (See mother’s comments above). Age 22: March: Norplant. Menstruation stopped for next 2 ½ years Age 22: July: first lupus outbreak. Doctors thought it was mononucleosis. Age 24: September. Discontinued
Norplant.
Current outbreaks Swollen glands, tender to touch. All glands in body. Worse in breasts “don’t want them there.” Breast pain makes her cry. Can’t fully extend elbows. Can’t sleep on side. Can’t wear bra or tight clothes. Low grade fever: 100 degrees. Morning-evening fever pattern. Fatigue. Brain “shuts off”, confused, forgetful. Aggravation, frustration. Hair loss is getting worse with latest outbreak (started 2-3 months ago) . Lasts 1-2 weeks. Main trigger is stress. Two outbreaks ago, preceded by flu. Prodromal insomnia. Better with hot bath, better with warm blankets, better with hot tea. Systems Urogenital: repeated uti and kidney infection in teens. Surgery to “stretch” the tubes, which doctor said was too narrow, promoting urinary retention. Female BC pills since age thirteen after ovarian cysts and ‘bad" periods. Norplant at age 22-25. Suppressed periods completely. Removed nine months ago. Periods now normal, no cramps, every four weeks, 5-6 days. Not “a lot” of blood, no clots. “nice” deep red color. “happy to have it back.” Digestive: Upper GI pain after meals. Bloating. Cramping in small intestine. Constant gas. Emotional: expressed these verbally but does not show strong emotions: sadness, anger, stress. Assessment: *Congenital immune weakness and tendency to allergy *Probable dairy allergy. *Severe antibiotic suppression. *Possible “leaky gut” syndrome. *Suppression of fertility and feminine psychological development *Stress and adrenal exhaustion. *Post-traumatic stress disorder (events confidential) Treatments: Intensive education about the issues involved: food allergy, stress, and leaky gut. Diet: Increase fruits and vegetables. Eliminate dairy
Increase vitamin C to 2-4 grams/day and add equal parts bioflavonoids. Stress: Reduce heavy exercise to a moderate level. Stress management around work. Rest in natural setting as often as possible. Chinese immunodulating soup Red reishi mushroom (Ganoderma lucidum), shiitake mushroom (Lentinus edodes), astragalus (Astragalus membranaceus), poria (Poria cocos), licorice (Glycyrrhiza glabra). Equal parts. Place three handfuls in a 2 quart pot and simmer for two hours. Take three cups per day. If too “heating” add equal part of peony root (Paeonia lactiflora) and reduce astragalus by one-half part. (The tea was not heating and was well-tolerated by the patient.) Digestive tea. Peppermint (Mentha piperita), chamomile (Matricaria recutita), fennel (Foeniculum vulgare), licorice, (Glycyrrhiza glabra), marshmallow (Althea officinalis). Equal parts. Decoct 1 ounce per pint of tea for 20-30 minutes. Let come to room temperature. Strain and store in refrigerator. 3 cups per day, rewarmed to taste, on empty stomach. Castor oil packs, 3 days a week. (Client was reluctant to comply, and did not) Diet for outbreaks (Client had no further outbreaks) Diluted citrus juice fast for duration of fever. No dairy whatsoever. Complete rest. Consider short stay at nearby spa. Flower essences Salvia — extreme stress Dill — releasing power to others, victimization Celery — immune support during stress Psycho-spiritual To local Wise Woman practitioner for a “blood rites” ceremony to celebrate the psychospiritual passage that had been suppressed at menarche. Results The visits included a two-hour intake, with a one-hour educational follow-up. The patient received a dose of the flower essence at the end of second visit, and the formula above to be taken t.i.d. Over the next few weeks, a healing crisis ensued around abuse issues, with a happy resolution involving forgiveness. Hair loss stopped. During this period she eliminated dairy completely, and reported better overall energy and improved digestive symptoms.
