Unique clinical characteristics, autoantibodies and medication use in Native American patients with systemic lupus erythematosus

Towards an understanding of the biopsychosocial determinants of CVD in SLE: a scoping review

OBJECTIVE

Systemic lupus erythematosus (SLE) is a chronic autoimmune condition with significant physical, mental, psychosocial and economic impacts. A main driver of SLE morbidity and mortality is cardiovascular disease (CVD). Both SLE and CVD exhibit disparities related to gender, race and other social dimensions linked with biological outcomes and health trajectories. However, the biospsychosocial dimensions of CVD in SLE populations remain poorly understood. The objective of this study was to systematically investigate the existing literature around known social factors influencing the development of CVD in SLE.

METHODS

A scoping review protocol was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines. The search strategy encompassed three main concepts: SLE, CVD and social factors. Four databases were searched (PubMed, SCOPUS, PsychINFO and CINAHL). 682 studies were identified for screening. Articles were screened in two phases (title/abstract and full text) to determine whether they fulfilled the selection criteria.

RESULTS

Nine studies were included after screening. All were conducted in the USA between 2009 and 2017. Six studies (67%) were cross-sectional and three (33%) were longitudinal. Most employed SLE cohorts (n=7, 78%) and two drew from healthcare databases (n=2; 22%). We identified five main themes encompassing social factors: socioeconomic status and education (n=5; 56%), race and/or ethnicity (n=7; 78%), mental health (n=2; 22%), gender (n=3; 33%) and healthcare quality and/or insurance (n=2; 22%). Overall, low income, fewer years of education, black race and/or ethnicity, depression, male gender, lack of insurance and healthcare fragmentation were all associated with CVD risk factors and outcomes in SLE.

CONCLUSIONS

While several social factors contribute to CVD in SLE populations, considerable gaps remain as many social determinants remain un(der)explored. There is rich opportunity to integrate social theory, advance conceptualisations of race and/or ethnicity and gender, expand investigations of mental health and explore novel geographical contexts. In healthcare policy and practice, identified social factors should be considered for SLE populations during decision-making and treatment, and education resources should be targeted for these groups.

Contributions of Synthetic Chemicals to Autoimmune Disease Development and Occurrence

PURPOSE OF REVIEW

Exposure to many synthetic chemicals has been linked to a variety of adverse human health effects, including autoimmune diseases. In this scoping review, we summarize recent evidence detailing the effects of synthetic environmental chemicals on autoimmune diseases and highlight current research gaps and recommendations for future studies.

RECENT FINDINGS

We identified 68 recent publications related to environmental chemical exposures and autoimmune diseases. Most studies evaluated exposure to persistent environmental chemicals and autoimmune conditions including rheumatoid arthritis (RA), systemic lupus (SLE), systemic sclerosis (SSc), and ulcerative colitis (UC) and Crohn's disease. Results of recent original research studies were mixed, and available data for some exposure-outcome associations were particularly limited. PFAS and autoimmune inflammatory bowel diseases (UC and CD) and pesticides and RA appeared to be the most frequently studied exposure-outcome associations among recent publications, despite a historical research focus on solvents. Recent studies have provided additional evidence for the associations of exposure to synthetic chemicals with certain autoimmune conditions. However, impacts on other autoimmune outcomes, particularly less prevalent conditions, remain unclear. Owing to the ubiquitous nature of many of these exposures and their potential impacts on autoimmune risk, additional studies are needed to better evaluate these relationships, particularly for understudied autoimmune conditions. Future research should include larger longitudinal studies and studies among more diverse populations to elucidate the temporal relationships between exposure-outcome pairs and to identify potential population subgroups that may be more adversely impacted by immune modulation caused by exposure to these chemicals.

Coccidioidomycosis in Oklahoma: A retrospective case series

BACKGROUND

Coccidioidomycosis is a systemic fungal disease endemic to arid regions of the Western Hemisphere. In the south-western US, Coccidioides spp. may account for up to 20%-25% of all cases of community acquired pneumonia. Clinical manifestations vary widely, from asymptomatic infection to life-threatening disease, especially in immunocompromised hosts.

OBJECTIVES

The primary objective of the study was to characterise cases of coccidioidomycosis in an area of the United States not considered traditionally endemic for the disease.

METHODS

We performed a single-centre retrospective study of all cases of coccidioidomycosis from 1 January 2000 to 31 December 2020, in the University of Oklahoma Health Sciences Medical Center.

