Lupus eritematosus sistemik (LES)

Penyakit autoimun yang melibatkan berbagai organ dengan

manifestasi klinis yang bervariasi dari yang ringan sampai berat .
Pada keadaan awal, sering sekali sukar dikenal sebagai LES,
karena manifestasinya sering tidak terjadi bersamaan.
Sampai saat ini penyebab LES belum diketahui ada dugaan faktor
genetik, infeksi dan lingkungan ikut berperan pada patofisiologi
LES
Lupus Eritematosus Sistemik

Lupus menyerang jaringan ikat pada seluruh tubuh, dengan penyebab

yang multifaktorial.
Biasanya terjadi pada seseorang yang memiliki predisposisi genetik dan
terekspos oleh beberapa faktor berikut ini :
Pengaruh lingkungan
Zat/agen infeksius
Obat-obat pencetus lupus
Sinar ultraviolet
Trauma fisik
Stress emosional atau faktor-faktor lainnya
Predisposisi genetik

Workshop LES-16-Februari-2008;Hotel Horison Bandung

Sel T
Sel T yang abnormal ( jumlah dan phenotipe)
Limfopenia
Penurunan subset supressor (CD4+CD45R+, 2H4+)
Penurunan 'naive cells (CD4/8CD45RA+).
Penurunan 'memory cells (CD4/8CD29). Berkorelasi
negatif dengan pembentukan anti DNA
Penurunan aktivitas sel suppressor
Peningkatan aktivitas sel helper (CD4+, DR+)

Respon proliperasi dan signal yang abnormal

Defective anti-CD2 proliferation
Circulating anti-CD45 antibodies
Sel B
Fungsi sel B yang abnormal
Aktifasi dari poliklonal sel B
Sel B intrinsik yang abnormal
Peningkatan respon terhadap stimulus sitokin
Mekanisme pengendapan imun kompleks
 Gambaran klinis LES
Limphadenopati Kelelahan
SSP 12-50% 90%
20% Panas lama
Hepotomepali/ 80-82%
Splenomegali BB turun
20% 60%

Sal cerna
LES Artritis/Artralgia
90%
18%
Kulit
Paru 50-58%
38% Ginjal
Hematologi 50%
Jantung Vaskulitis
50%
48%
Faktor pencetus/eksaserbasi
Procainamid
Hidralazin Sinar UV
Obat : (320-400 nm)
Metildopa
CPZ

Keguguran Infeksi
LES

Tindakan
Kehamilan pembedahan
 ANA
Negative Positive

No disease Peripheral (rim) Diffuse (homogeneous) Centromere Nucleoli

Lab error
Treatment
Remission Anti-dsDNA Anti-nucleoprotein Histone Raynauds
Antigen XS phenomenon
Nephrotic syndrome
SLE SLE SLE Scleroderma
RA RA
Drug LE Drug LE
CREST
Sdleroderma

Speckled

RNP Sm RO (SS-A) La PcNA Scl-70 PM/Jo/Ku/Mi No specificity

UCTD
SLE
SLE SLE SLE SLE SLE Scleroderma PM/DM RA
MCTD Sogrens Sogrens Liver disease
RA syndrome syndrome Mono
Scleroderma Any chronic
UCTD inflammatory disease
Lupus Eritematosus Sistemik

American College of Rheumatology (ACR) membuat kriteria LES yang

secara bertahap (revisi 3 kali)
Kriteria klasifikasi tersebut memiliki penekanan pada kelainan yang
berbeda-beda yaitu :
1. 1971, konsentrasi di kelainan kulit : fotosensitiviti pada kulit,
oral ulcer, butterfly rash dan lesi discoid
2. 1982, berkaitan dengan organ spesifik : pleuritis, kelainan ginjal,
kelainan neurologi dan persendian.

