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original article

A crosssectional hospital based study of clinical and

immunological profile of systemic lupus erythematosus
patients from central rural India
Sachin Ratanlal Agrawal, Iadarilang Tiewsoh, Atulsingh Rajput, Ajitprasad Jain

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ABSTRACT

Website: www.ijaai.in

DOI: 10.4103/0972-6691.116614
Quick Response Code:

Introduction: Systemic lupus erythematosus(SLE) is a multisystem autoimmune

disorder, the expression of which is greatly influenced by the combined effect
of genetic, environmental, demographic and geographical factors. Various
studies regarding clinical and immunological profile of SLE patients in India
has been reported from a different region of India, especially from the urban
area. We performed this study to understand the clinical and immunological
profile of the SLE patients presenting to tertiary care center in rural central India.
Materials and Methods: This study was conducted at a rural teaching hospital
in central India. All patients records from 2007 to 2012 available with hospital
having a discharge diagnosis of SLE and fulfilling the revised American College
of Rheumatology criteria(1997) for SLE were analyzed regarding clinical and
immunological profile. Results: We found 87 SLE patients out of 52,133patients
admitted in medicine department from 2007 to 2012 in the hospital record and
included in the analysis. Nearly, 98% patients were female and 84% patients
were under the age of 40years. Common features present in these patients
were immunological(97.7%), mucocutaneous(83.9%), hematological(72.4%)
and renal(69.0%). Malar rash was the most common clinical feature presented
in 71.3% patients followed by photosensitivity(63.2%) and oral ulcers(42.5%).
Lymphopenia was the most common hematological abnormality present in
48.3%. Involvement of neurological, cardiovascular and respiratory system was
found to be less common. Antinuclear antibodies were found to be positive in
nearly 98% patients. Conclusion: Analysis of clinical profile of hospitalized SLE
patients shows that the disease is more common in female patients, especially
during the child bearing age group. The present study shows high frequency
of mucocutaneous, hematological and renal manifestation in these patients.
Key words: Central rural India, clinical and immunological profile, systemic
lupus erythematosus

Department of Internal Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
Address for correspondence: Dr.Sachin Ratanlal Agrawal, Department of Internal Medicine, Mahatma Gandhi Institute of Medical Sciences,
Sevagram, Wardha442001, Maharashtra, India. Email:dragrawal82@gmail.com

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Agrawal, etal.: Clinical and immunological profile of SLE

INTRODUCTION
Systemic lupus erythematosus(SLE) is a multisystem
autoimmune disorder affecting mainly female gender
especially during child bearing age group. The prevalence
rate has been reported to be 52/100,000 populations in
United States with higher rates reported among black and
Hispanic group.[1] Review study conducted from Asia has
shown the prevalence rate of disease from 30 to 50/100,000
population.[2] One prevalence study conducted from rural
India has shown very low prevalence rate(3.2/100,000
population). [3] In another study conducted in Eastern
India found that 3.9% of the children in the rheumatology
department had SLE.[4] However, larger epidemiological
studies are needed to confirm the finding of these studies
regarding the prevalence of disease in India. Due to the
role of estrogen in etiopathogenesis of disease, SLE is more
common in female as compare with male, especially in child
bearing age group with a ratio ranging from 7:1 to 15:1.[5]
The disease expression is greatly influenced by the
combined effect of genetic, environmental, demographic
and geographical factors. Genetic factor superimposed
on certain environmental factors plays a very pivotal
role in manifesting abnormal immunological response.
Considerable variation has been observed regarding various
clinical manifestation of SLE among various ethnic groups
as well as various geographical regions. The first case of SLE
in India was reported in 1955.[6] Subsequently, studies have
been conducted in different parts of the country describing
the encountered manifestations in the Indian population
with SLE.
Various studies regarding clinical and immunological profile
of SLE patients in India has been reported from different
region of India. [712] Most of these studies come from
northern or western part of India and only one study has been
reported from central India.[13] Thus, there exists a gap in our
understanding regarding clinical and immunological profile
of SLE patients, especially from rural India. We performed
this study to understand the clinical and immunological
profile of the SLE patients presenting to tertiary care center
in rural central India.