RESULTS

A total of 26 patients were included for analysis. The central nervous system (CNS) and the lungs were the sites most frequently involved. Twenty (77%) had travelled to a coccidioidomycosis endemic region. Most were male (81%) with a median age of 42 years (range: 3-78 years). The majority (46%) were Caucasians, 19% were African American, 19% Hispanic, and 12% Native American. The most common comorbidities were diabetes mellitus and acquired immunodeficiency syndrome, identified in 27% and 23% of patients, respectively. Patients on immunosuppressive therapy accounted for 12% of all cases.

CONCLUSION

Our study is one of the largest single-centre case series of coccidioidomycosis from a non-endemic area. Diabetes mellitus was the most frequent comorbidity. Compared to other case series of coccidioidomycosis, our patient population had higher rates of immunosuppression and had both a higher rate of disseminated disease and overall mortality.

Systemic lupus erythematosus in American Indian/Alaska natives: Incorporating our new understanding of the biology of trauma

OBJECTIVE

To review the literature regarding systemic lupus erythematosus (SLE) in American Indian/Alaska Native (AI/AN) people and relate prevalence and/or disease severity to our emerging understanding of the biology of trauma and toxic stress.

METHODS

We conducted a search and review of the literature using search terms "lupus and American Indians" "ACEs and disease outcome" "Biology of Adversity" "lupus and ACE scores," " lupus and childhood abuse." These search criteria were entered into Google Scholar and articles retrieved from PubMed, NBCI. This approach yielded a small numbers of papers used throughout this review. We excluded articles that were not published in a peer reviewed journals, as well as editorial commentaries.

RESULTS

In the AI/AN population, SLE shows high prevalence rates and severe disease manifestations, comparable to the African American population. AI/AN populations also have high rates of childhood trauma. Toxic stress and trauma such as those catalogued in the Adverse Childhood Experiences (ACE) study have broad-reaching immunologic and epigenetic effects that are likely to be relevant to our understanding of SLE in AI/AN people.

CONCLUSIONS

AI/AN people have high rates of SLE. These high rates are likely to be driven by many complex factors, not all of which are genetic. Future research is needed to establish (or refute) a causal connection between the biology of adversity and SLE in socially marginalized and historically traumatized populations.

Exposure of Akwesasne Mohawk women to polychlorinated biphenyls and hexachlorobenzene is associated with increased serum levels of thyroid peroxidase autoantibodies

Persistent organic pollutants (POPs) including polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB), and dichlorodiphenyltrichloroethane (p,p'-DDT) were reported to influence immunological activity. As endocrine-disrupting chemicals (EDC), these pollutants may disrupt normal thyroid function and act as catalysts for development of autoimmune thyroid disease by directly and indirectly affecting levels of thyroid peroxidase antibodies (TPOAbs). Native American communities are disproportionately exposed to harmful toxicants and are at an increased risk of developing an autoimmune disease. The aim of this study was to determine the association between POPs and TPOAbs in serum obtained from Native American women. This assessment was used to measure whether increased risk of autoimmune thyroid disease occurred as a result of exposure to POPs. Data were collected from 183 Akwesasne Mohawk women, 21-38 years of age, between 2009 and 2013. Multivariate analyses were conducted to determine the association between toxicant exposure and levels of TPOAbs. In multiple logistic regression analyses, exposure to PCB congener 33 was related to elevated risk of individuals possessing above normal levels of TPOAbs. Further, HCB was associated with more than 2-fold higher risk of possessing above normal levels of TPOAbs compared to women with normal levels of TPOAbs. p,p'-DDE was not associated with TPOAb levels within this study. Exposure to PCB congener 33 and HCB was correlated with above normal levels of TPOAbs, a marker of autoimmune thyroid disease. Additional investigations are needed to establish the causes and factors surrounding autoimmune thyroid disease which are multiple and complex.

Ancestry-based differences in the immune phenotype are associated with lupus activity

Systemic lupus erythematosus (SLE) affects 1 in 537 Black women, which is >2-fold more than White women. Black patients develop the disease at a younger age, have more severe symptoms, and have a greater chance of early mortality. We used a multiomics approach to uncover ancestry-associated immune alterations in patients with SLE and healthy controls that may contribute biologically to disease disparities. Cell composition, signaling, epigenetics, and proteomics were evaluated by mass cytometry; droplet-based single-cell transcriptomics and proteomics; and bead-based multiplex soluble mediator levels in plasma. We observed altered whole blood frequencies and enhanced activity in CD8+ T cells, B cells, monocytes, and DCs in Black patients with more active disease. Epigenetic modifications in CD8+ T cells (H3K27ac) could distinguish disease activity level in Black patients and differentiate Black from White patient samples. TLR3/4/7/8/9-related gene expression was elevated in immune cells from Black patients with SLE, and TLR7/8/9 and IFN-α phospho-signaling and cytokine responses were heightened even in immune cells from healthy Black control patients compared with White individuals. TLR stimulation of healthy immune cells recapitulated the ancestry-associated SLE immunophenotypes. This multiomic resource defines ancestry-associated immune phenotypes that differ between Black and White patients with SLE, which may influence the course and severity of SLE and other diseases.

