title: Clinical criteria for systemic lupus erythematosus precede diagnosis, and associated autoantibodies are present before clinical symptoms.
abstract: OBJECTIVE
  Specific events that occur during the development of systemic lupus erythematosus (SLE) can be quite variable among individual patients. The aim of this study was to identify patterns that distinguish early clinical events in SLE and to assess whether the presence of associated autoantibodies precedes the fulfillment of clinical criteria.
  
  
  METHODS
  Through a retrospective chart review of military medical records, 130 patients who met the American College of Rheumatology (ACR) criteria for the classification of SLE were identified. The initial time at which each criterion was fulfilled was recorded. Autoantibody analysis was performed on serum samples, using enzyme-linked immunosorbent assays or immunofluorescence.
  
  
  RESULTS
  The clinical features that were observed earliest were discoid rash and seizures, which developed a mean 1.74 and 1.70 years, respectively, before the diagnosis of SLE; however, arthritis was the criterion that was most commonly observed before diagnosis. The presence of IgG rheumatoid factor (IgG-RF) preceded the development of arthritis in 15 (94%) of the 16 patients who were positive for IgG-RF and in whom arthritis developed (Z = 10.2, P < 0.0001). Analogously, IgM-RF appeared before the development of arthritis in 13 (76%) of 17 patients. Anti-double-stranded DNA antibodies were associated with renal disease and appeared before evidence of nephritis in most patients (92%) (Z = 13.3, P < 0.0001). An analysis of the appearance of autoantibodies compared with the appearance of clinical criteria not associated with them revealed no significant temporal relationship.
  
  
  CONCLUSIONS
  Symptoms associated with the ACR criteria for classification of SLE are commonly present before the diagnosis of SLE, and development of organ-associated autoantibodies generally precedes the appearance of their associated clinical features.
authors.affiliation: Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA.
authors.forename: Latisha D
authors.initials: LD
authors.lastname: Heinlen
authors.forename: Micah T
authors.initials: MT
authors.lastname: McClain
authors.forename: Joan
authors.initials: J
authors.lastname: Merrill
authors.forename: Yasmin W
authors.initials: YW
authors.lastname: Akbarali
authors.forename: Colin C
authors.initials: CC
authors.lastname: Edgerton
authors.forename: John B
authors.initials: JB
authors.lastname: Harley
authors.forename: Judith A
authors.initials: JA
authors.lastname: James
mesh_terms: D001323:Autoantibodies / Q000097:blood*; D015415:Biomarkers / Q000097:blood; D015922:Complement C1q / Q000276:immunology; D003937:Diagnosis, Differential; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood; D008180:Lupus Erythematosus, Systemic / Q000175:diagnosis* / Q000276:immunology*; D008889:Military Personnel; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012217:Rheumatoid Factor / Q000097:blood; D014481:United States
chemical_list: D001323:Autoantibodies; D015415:Biomarkers; D007074:Immunoglobulin G; D015922:Complement C1q; D012217:Rheumatoid Factor