Three month follow-up. Her lupus outbreaks had previously happened “like clockwork” every three months. At the anticipated three-month point, she ‘felt bad’ for a day and a half, but had no further symptoms. Referred to MD-homeopath for constitutional homeopathy and ongoing monitoring of immune status. Compliance with herbal treatments and elimination of dairy was good. Five-month follow-up. Patient called and said she had borderline diastolic hypertension, and asked if the herbs could cause this. I suggested she remove the licorice from all formulas. No further follow-ups. Case 2: Advanced Systemic Lupus with severe drug side effects Patient: 45 y.o. female Diagnosed with SLE at age 40. Drug-induced (methotrexate) cervical cancer at age 43. Chronic constipation since childhood: BM (dry) once in 5-7 days. Chronic gas, bloating, indigestion. Chronic lifelong PMS: bloating, weight-gain, breast tenderness, irritability, mild depression. History Almost died at age 2-3 from unidentified illness. Bleeding and convulsions. Measles, mumps, chicken pox during childhood. Age eight: Adverse reaction to multiple immunizations for travel: nausea, dizziness, and swelling of arm lasted two weeks. Chronic fatigue in teenage years. Blackout spells as teenager. Ran car into tree. No medical treatments Menses at 14 y.o.. History of physical and sexual abuse. Major PMS in teens and all adult life. 20 y.o. Severe PMS. Arthritic pains during PMS. Prednisone 10 mg for two years. Followed by strep throat in twenties on three occasions, emergency room treatment for one incident. Bladder infections. Treated with short-term antibiotics. Chronic fatigue in twenties.
Diagnosed as hypoglycemic in thirties. Married at 35 to chronic addict-alcoholic Extreme fatigue. Worse after marriage. Four miscarriages. Lupus onset was after last miscarriage, which coincided with family financial crisis. 38 y.o. Onset symptoms: Major itching all over body for one month; deep pain in both arms. One month later: joint pain throughout body. Right little finger ballooned. Could not move neck. Severe headaches. Crying with pain. Physically immobilized. Chills. Peripheral neurological symptoms. First diagnosis: “transient arthritis” Prednisone 60 mg plus NSAID, oral gold, and Darvocet for sleep. Moved to rental home after losing house. Collapsed with stress and slept for most of a week. Second diagnosis: rheumatoid arthritis. Cortisone 60 mg plus gold shots. Adverse (rash) reaction to gold. Gradually tapered cortisone to 5 mg. Rash. Methotrexate 7.5 mg/week. Hands crippled. Methotrexate 10 mg/wk. 40 y.o. major regression: low back pain, memory loss, discoid rash. Bronchitis (treated with antibiotics). Blurry vision. Temporary paralysis of right arm. Pain in eyes. Third diagnosis: “Mixed connective tissue arthritis.” Plaquenil (hydroxychroloquine) 200 mg day and methotrexate 12.5 weekly dose and cortisone (10-12 mg) and NSAID. Ocular side effects to Plaquenil. Fourth diagnosis: SLE. Prednisone 10 mg; methotrexate 10 mg/wk; NSAID; folic acid 1 mg; Plaquenil 200 mg. 41 y.o. CNS involvement with seizures. NSAID-induced ulcers. Weight loss in spite of prednisone. Plaquenil-induced photosensitivity. Had to wear sunglasses in house. Multiple infections. Excessive bleeding (clotting disorder). Proteinuria — upped cortisone to 30-50 mg. 42 y.o. Diagnosis: SLE and fibromyalgia. Methotrexate 12.5 mg/wk, prednisone 10 mg; Plaquenil 200 mg. Mixed NSAID. Cortisone injection in wrists. 43 y.o. Bitten by dog and had tetanus shot. Caused lupus flareup. Severe squamous cell cervical dysplasia and cervical carcinoma in-situ with endocervical gland involvement. Hysterectomy recommended. Patient was told she would die of cancer unless she stopped taking the drugs, or of kidney failure if she stopped taking them. Treatments
faced with a likely fatal diagnosis, the patient began to pray and study herbalism and natural healing. Over six months she started taking herbs and weaned herself from all drugs. Was drug-free by September 1995. Chinese tonic soup. The exact components have varied somewhat but include such items as: Shiitake and reishi mushrooms, astragalus, poria, coix, burdock, watercress, vegetables, brown rice, and millet. Major juice fast (three months). September 1995. Green juice and carrot. No joint pain. Energy good. “Never felt better.” Major juice fast (three months). Healing crisis with acne, boils, and mucous discharge. December 1995. Reintroduced foods, and identified dairy, meat, and wheat allergies. Diet Sardines four times a week. Salmon (contain antiinflammatory essential fatty acids). Organic vegetables. Organic grains, fresh-ground in vita-mix. Juice in AM: carrot, parsley, fresh ground flax, sesame and sunflower seeds, blackstrap molasses; ½ clove garlic. Soy protein. Other herbal treatments Chinese Artemisia (A. argyi) as “Plaquenil substitute” (antimalarial) 19 grams in three cups of water boil ten minutes. Reduces heat and joint pain. Deglycyrrhizinated licorice (DGL) for NSAID-induced ulcers. Bupleurum as a simple for PMS Supplements Bromelain 1800 mcu tid; Curcumin 500 tid (Patient says turmeric powder is more effective than the extracted curcumin for antiinflammatory effects); Vitamin C 5-6 grams; Pantothenic acid 500 mg bid; Multivitamin; Vitamin E (mixed toc.) 800 iu; B complex bid Results Patient had normal pap in Fall 1995 and has had four more normal paps since. Possible lupus flareups during herbal treatment: Hives: treated by Chinese practitioner, cleared in one week. Pleurisy: Treated successfully with Asclepias tuberosa Proteinuria: Treated successfully with ground flax seeds and flax seed oil. Treatment She approached the author for herbal advice in Summer 1996. Reduced astragalus and increased burdock in tonic soup to reduce heating effects.