Unique Serum Immune Phenotypes and Stratification of Oklahoma Native American Rheumatic Disease Patients

OBJECTIVE

Native American (NA) populations have higher rates of rheumatic disease and present with overlapping disease symptoms and nontraditional serologic features, thus presenting an urgent need for better biomarkers in NA diagnostics. This study used a machine learning approach to identify immune signatures that more effectively stratify NA patients with rheumatic disease.

METHODS

Adult NA patients with autoantibody-positive (AAB+) rheumatoid arthritis (RA; n = 28), autoantibody negative (AAB-) RA (n = 18), systemic autoimmune rheumatic disease (n = 28), arthralgia/osteoarthritis (n = 28), or polyarthritis/undifferentiated connective tissue disease (n = 28), and control patients (n = 28) provided serum samples for cytokine, chemokine, and AAB assessment. Random forest clustering and soluble mediator groups were used to identify patients and control patients with similar biologic signatures. The American College of Rheumatology criteria specific for systemic disease and RA identified differences in disease manifestations across clusters.

RESULTS

Serum soluble mediators were not homogenous between different NA rheumatic disease diagnostic groups, reflecting the heterogeneity of autoimmune diseases. Clustering by serum biomarkers created 5 analogous immune phenotypes. Soluble mediators and pathways associated with chronic inflammation and involvement of the innate, B cell, T follicular helper cell, and interferon-associated pathways, along with regulatory signatures, distinguished the 5 immune signatures among patients. Select clinical features were associated with individual immune profiles. Patients with low inflammatory and higher regulatory signatures were more likely to have few clinical manifestations, whereas those with T cell pathway involvement had more arthritis.

CONCLUSION

Serum protein signatures distinguished NA patients with rheumatic disease into distinct immune subsets. Following these immune profiles over time may assist with earlier diagnoses and help guide more personalized treatment approaches.

Associations between autoimmune dysfunction and pollutants in Akwesasne Mohawk women: Dichlorodiphenyltrichloroethane and polychlorinated biphenyl exposure

BACKGROUND

Pollutant exposures, including polychlorinated biphenyls (PCBs) and dichlorodiphenyltrichloroethane (DDT), have been found to disrupt normal immune function. Native American communities are disproportionately affected by autoimmune dysfunction and are more likely to be exposed to harmful pollutants than the general population.

OBJECTIVE

To determine the association between autoimmune dysfunction and pollutant exposure levels, this study evaluates the statistical relationship between the presence of autoimmune dysfunction and pollutant exposure.

METHODS

Information was collected from Akwesasne Mohawk women (n = 182), 21-39 years of age, between 2009 and 2013. Data collection included anthropometric measurements, medical diagnoses of autoimmune disease and symptoms of autoimmune dysfunction in the medical record, and blood draws for measurement of pollutants. Multivariate analyses determined the association between toxicant exposure and autoimmune dysfunction.

RESULTS

Toxicant p,p'-DDE was positively associated with an almost two-fold risk of autoimmune dysfunction. p,p'-DDE and PCB congeners 32, 136, and 138 were positively associated in a multivariate analysis with an autoimmune diagnosis.

CONCLUSIONS

Pollutant exposures, specifically to p,p'-DDE and some PCB congeners, are common exposures that are associated with autoimmune dysfunction and autoimmune disease, although there are other factors and causes related to autoimmune dysfunction incidence.

Racial Disparities in Renal Outcomes over Time among Hospitalized Children with Systemic Lupus Erythematosus

OBJECTIVES

Racial and ethnic minority groups have excess morbidity related to renal disease in pediatric-onset systemic lupus erythematosus (SLE). We evaluated temporal trends in renal outcomes and racial disparities among hospitalized children with SLE over 14 years.

