Spotlight on Research 2008

February 2008 (historical)

Researchers Correlate Clinical Criteria and Associated Antibodies in Lupus Patients

A retrospective study of people diagnosed with systemic lupus erythematosus (SLE) found that symptoms defined in the American College of Rheumatology (ACR) criteria for SLE, as well as certain autoantibodies, were generally present before the diagnosis was made. The research was partly supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Because SLE is a heterogeneous disease characterized by autoimmunity in various systems of the body, the initial presentation can be unpredictable. Many symptoms wax and wane over time, often delaying diagnosis and the start of therapy. Previous retrospective studies have explored the order of onset of clinical symptoms for SLE, but the findings of these studies were not correlated with the development of autoantibodies.

Judith A. James, M.D., Ph.D., and her colleagues at the Oklahoma Medical Research Foundation, the University of Oklahoma and Walter Reed Army Medical Center , sought to identify patterns among early clinical events in SLE as well as to assess whether the presence of SLE-associated autoantibodies precedes clinical manifestations.

Investigators conducted a retrospective chart review of 130 lupus patients, analyzing 633 serum samples taken at different times and noting when a criterion for SLE was fulfilled. (To be classified as having SLE, a person needs to meet at least 4 of the 11 ACR criteria.) The significant findings of the chart review included:

  • In 80 percent (104) of the patients, at least one clinical criterion for SLE appeared before SLE was diagnosed.
  • Among patients in whom criteria developed before diagnosis and who also ever developed antinuclear antibodies (ANAs), 84 percent (81) developed the ANAs before the first criterion appeared.
  • Discoid rashes and seizures were the earliest observed symptoms (with a mean onset of 1.74 years and 1.70 years prior to diagnosis, respectively).
  • Neither discoid rashes nor seizures tended to appear after diagnosis, whereas oral ulcers tended to appear only after diagnosis, making the latter a less useful diagnostic tool.
  • Among SLE patients with renal disease, anti-double-stranded deoxyribonucleic acid antibodies (or anti-dsDNA antibodies) appeared prior to, or at the same time as, ACR-defined renal disorder in the majority of patients who had both the autoantibodies and the renal disorder.
  • Arthritis was the most common symptom observed prior to the diagnosis of SLE. Arthritis-related findings included:
    • The autoantibody rheumatoid factor can be present in sera from patients with arthritis and in patients with SLE. The investigators noted that distinguishing between the two conditions is key because while treatment with biologic response modifiers may be suitable for patients with rheumatoid arthritis, these treatments may present concerns for SLE patients.
    • Rheumatoid factor appeared in 38 percent (49) of the SLE patients. Among those who were positive for rheumatoid factor and who also developed arthritis, the rheumatoid factor was almost always present before the arthritis.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the Department of Health and Human Services' National Institutes of Health, is to support research into the causes, treatment and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. For more information about NIAMS, call the information clearinghouse at (301) 495-4484 or (877) 22-NIAMS (free call) or visit the NIAMS Web site at


Heinlen L, et al. Clinical criteria for systemic lupus erythematosus precede diagnosis, and associated autoantibodies are present before clinical symptoms. Arthritis & Rheumatism 2007;56(7):2344-2351.