Chamomile for sleep (patient could not tolerate valerian) and antiinflammatory effects. Leaky gut formula: Equal parts of peppermint, chamomile, fennel, licorice, slippery elm, and marshmallow. Patient removed the licorice because of increased bloating. Flower essences Broccoli — balance of personal power Celery — immune support during stress Comfrey — higher vibrational damage or injury Salvia — extreme stress Dill — Victimization (Take several drops three times a day or as desired) Within a week, the flower essences appeared to provoke a strong healing crisis. First symptoms were the emergence of suppressed emotions around her marriage. Then bleeding from rectum, shortness of breath, gums bleeding, cheeks puffed up. Self medicated with raspberry, white oak bark, witch hazel, and slippery elm. Lasted four days. Afterwards could manage lupus symptoms with one-fourth the previous dose of tonic herbs and artemisia. Fall 1996-Winter 1997 Patient discontinued most of herbal treatments, except for leaky gut formula. Feels generally worse, but is functional. One outbreak of hives (treated by Chinese herbalist). In February 1997 normal bowel movements (1x/day) began for first time in her life. Reintroduce the tonic soup and artemisia. Patient was under unusual stress during this time, and was counseled on stress-management strategies. Common elements in both cases Diagnosis: Patient 1 was told she probably had lupus but did not fit all the diagnostic criteria for it. Patient 2 received multiple misdiagnoses before finally being diagnosed with SLE. This illustrates the vague nature of the diagnosis of SLE. Etiology:
Successful treatment:
Table 1: Systemic Lupus Erythematosus Definition and prevalence Tissues and cells damaged by deposition of pathogenic auto-antibodies and immune complexes. Specific symptom manifestation is highly variable, and depends on which tissues are involved in the autoimmune response. Exacerbations and remissions are typical. 90% of cases are in women, usually of child-bearing age. More common in Blacks and Hispanics than in whites. Pathogenesis Production of pathogenic auto-antibodies and immune complexes coupled with failure to suppress them. Antigen-antibody complexes may be deposited in tissues, initiating inflammation. Usually phagocytosed, but clearance is poor in this and related diseases. Size of complexes may be an important factor C larger cause more tissue damage. Antigen or antibody excesses tend to smaller complexes. Antigen-antibody equivalence or mild antigen excess tend to larger complexes. Etiology Genetic factors: Abnormal humoral and cell-mediated immune responses. Genetic defects in aptosis (natural death) of B and/or T-cells. Pharmaceutical Drugs: SLE may be triggered or aggravated by procainamide, hydralazine, anticonvulsants, penicillins, sulfa drugs, immunizations, and oral contraceptives. Digestive: Phospholipids in cell walls of enteric bacteria may activate B-cells or antibodies and elicit cross-reactivity to ribose-phosphate backbone in DNA. Suggests important role for ALeaky Gut@ syndrome and molecular mimicry. See accompanying article ALeaky gut, molecular mimicry, and microchimerism@ Hormonal: Estrogen enhances and testosterone reduces antibody responses. May explain higher incidence in women, and triggering effect of oral contraceptives. Suggests importance of avoiding xeno-estrogens, and maximizing hepatic clearance of estrogens. Immune: B-cell hyperactivity. T-4 and T-cytotoxic cell deficiency during attacks. Elevated anti-nuclear and/or anti-DNA antibody titer and decreased serum complement (C3 and C4) during attacks. Interleukin secretion is diminished. Slow clearance of immune complexes due to inherited or acquired deficiencies in complement system. Overall pattern is one of elevated antibody activity with overall immune deficiency. Infection: Streptococcal or viral infections may trigger or aggravate. Stress: Physical or mental stress may