METHODS

We identified patients ≤21 years-old with discharge diagnoses of SLE in the Pediatric Health Information System® inpatient database (2006-2019). Adverse renal outcomes included end-stage renal disease (ESRD), dialysis, or transplant, analyzed as a composite and separately. We estimated the odds of adverse renal outcomes at any hospitalization, or the first occurrence of an adverse renal outcome, adjusted for calendar period, patient characteristics, and clustering by hospital. We tested whether racial disparities differed by calendar period.

RESULTS

There were 20,893 admissions for 7,434 SLE patients, of which 32%, 16%, 12% and 8% were Black, Hispanic White, Hispanic Other and Asian, respectively. Proportions of admissions with adverse renal outcomes decreased over time (p<0.01). Black children remained at highest risk of adverse renal outcomes at any admission (OR 2.5, 95% CI [1.8-3.5] vs. non-Hispanic White). Black and Asian children remained at higher risk of incident adverse renal outcomes, driven by ESRD among Black children (OR 1.6 [1.2-2.1]) and dialysis among Asians (OR 1.7 [1.1-2.7]). Relative disparities did not change significantly over time.

CONCLUSION

Significant reductions in ESRD and dialysis occurred over time for children with SLE across all racial and ethnic groups. The lack of corresponding reductions in racial disparities highlights the need for targeted interventions to achieve greater treatment benefit among higher risk groups.

Understanding the Disproportionate Burden of Rheumatic Diseases in Indigenous North American Populations

Studies have described a high incidence and prevalence of several rheumatic diseases in indigenous North American populations. Conditions studied most frequently with consistently high burden of disease include rheumatoid arthritis, spondyloarthritis, and systemic lupus erythematosus. Crystal-induced arthritis has been reported to have a lower prevalence than expected. Information about genetic and environmental risk factors is available for some of these conditions. An awareness of the epidemiology of rheumatic diseases in indigenous North American populations is important for clinicians involved in caring for patients in these populations as well as for planning health service delivery in these communities.

Patient ancestry significantly contributes to molecular heterogeneity of systemic lupus erythematosus

Gene expression signatures can stratify patients with heterogeneous diseases, such as systemic lupus erythematosus (SLE), yet understanding the contributions of ancestral background to this heterogeneity is not well understood. We hypothesized that ancestry would significantly influence gene expression signatures and measured 34 gene modules in 1566 SLE patients of African ancestry (AA), European ancestry (EA), or Native American ancestry (NAA). Healthy subject ancestry-specific gene expression provided the transcriptomic background upon which the SLE patient signatures were built. Although standard therapy affected every gene signature and significantly increased myeloid cell signatures, logistic regression analysis determined that ancestral background significantly changed 23 of 34 gene signatures. Additionally, the strongest association to gene expression changes was found with autoantibodies, and this also had etiology in ancestry: the AA predisposition to have both RNP and dsDNA autoantibodies compared with EA predisposition to have only anti-dsDNA. A machine learning approach was used to determine a gene signature characteristic to distinguish AA SLE and was most influenced by genes characteristic of the perturbed B cell axis in AA SLE patients.

Transcriptional profiling of lupus patients and healthy controls reveals ancestry-related differences and transcriptional heterogeneity among lupus patients.

Molecular Decolonization: An Indigenous Microcosm Perspective of Planetary Health

Indigenous peoples are resilient peoples with deep traditional knowledge and scientific thought spanning millennia. Global discourse on climate change however has identified Indigenous populations as being a highly vulnerable group due to the habitation in regions undergoing rapid change, and the disproportionate burden of morbidity and mortality already faced by this population. Therefore, the need for Indigenous self-determination and the formal recognition of Indigenous knowledges, including micro-level molecular and microbial knowledges, as a critical foundation for planetary health is in urgent need. Through the process of Indigenous decolonization, even at the smallest molecular scale, we define a method back to our original selves and therefore to our planetary origin story. Our health and well-being is directly reflected at the planetary scale, and we suggest, can be rooted through the concept of molecular decolonization, which through the English language emerged from the ‘First 1000 Days Australia’ and otherwise collectively synthesized globally. It is through our evolving understanding of decolonization at a molecular level, which many of our Indigenous cultural and healing practices subtly embody, that we are better able to translate the intricacies within the current Indigenous scientific worldview through Western forms of discourse.

Expanded Autoantibody Profiles for Subsetting of Native American, African American, and European American Patients With Systemic Lupus Erythematosus

Objective

Many Native American (NA) patients with systemic lupus erythematosus (SLE) do not exhibit the classical SLE autoantibody profiles of European American (EA) and African American (AA) patients with SLE. The poorer SLE disease outcomes noted in NA patients highlights a need for more equitable diagnostic and prognostic tools for NA patients with SLE. The objective was to identify informative autoantibody profiles for NA, AA, and EA patients with SLE using an expanded set of autoantigens.