Workshop LES-16-Februari-2008;Hotel Horison Bandung

Lupus Eritematosus Sistemik

Penegakkan diagnosis
3. 1996 : merupakan revisi terakhir, meliputi kriteria
berikut :
Kriteria untuk kelainan kulit
Butterfly rash (lupus/malar rash yang meliputi pipi dan hidung)
Discoid rash (kelainan kulit lebih tebal, biasanya disertai skar,
biasanya didaerah kulit yang terpapar sinar matahari)
Fotosensitivity/ sun sensitivity (rash/kulit kemerahan setelah
terpapar sinar ultraviolet A dan B)
Oral ulcer (ulkus di mulut, biasanya di langit-langit rongga
mulut atau hidung, dan tidak nyeri.

Workshop LES-16-Februari-2008;Hotel Horison Bandung

Lupus Eritematosus Sistemik

Penegakkan diagnosis
Kriteria sistemik
Artritis (peradangan pada sendi sendi jari tangan dan kaki disertai
pembengkakan, nyeri bahkan penumpukan cairan)
Serositis (peradangan pada selaput pleura, selaput pericardial dan
peritoneum)
Kelainan ginjal (proteinuri atau kelainan pada sediment urine secara
mikroskopis)
Kelainan neurology (kejang atau psikosa tanpa sebab yang jelas)

Workshop LES-16-Februari-2008;Hotel Horison Bandung

Lupus Eritematosus Sistemik

Penegakkan diagnosis

Kriteria laboratoris :
Kelainan darah (anemia hemolitik, leucopenia,
trombositopenia)
Kelainan imunologi (Anti-DsDNA [+],
antiphospholipid antibodi [+], lupus
anticoagulant [+], false positif test sifilis, atau
anti-Sm[+])
ANA test [+].

Workshop LES-16-Februari-2008;Hotel Horison Bandung

Pemeriksaan SLE
Diagnosis (ANA test, ds DNA, ANA panel)
Defisiensi komplemen-berhubungan dengan
reaksi hipersensitivitas (CH50,C3,C4,C1q)
Complement activation plays a
critical role in the inflammatory
process and tissue damage in SLE,
but early complement deficiencies
cause SLE.

Complement prevents SLE through:

processing and clearing of
immune complexes
Clinical Laboratory Testing
Serum complement hemolytic activity: CH50
(serum dilution at which 50% hemolysis occurs)
if low = complement deficiency
PEMERIKSAAN AKTIVITAS
KOMPLEMEN CH50
CH50 is a measure of total complement (dilutions
until will not lyse 50% if antibody coated cells)
If CH50 is low, then order C3 and C4 quantitative
levels
C3 with normal C4: defect in alternate pathway
C4 suggests defect in classic pathway
 Lysis of cell
CH50

+
90
80
70

% Hemolysis
60
50 CH50 =
40
30 98
37 C incubated
20
10
0
0 100 200 300
Dilutions of serum

Sample with different dilution 50% hemolysis occurs

CH50
CH50 assay a test of total complement activity as the
capacity of serum to lyse a standard preparation of
sheep red blood cells coated with antisheep
erythrocyte antibody. The reciprocal of the dilution of
serum that lyses 50 per cent of the erythrocytes is the
whole complement titer in CH50 units per milliliter of
serum.
Pemeriksaan C3 dan C4
PEMERIKSAAN CIRCULATING IMUN COMPLEX
C1q-CIC