trigger or aggravate. Reproductive: Fertility is normal, but miscarriage is high (30-50%). First trimester of pregnancy and first six weeks post-partum may trigger lupus (See accompanying article ALeaky gut, molecular mimicry, and microchimerism@) Clinical manifestations (only those occurring in a majority of patients are listed, others being possible.) Systemic (95%): Fatigue, malaise, fever, anorexia, nausea, weight loss Musculoskeletal (95%): Most common are arthralgias/myalagias and polyarthritis (60%) Cutaneous (80%): Most common are rashes, oral ulcers, and alopecia. Butterfly rash across nose and cheeks occurs in less than 50%. Hematologic (85%): Anemia and leukopenia are most common. Clotting and bleeding disorders may also develop. Neurologic (60%): Possible manifestations are organic brain syndromes, seizures, and peripheral neuropathies. Mild mental dysfunction is most common manifestation. Cardiopulmonary (60%): Pleurisy, pleural effusions, and pericarditis are most common. Renal (50%): Proteinuria and cellular casts are most common. Nephrotic syndrome (25%) and renal failure (5-10%) may occur. Most common cause of death in lupus patients. Gastrointestinal (45%): Nonspecific (anorexia, mild pain, diarrhea) and ascites are most common. Diagnosis Symptoms overlap with those of related connective tissue autoimmune disease. The American Rheumatism Association has issued a list of criteria for diagnosis of SLE as follows. Four or more of the signs must be present at some time during the course of the disease. Malar or discoid rash Photosensitivity Oral or nasopharyngeal ulcerations Nonerosive arthritis of two or more peripheral joints Pleuritis or pericarditis Profuse proteinuria, exceeding 0.5 g./day, or excessive cellular casts in the urine Seizures or psychoses Hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia Positive lupus erythematosus cell, anti-DNA, or anti-Sm test or chronic false-positive serologic test for syphilis Abnormal titer of antinuclear antibody. Prognosis Death may occur in 10-15% of cases due to kidney failure or autoimmune damage to the heart. Serious damage to central nervous system is also possible. Conventional treatments Non-steroidal antiinflammatory drugs (NSAID). Gastrointestinal side effects common. Nephrotoxicity is possible. Corticosteroids. Full range of side effects common: adrenal disorders, weight gain, infections, hypertension, osteoporosis, bone necrosis, cataracts, glaucoma, diabetes mellitus, myopathy, irregular menses, irritability, insomnia, and psychosis. Antimalarials. Ocular side effects common. Sources: Braunwald; Cahill References Braunwald, E. Harrison’s Principles of Internal Medicine, Eleventh Edition. New York: McGraw-Hill, 1987 Cahill, M. Professional Guide to Diseases. Springhouse, Pennsylvania: Springhouse Corporation, 1998 Chang R Functional properties of edible mushrooms. Nutr Rev 1996 Nov;54(11 Pt 2):S91-S93 Dharmananda S. A Bag of Pearls. Portland, Oregon: Institute for Traditional Medicine, 1990 He J, Li Y, Wei S, Guo M, Fu W. Effects of mixture of Astragalus membranaceus, Fructus Ligustri lucidi and Eclipta prostrata on immune function in mice Hua Hsi I Ko Ta Hsueh Hsueh Pao 1992 Sep;23(4):408-411 He Y, Li R, Chen Q, Lin Z, Xia D, Ma L Chemical studies on immunologically active polysaccharides of Ganoderma lucidum(Leyss. ex Fr.) Karst Chung Kuo Chung Yao Tsa Chih 1992 Apr;17(4):226-228 Pizzorno, J. Total Wellness. Rocklin, California: Prima Publishing, 1996 Trowell, H.C. and Burkitt, D.P. Western Diseases, their Emergence and Prevention. Cambridge, Massachusetts: Harvard University Press, 1981 Wang GL, Lin ZB The immunomodulatory effect of lentinan. Yao Hsueh Hsueh Pao 1996;31(2):86-90 Yoshida Y, Wang MQ, Liu JN, Shan BE, Yamashita U. Immunomodulating activity of Chinese medicinal herbs and Oldenlandia diffusa in particular Int J Immunopharmacol 1997 Jul;19(7):359-370. |
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