MATERIALS AND METHODS

Setting
The study was conducted in Kasturba Hospital Sevagram,
which is a 648bedded tertiary teaching hospital. All patients
who are discharge from the hospital are given electronic
discharge summary, which consist of detail clinical history,
examination and relevant investigations. All discharge
diagnosis and summaries are filed with hospital information
system and classified as per international classification of
disease10.
34

Data collection
We screened retrospectively all patients admitted to
medicine department from the period of 20072012
through the hospital information system. We chose this
period because detail information about the patient was
not available through hospital information system prior
to this period. All patients having a discharge diagnosis
of SLE and fulfilling the revised American College of
Rheumatology(ACR) criteria(1997) for SLE were included
in the study. We collected the detail information of all
these patients with respect to demographic characteristics,
duration of disease and assessment of various organs
involvement like cutaneous, musculoskeletal, renal,
gastrointestinal tract, nervous and cardiopulmonary. We
collected data regarding various investigation including
complete blood count, urine microscopic examination,
24h urine protein excretion, serum creatinine, blood urea,
chest radiograph and electrocardiogram. We retrieved
the information regarding auto antibodies level in all
included patients mainly antinuclear antibodies(ANAs)
and antidoublestranded deoxyribonucleic acid(Ds DNA)
antibodies. However, due to financial constraints, antiDs
DNA antibodies level could be obtained only in 49patients
out of 87. The Institutional Ethics Committee approved
the study design. We did not collect any personal identity
information from the discharge certificates.
Analysis
We did a descriptive analysis of all demographic features
of all included patients. We performed the analysis of all
clinical features present in SLE patients and calculated
the cumulative percentage frequency of all clinical features
present in SLE patients. We also calculated the cumulative
percentage frequency of various systems involved in SLE
patients.

RESULTS
Out of 52,133patients admitted in medicine department
from 2007 to 2012, 87patients were found to have SLE.
85(97.7%) patients were female and 2(2.3%) were male. The
patients age at the time of presentation varies from 15years
to 60years with a mean of 31years(SD10.75years). Out
of 87patients, 73(83.9%) patients were under the age of
40years.
Figure1 show the various systems involved in SLE
patients. Most common features involved in these patients
were immunological(97.7%), mucocutaneous(83.9%),
hematological(72.4%) and renal(69.0%). Table1
shows the clinical profile of all SLE patients. Among
the various mucocutaneous manifestation, malar rash
was the most common clinical feature presented in
62(71.3%) patients followed by photosensitivity and oral
ulcers in 55(63.2%) and 37(42.5%) patients respectively.
Renal involvement was present in 60(69%) patients

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Agrawal, etal.: Clinical and immunological profile of SLE

and hemolytic anemia was present in 13(14.9%) and

7(8.1%) patients respectively. Regarding immunological
profile, 85patients(97.7%) were positive for ANA. Data
about antiDs DNA antibodies was available for 49patients,
out of which 46(94%) were found to be positive.

Figure1: Various systems involved in systemic lupus

erythematosus patients(n=87)

Table1: Clinical and immunological profile of SLE patients

Variables
Age distribution
<20years
2140years
>40years
Sex distribution
Male
Female
Clinical features
Mucocutaneous manifestation
Malar rash
Discoid rash
Alopecia
Oral ulcer
Photosensitivity
Hematological
Hemolytic anemia
Leucopenia
Lymphopenia
Thrombocytopenia
Renal
Proteinuria(>0.5 g/d)
Elevated serum creatinine
Active urinary cast
Neurological
Psychosis
Seizures
CVA
Musculoskeletal
Arthralgia
Nonspecific symptom(unexplained fever, myalgia)
Serositis
Pleural effusion
Pericardial effusion
Antinuclear antibodies
AntiDs antibodies(49/87)

No. of cases(%)
19(21.8)
54(62.1)
14(16.1)
2(2.3)
85(97.7)
62(71.3)
28(32.2)
9(10.34)
37(42.53)
55(63.2)
7(8.1)
16(18.4)
42(48.3)
13(14.9)
57(65.5)
21(25.3)
3(3.5)
3(3.5)
0
1(1.15)
46(52.9)
72(82.8)
6(6.9)
2(2.3)
85(97.7)
46(93.9)

