MUCO CUTANEOUS MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS : SLE is a multi organ autoimmune disease of unknown etiology with many clinical manifestations. Cutaneous lesions account for 4 of 11 revised ACR criteria of SLE. CUTANEOUS MANIFESTATIONS OF SLE : SLE includes 3 major subtypes 1.Acute cutaneous LE. 2.Sub acute cutaneousLE. 3.Chronic cutaneous LE. 1.MALAR /BUTTERFLY RASH. 2.DISCOID LE (DLE) * Localised DLE. *Generalized DLE 3.PHOTOSENSITIVITY. 4.MUCOSAL DLE. *Oral DLE. *Conjunctival DLE. *Nasal DLE. *Genital DLE. 5.SUB ACUTE CUTANEOUS LE. 6.ALOPECIA. 7.LUPUS PANNICULITIS /LUPUS PROFUNDUS. 8.LICHENOID DLE. 9.SMALL VESSEL CUTANEOUS LEUCOCYTO- CLASTIC VASCULITIS SECONDARY TO SLE *Dependable palpable purpura. *Urticarial vasculitis. 10.SECONDARY ATROPHIE BLANCHE. 11.PERIUNGUAL TELENGIECTASIAS. 12.LIVEDO RETICULARIS. 13.RAYNAUD'S PHENOMENON. 14.BULLOUS LESIONS (BSLE). Diagnosis of cutaneous SLE is based on *Clinical features. *Histopathology. *Immunohistology. *Serum auto antibodies. 1.MALAR RASH. Characterized by erythematous rash over cheeks and nasal bridge.This typically spares naso labial folds.This is a fixed erthema which can be painful or pruritic. 2.PHOTOSENSITIVITY: Exposure to ultraviolet light causes skin rash or other symptoms of SLE flareups. A macular or diffuse erythematous rash occurs in sun exposed areas as face,arms or haands that persist for more than a day. 3.DISCOID RASH : DLE is a chronic dermatological disease. Lesions are disc shaped ,erythematous plaques of varying size which spread centrifugally. 4.ORAL ULCERS : The buccal mucosa,hard palate and vermilion border are the most frequently involved areas. There are 3 tpes oof oral lesions. *Discoid lesions :appear as central areas of erythema with white spots surrounded by radiating white striae and telengiectasia at the periphery. *Erythematous lesions. *Ulcers.. 5.ALOPECIA : 6.SUB ACUTE CUTANEOUS LE :(SCLE) SCLE is a photosensitive ,non scarring , non-indurated form of LE. Etipathogenesis of SCLE are *Reduced tolerance. *Induction of auto immunity (ultraviolet light , photosensitising drugs ,chemicals,cigerette, infection,phychological stress.). * Susceptibility genetic patrimony. HLA 8.1 ancestral hapotype. C2,C4 deficiency. TNF-ALPHA -308 A polymorphism C1q deficiency. *High levels of auto antibodies (Ro/SS-A). *Increased imune complexes,autoreactiveT cell *Tissue injury resulting from various autoimmune effector mechanisms. -direct T cell mediated cytotoxicity. -antibody-dependant cell mediated cytotoxicit The aim of treatment in SCLE is to improve patient's appearance and prevent the development of additional lesions. TREATMENT : Sun protective measures. corticosteroids(topical,intralesional) Anti malarials. Anti inflammatory immunosuppressive, immunomodulatory therapies like -auranofin -dapsone. -thalidomide. -retinoids. -interferon.

11 year old girl presented will complain of blackish discoloration of right hand fingers for 6-7 months. History of intravenous injection 7 month back and patient developed a gangrenous patch which is gradually increasing. C/o pain in right hand. On examination gangrenous of all 5 digits present. Radial artery is feeble. Wrist extenders are week. Patient also complaining of right sided chest pain. How to manage this patient and what could be cause of chest pain ?

CLINICAL FEATURES OF SYSTEMIC LUPUS ERYTHEMATOSUS: SLE is a chronic inflammatory disease which occurs when the body's immune system attacks its own tissues and organs. The body's immune system becomes hyperactive and attacks normal ,healthy tissue .Lupus can attack every organ in the body. Clinical features are described as follows. 1.Mucocutaneous features. 2.Nervous system features. 3.Ophthalmic features. 4.Cardiovascular features. 5.Pulmonary features. 6.Gastrointestinal tract&liver features. 7.Renal features. 8.Lymphadenopathy and spleenomegaly. 9.Hematological features. 10.Musculoskeletal features. MUCOCUTANEOUS FEATURES: Mucocutaneous features of SLE are classified as Acute,Subacute and Chronic lesions. ACUTE : MALAR RASH/BUTTERFLY RASH. The classic butterfly rash presents acutely as an erythematous,elevated lesion in a malar distribution over the bridge of the nose and cheeks ,commonly precipitated by exposure to sunlight.This rash is transient and heals without scarring. SUBACUTE RASH /SUBACUTE CUTANEOUS LUPUS ERYTHEMATOSUS(SCLE) SCLE lesions begin as small , erythematous, slightly scaly papules that evolve into either a psoriasiform /papulosquamous form or annular form which coalesce to form polycyclic or figurative patterns. These subacute lesions typically are symmetric widespread,superficial and non-scarring lesions.Neck,shoulders,upper chest,upper back. and extensor surface of hand are commonly involved.SCLE has been associated with the presence of anti-Ro/SS-A antibodies, genetic deficiencies of complement C2&C4. certain medications like hydrochlorothiazide. CHRONIC RASHES /DISCOID LUPUS ERYTHEMATOSUS(DLE). DLE lesions are characterised by discrete, erythematous,slightly infiltrated plaques covered by a well formed adherant scale that extends into dilated hair follicles (follicular plugging).They are mostly seen on the face,neck,scalp and ears.The characteristic pattern of slow expansion with active inflammation at the periphery which heal , leaving behind depressed central scars, atrophy,telangiectasias and dyspigmentation (hypo or hyper pigmentation) LUPUS PROFOUNDUS These are firm,nodular lesions which are painful and consists of peri-vascular infiltrates of mononuclear cells plus panniculitis .They usually appear on the scalp,face,arms ,chest back,thighs and buttocks. LUPUS TUMIDUS Characterised by photo distributed lesions with chronic pink,indurated plaques that are slow to heal. ALOPECIA. Alopecia occurs in SLE patients.It involves scalp,eyebrows,eyelashes,beard and body hair.Lupus hair is characterised by thin hair that easily fractures. PHOTOSENSITIVITY. Photosensitivity is defined as the development of rash after exposure to ultraviolet light coming from sunlight or florescent lights. MUCOUS MEMBRANES. The most common manifestations include irregularly shaped,raised white plaques,areas of erythema,silvery white scarred lesions and ulcers with surrounding erythema on the soft or hard palate or buccal mucosa.Oral ulcers in SLE are usually painless.

A male child presented with the history of hyperpigmented patches on the buttocks and leg for the past 2 days . The parents gave the history of fever with chills and rigor for the past 7 days for which he was admitted in a nursing home and has now recovered. He has not brought the previous case records. There is a history of joint pain in the child which has not fully recovered. On examination multiple irregular hyperpigmented patches with surrounding erythema present. They are tender on palpation.Cutaneous lymph nodes ( inguinal) are palpable and tender. The patient refuses investigation. Please give your opinion

11,/f first time in this winter.diagnisus?needed test? treatment?