Mendeteksi CIC yang mengandung

fragmen komplemen C1q
Prinsip pemeriksaan : ELISA
Nilai referensi : 40 g/ml : negatif
Positif > 50 g/ml
Equivocal 40-50 g/ml
Prinsip test
The assay wells are coated with a monoclonal
antibody specific for the C1q component of
complement. On adding diluted serum to the
wells, any C1q containing CICs present bind to
the antigen. After incubating and washing away
unbound material, horseradish peroxidase
conjugated anti-human IgG monoclonal
antibody is added which binds to C1q and IgG
containing CICs.
 Following incubation and washing, the
substrate (tetramethyl benzidine) is added
to each well. The presence of the {conjugate -
cic - antigen} complex turns the substrate to a
dark blue colour. Addition of stop solution
turns the colour to yellow.
The colour intensity is proportional to the
amount of C1q containing CICs present in
the serum.
 Grossly haemolysed, lipaemic or
microbiologically contaminated samples should
not be used.
A negative result should not be used as a sole
criterion to rule out SLE, RA or other
autoimmune disease but must be taken in
relation to other clinical observations and
diagnostic tests.
It should be noted that C1q containing CICs do
occur in other autoimmune or non-
autoimmune conditions..
C4 C3 Fc.B Jalur cth
N klasik SLE
Alternatif
inf.bakteri
sintesis komponen
inf.akut
ANA TEST
 IFA
Tahap 1 : serum pasien direaksikan dengan
substrat ag pada well sehingga terbentuk
komplek ag-ab
Tahap 2: fluorescen yang dilabel ab antihuman
akan terikat dengan kompleks dan hasilnya
adalah fluorescen hijau cerah
Jika tidak terbentuk kompleks maka fluorescen
negatif
interpretasi
Pola utama :
1.Periferal
2.Homogenous
3.Speckled
4.nucleolar
 ANA PATTERN, AUTOANTIGENS AND DISEASE ASSOCIATION
PATTERN/POLA ANTIGEN TARGET DISEASE ASSOCIATIONS
PERIPHERAL Histones; ds DNA; Lamin A,B,C SLE
Membrane pore protein Chronic autoimmune hepatitis
Primary biliary cirrhosis
Polymyositis
HOMOGENOUS Histones;dsDNA SLE
Drug induced lupus
Rheumatoid arthritis
SPECKLED SSA+SSB; RNA polymerase; Scl-70 SLE
Sm; snRNP,hnRNP Sjogren
Nuclear matrix protein; hnRNA Scleroderma
Polymyositis
Dermatomyositis
SLE
MCTD
SLE
Chronic rheumatic disease
NUCLEOLAR PM-Scl; multiprotein complex Polymyositis-Scleroderma overlap
Ku syndrome
RNA polymerase; Rnase Polymyositis-Scleroderma
Fibrillarin protein (U3) SLE
Scleroderma
Systemic sclerosis
NUCLEAR DOTS P80collin +sn RNA Primary biliary cirrhosis
Sjogren
Rarely SLE
RIBOSOMAL Actin; cytokeratin;tropomyosin; Vimentin, Autoimmune hepatitis
Vinculin Rheumatoid arthritis
Non-specific inflammatory dis.
 ELISA
Anti-Nuclear Antibodies (ANA) ELISA kit is based on
binding of ANA from serum samples to extracted nuclear
antigen immobilized on microtiter wells. After a washing
step, goat anti-human IgG-HRP conjugate is added. After
another washing step, to remove all the unbound enzyme
conjugate, chromogenic substrate (TMB) is added and
color developed. The enzymatic reaction (color) is directly
proportional to the amount of ANA present in the sample.
Adding stopping solution terminates the reaction.
Absorbance is then measured on a microtiter well ELISA
reader at 450 nm and the concentration of ANA in samples
is calculated as ANA index (AI) which is defined as the ratio
of net absorbance of the test sample and net absorbance of
the negative or endpoint-cutoff control.
 Negative samples <0..90
Equivocal (borderline) >0.91-0.99
>1.00 is interpreted as positive for IgG ANA.
ELISA
 ANA PROFILE
Immunoblotting
Uses enzyme labeled antibodies
against human immunoglobulin to
detect antinuclear antibodies
which bind to nuclear antigen
displayed in characteristic position
on the agarose gel after they have
been electrophoretically
separated. The antibodies
detected by reaction of the
enzyme labeled antibodies with a
colour producing enzyme
substrate. The positive colour
changes in the band are read
visually.
43
 Coombs test?
Pemeriksaan immunohematology yang
menggunakan reagensia coombs serum atau
AHG (Anti Human Globulin)

Direct Coombs Test : Sel darah merah Ab

coated invivo

Indirect Coombs Test : Serum / Plasma Ab

invitro

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