SLE-Systemic lupus erythematosus, CVA-Cerebrovascular accidents

of whom the most common feature was proteinuria in

57(65.5%) patients followed by deranged creatinine
and active urinary sediment in 21(25.3%) and 3(3.5%)
patients respectively. Hematological features were found
in 63(72.4%) patients. Lymphopenia(<1,500/cumm) was
the most common hematological abnormality present in
42patients(48.3%) followed by leucopenia(<4,000/cumm) in
16patients(18.5%). Thrombocytopenia(<100,000/cumm)

Arthralgia was noticed in 46patients(52.9%). Regarding

neurological problems, 3patients(3.5%) were found to
have psychosis and 1(1.2%) patient suffered an ischemic
stroke. With respect to pulmonary and cardiac involvement,
6patients(7%) were found to have pleural effusion and
2patients(2.3%) had pericardial effusion. 3patients(3.5%)
were suffering from interstitial fibrosis and 2patients had
pulmonary tuberculosis.

DISCUSSION
In the present study of clinical and immunological profile
of hospitalized SLE patients, we found that the disease
was more common in female patients especially during the
child bearing age group. Our study showed higher frequency
of immunological, mucocutaneous, hematological and
renal involvement in hospitalized patients. Involvement
of neurological, cardiovascular and respiratory system
was found to be less common. This study signifies detail
clinical examination and focused investigation in patients
suspected to have SLE, especially in female patients of
child bearing age.
Various studies have been conducted from different part
of the country regarding clinical and epidemiological of
SLE[Table2]. Astudy done by Malaviya etal.[9] analyzing
1366 SLE patients from different part of India shows
significant high proportion of patients presenting with
mucocutaneous manifestations specially arthralgia(85%)
malar rash(58.5%) and renal involvement(57%). Similar
result has been found in our study showing involvement
of mucocutaneous and renal manifestations in 83.9% and
70% patients. Malar rash(71.3%) and fever(82.8%) was
the most common clinical feature in the present study.
However, studies conducted by Binoy etal.[10] and Kosaraju
etal.[11] from the south India have shown less prevalence of
mucocutaneous manifestation, which might be because of
dark complexion of the study population making it difficult
to detect these features.
Regional variation has been observed regarding renal
involvement in SLE patients ranging from 20% to 73%.
Study conducted from the northern[7] and western India[12]
has shown high prevalence of renal involvement as compare
with south India. [8,10,11] Present study has shown similar
finding of high prevalence of renal involvement(69%) in the
SLE patients. However, one study conducted from central
India has shown less prevalence of renal involvement.[13]
Prevalence of neuropsychiatric manifestation among SLE
patients varies worldwide with higher prevalence noted

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Agrawal, etal.: Clinical and immunological profile of SLE

Table2: Cumulative percentage frequency of clinical manifestations in patients with SLE from different studies in India
Clinical
manifestations
Malar rash
Discoid rash
Alopecia
Oral ulcer
Photosensitivity
Arthralgia
Fever
Hemolytic anemia
Leucopenia
Lymphopenia
Thrombocytopenia
Renal
Neuropsychiatric
Pulmonary
Cardiovascular
ANA
Ds DNA

Malaviya
(1988)[7]
n=329(%)
85
NA
82
64
67
92
NA
7
16
20
11
73
38
NA
29
98
55

Madhavan
(1988)[8]
n=330(%)
74
NA
75
51
52
90
74
1
12.6
7.5
7.5
45
29
NA
28
96
60.5

Malaviya
(1997)[9]
n=1366(%)
58.5
7
NA
57
48
85
77
4
NA
NA
9
57
51
NA
NA
97
68

Binoy
(2003)[10]
n=75(%)
40
5.3
60
64
32
89.3
NA
1.3
14.7
NA
12
33.3
13.3
8
5.3
93.3
76

Kosaraju
(2010)[11]
n=48(%)
35.41
NA
18.75
25
27.08
64.58
58.33
2
NA
NA
NA
20.83
8.33
12.5
NA
64.28
89.36

Saigal
(2011)[12]
n=60(%)
43.3
1.7
65
61.7
75
86.7
NA
25
43.3
NA
33.3
56.7
13.3
11.7
6.7
98.3
65

Present study
n=87(%)
71.3(n=62)
32.2(n=28)
10.34(n=9)
42.53(n=37)
63.2(n=55)
52.9(n=46)
82.8(n=72)
8.1(n=7)
18.4(n=16)
48.3(n=42)
14.9(n=13)
69(n=60)
4.6(n=4)
12.6(n=11)
2.3(n=2)
97.7(n=85)
93.9(n=46/49)

