Please indicate in the box with an “x” which criteria the ...



Instructions and Glossary

Please indicate in the box with an “x” which criteria the patient meets ever.

Do not forget to also indicate which sub-sections apply to this particular person.

ACR Criteria for Classification of SLE*:

|Malar Rash: |Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds. |

|Discoid Rash: |Erythematosus raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur in |

| |older lesions. |

|Photosensitivity: |Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation. |

|Oral Ulcers: |Oral or nasopharyngeal ulceration, usually painless, observed by a physician. |

|Arthritis: |Non-erosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling or effusion. |

|Serositis: |a) Pleuritis-convincing history of pleuritic pain or rub heard by a physician or evidence of pleural effusion. |

| |b) Pericarditis-documented by ECG or rub or evidence of pericardial effusion. |

|Renal Disorder: |a) Persistent proteinuria greater than 0.5 grams per day or greater than 3+ if quantitation not performed. |

| |b) Cellular casts - may be red cell, hemoglobin, granular, tubular, or mixed. |

|Neurologic Disorder: |a) Seizures - in the absence of offending drugs or known metabolic derangements; e.g., uremia, ketoacidosis, or |

| |electrolyte imbalance. |

| |b) Psychosis in the absence of offending drugs. |

|Hematologic Disorder: |a) Hemolytic anemia - with reticulocytosis. |

| |b) Leukopenia - less than 4,000/mm3 total on two or more occasions. |

| |c) Lymphopenia - less than 1,500/mm3 on two or more occasions. |

| |d) Thrombocytopenia - less than 100,000/mm3 in the absence of offending drugs. |

|Immunologic Disorder: |a) Anti-DNA - presence of antibody to native DNA abnormal titer. |

| |b) Anti-Sm - presence of antibody to Sm nuclear antigen. |

| |c) Positive finding of antiphospholipid antibodies based on: |

| |an abnormal serum level of IgG or IgM anticardiolipin antibodies; |

| |a positive test for lupus anticoagulant using a standard method, |

| |a false-positive serologic test for syphilis known to be positive for at least 6 months and confirmed by Treponema |

| |pallidum immobilization or fluorescent treponemal antibody absorption test. |

|Antinuclear Antibody: |An abnormal titre of antinuclear antibody for immunofluorescence or an equivalent assay at any point in time and in the|

| |absence of drugs known to be associated with "drug-induced lupus”. |

*The proposed classification is based on 11 criteria. For the purpose of identifying patients in clinical studies, a person shall be said to have systemic lupus erythematosus if any 4 or more of the 11 criteria are present, serially or simultaneously, during any interval of observation.

Tan et al, (1982); Hochberg et al (1997)

|ACR Criteria for SLE |

|Date of Birth: | |Date of Diagnosis: |└─┴─┘/└─┴─┴─┴─┘ |

| |└─┴─┘/└─┴─┴─┘/└─┴─┴─┴─┘ | | |

| | dd mmm yyyy | | mm yyyy |

|Please provide the onset month and year for each criterion checked. |

|1. Malar rash |_________ /_____ |9. Hematologic |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|2. Discoid rash |_________ /_____ |9a. Hemolytic anemia |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|3. Photosensitivity |_________ /_____ |9b. Leucopenia |_________ /_____ |

| |Onset month/ year |(4.0 g/L) |Onset month/ year |

|4.Oral/nasal ulcerations |_________ /_____ |9c. Lymphopenia |_________ /_____ |

| |Onset month/ year |(1.5 g/L) |Onset month/ year |

|5. Arthritis |_________ /_____ |9d. Thrombocytopenia |_________ /_____ |

| |Onset month/ year |(100 g/L) |Onset month/ year |

|6. Serositis |_________ /_____ |10. Immunologic |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|6a. Pleuritis/ Pleural effusion |_________ /_____ |10b. Anti-dsDNA antibody positive |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|6b. Pericarditis |_________ /_____ |10c. Anti-Sm antibody positive |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|7. Renal |_________ /_____ |10d. Antiphospholipid antibody positive |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|7a. Proteinuria |_________ /_____ |10di. Anticardiolipin antibody positive |_________ /_____ |

|(persistant >0.5 g/24hrs) 0.5g/day, >3+ |Onset month/ year | |Onset month/ year |

|7b.Cellular casts (red blood cells, granular, |_________ /_____ |10dii. Lupus anticoagulant / inhibitor |_________ /_____ |

|hemoglobin, tubular, mixed) |Onset month/ year |positive |Onset month/ year |

|8. Neurologic |_________ /_____ |10diii. False Positive VDRL |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|8a. Seizures |_________ /_____ |11. ANA Antibody Positive |_________ /_____ |

| |Onset month/ year | |Onset month/ year |

|8b. Psychosis |_________ /_____ | | |

| |Onset month/ year | | |

| | | |

| |Total Score: _______ |

| | |

| Lupus Manifestations (Please check all that may apply) |

Please provide the onset month and year for each manifestation checked.

| | | |

|Constitutional |Onset date |Pulmonary |Onset date |Joints |Onset date |

|□ Arthralgias | |□ Pneumonitis | |□ Inflammatory arthritis | |

|□ Fever | |□ Pulmonary fibrosis | |□ Erosive arthritis | |

|□ Raynaud’s | | | | | |

|□ Weight loss | |□ Shrinking lung | |□ Deforming arthritis | |

|□ Fatigue | |□ Pulmonary hypertension | | |

|□ Raynaud’s | | |Immunologic Disorders | |

| | |Cardiovascular | |□ Sicca complex | |

|Integument | |□ Hypertension | |□ Diabetes | |

|□ Other lupus rash | |□ Libman Sachs endocarditis | |□ Fibromyalgia | |

|□ Cutaneous vasculitis | |□ CVA | |□ Overlap syndrome | |

|□ Major organ vasculitis | |□ TIA | |□ Other autoimmune disease | |

|□ Alopecia | |□ Thromboembolism | | |

|□ Alopecia totalis | | | |

|□ Myositis | |Gastrointestinal | |Immunologic Bloodwork | |

|□ Vitiligo | |□ Splenomegaly | |□ Anti-RNP antibody | |

|□ Digital ulcer | |□ Peritonitis | |□ Anti-Ro antibody | |

|□ Digital infarct | |□ Pancreatitis | |□ Anti-La antibody | |

|□ Periungual erythema | |□ Ischemic bowel | |□ Hypocomplementemia | |

|□ Splinter hemorrhages | |□ Autoimmune hepatitis | |□ Anti-jo-1 | |

|□ Livedo reticularis | |□ Cirrhosis | |□ Anti-scl70 | |

|□ Large telangiectasia | | |□ Anti-centromere | |

|□ Panniculitis/ E. nodosum | |Genitourinary | |□ P-ANCA | |

| |□ Spontaneous abortions | |□ C-ANCA | |

|Neurological | | |□ Other______________ | |

|□ Cognitive dysfunction | | |□ Other______________ | |

|□ Lupus Headache | |Renal | | | |

|□ Depression | |□ Nephrotic syndrome | | |

|□ Mononeuritis multiplex | |□ Interstitial nephritis | |Other Manifestations |

|□ Transverse myelitis | | |□ Diffuse lymphadenopathy | |

|□ Pseudotumor cerebri | | |□ Other_________________ | |

| | | |

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