NA-Not available, Ds DNA-Doublestranded deoxyribonucleic acid, ANA-Antinuclear antibody, SLE-Systemic lupus erythematosus

in the Indian patients as compare to other ethnic

groups.[14] Study conducted by Malaviya etal.[9] from India
has shown that nearly half of the Indian patients of SLE
has neuropsychiatric manifestation during the course of
illness with more prevalence from the northern India[6] as
compare to western or south India.[1012] Our study showed
only 4patients(4.6%) presenting with neuropsychiatric
manifestation. Higher prevalence of neuropsychiatric
manifestations in the previous study might be because of
inclusion of the broader group of manifestation included in
the study population and lack of standard definition given
by ACR in 1997.
Hematological involvement was seen in 72.4% patients
in the present study. Among the various hematological
criteria defined by ACR, lymphopenia was the most
prevalence(48.3%) in our study. This might be because
of unregulated cell mediated immunity playing a vital
role in the pathogenesis of disease. Other significant
hematological abnormality found in the present study
was leucopenia(18.4%) and thrombocytopenia(14.9%).
Overall prevalence of hematological manifestation has
been found to be low in various Indian studies with the
highest prevalent found to be in the study conducted by
Binoy etal. [10] from western India. Pleuroparenchymal
involvement in the form of serositis was present only in
8patients(9.2%); however, study from North and South
India[8,9] have shown higher prevalence of cardiovascular
manifestations.
ANA is highly sensitive diagnostic test that can be used for
screening the patients suspected to have SLE on clinical
evaluation. However, because of low specificity it cannot
be used for confirmation of disease. Our study shows that
nearly 98% of patients were positive for ANA by indirect
immunoflorescence method, which was consistence with
36

other studies done from different part of India. However,

a study conducted from South India[11] have shown low
positivity for ANA(64.28%). The possible explanation
for this as given by the author might be because of low
titer of ANA to be detected by diagnostic test or not long
enough followup of patients. In contrast to ANA, antiDs
antibody is highly specific test to confirmation of SLE.
Various epidemiological studies from the India have shown
positivity of antiDs DNA antibody ranging from 55% to
76% with the exception of the study conducted from South
India,[11] which had high positive result in 89% patients.
The present study also has very high percentage of positive
antiDs DNA antibody results(94%). Since we could retrieve
the data regarding antiDs DNA antibody level only in
49patients(56%), this might be giving high number of a
positive result regarding antiDs DNA antibody. Unlike ANA
level, antiDs DNA antibody level correlates very well with
disease severity.[15]
Our study has certain strengths. Our study included all the
consecutive patients of SLE diagnosed based on American
Rheumatology Association criteria to minimize sampling
bias. We included all the physician verified clinical features
based on their discharge summary for the analysis purpose.
However, our study has few limitations. First, since it was
a crosssectional study based on hospitalized patients, it
might be possible that more severe SLE patients requiring
hospitalization was included in the study and SLE patients
presenting on outpatient basis might differ in clinical
presentation as compare to inpatients. Hence, this clinical
profile of the SLE patients may not be truly representative
of clinical profile of SLE patients in the community. Second;
since followup of these SLE patients was not available;
hence, we could not observe the change in clinical profile
of these patients as the disease progress. Third, we could
obtain antiDs DNA antibody level only in around half of the

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Agrawal, etal.: Clinical and immunological profile of SLE

patients, which might be the reason for very high proportion

of patients positive for antiDs DNA.
To conclude, analysis of clinical profile of hospitalized SLE
patients shows that the disease is more common in female
patients, especially during the child bearing age group.
Present study shows high frequency of mucocutaneous,
hematological and renal manifestation in these patients.
Various geographical variations across the country need to
be kept in mind while dealing with these patients.

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How to cite this article: Agrawal SR, Tiewsoh I, Rajput A, Jain A. A

cross-sectional hospital based study of clinical and immunological profile
of systemic lupus erythematosus patients from central rural India. Indian
J Allergy Asthma Immunol 2013;27:33-7.
Source of Support: Nil, Conflict of Interest: None declared.

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