Methods

Sera from 49 NA, 49 AA, and 49 EA age‐, sex‐, and antinuclear autoantibody titer–matched patients with SLE who met the American College of Rheumatology classification criteria and 10 ethnicity‐, sex‐, and age‐matched controls were tested for autoantibody reactivity by autoantigen microarrays. Autoantibodies that were significantly elevated in patients with SLE compared with ethnicity‐specific controls were selected for hierarchical clustering. Differences in clinical criteria between patient clusters were determined by Fisher's exact test and corrected for multiple comparisons.

Results

NA, AA, and EA patients with SLE each had a cluster distinguished by higher levels of anti‐Ro52 and another cluster distinguished by nucleic acid–specific autoantibodies. Additional clusters were distinguished in NA patients by elevated extracellular matrix autoantibodies and were distinguished in AA patients by elevated Sm/RNP autoantibody and elevated nucleolin/histone autoantibody. Two EA patient clusters with similar nucleic acid– and Ro52‐specific autoantibodies were distinguished by either high or low histone 2A reactivity. Renal manifestations trended higher in the NA Ro52 cluster and were significantly enriched in the AA nucleolin/histone cluster. The AA nucleolin/histone cluster and EA H2A cluster had higher disease activity.

Conclusion

Expanded autoantibody profiles can identify informative subsets of patients with SLE.

Autoantibody-positive healthy individuals with lower lupus risk display a unique immune endotype

BACKGROUND

Autoimmune diseases comprise a spectrum of illnesses and are on the rise worldwide. Although antinuclear antibodies (ANAs) are detected in many autoimmune diseases, up to 20% of healthy women are ANA-positive (ANA+) and most will never develop clinical symptoms. Furthermore, disease transition is higher among ANA+ African Americans compared with ANA+ European Americans.

OBJECTIVE

We sought to determine the immune features that might define and prevent transition to clinical autoimmunity in ANA+ healthy individuals.

METHODS

We comprehensively phenotyped immune profiles of African Americans and European Americans who are ANA-negative (ANA-) healthy, ANA+ healthy, or have SLE using single cell mass cytometry, next-generation RNA-sequencing, multiplex cytokine profiling, and phospho-signaling analyses.

RESULTS

We found that, compared with both ANA- and ANA+ healthy individuals, patients with SLE of both races displayed T-cell expansion and elevated expression of type I and II interferon pathways. We discovered a unique immune signature that suggests a suppressive immune phenotype and reduced CD11C⁺ autoimmunity-associated B cells in healthy ANA+ European Americans that is absent in their SLE or even healthy ANA- counterparts, or among African American cohorts. In contrast, ANA+ healthy African Americans exhibited elevated expression of T-cell activation markers and higher plasma levels of IL-6 than did healthy ANA+ European Americans.

CONCLUSIONS

We propose that this novel immune signature identified in ANA+ healthy European Americans may protect them from T-cell expansion, heightened activation of interferon pathways, and disease transition.

Comparative United States autoimmune disease rates for 2010-2016 by sex, geographic region, and race

PURPOSE

AIDs may disproportionately impact specific racial groups, but autoimmune (AID) prevalence information by minority racial group is sparse for many AIDs. The objective of this analysis was to supplement previously published AID prevalence rates by providing information on race rate ratios (minority race populations compared to Caucasian populations) in the United States. Preliminary to estimating race rate ratios, contemporary US-specific, health care utilization-based AID prevalence rates and female-to-male ratios were estimated and compared to previously published AID prevalence rates.

METHODS

We used a large national electronic medical record database of 52 million individuals to estimate age-adjusted direct standardized rates for 22 AIDs for 2010 through 2016 by gender, race, and US census division. These were compared to previously published estimates.

RESULTS

Female-to-male ratios were comparable with published studies. Almost all observed Multiracial AID rates were significantly higher than Caucasian rates, as well as 9 of 22 AID rates observed among Native Americans and 8 of 22 AID rates estimated among African-American patients. Regional variation was noted: highest African-American systemic lupus erythematosus rates were observed in the West North Central and South Atlantic divisions, highest African-American multiple sclerosis rates in the South Atlantic and Pacific divisions, and highest Native American rheumatoid arthritis rates in the West North Central, Mountain, and Pacific divisions.

CONCLUSIONS

Substantial AID heterogeneity exists by race and by geographic area. An important research area is further exploring factors related to heterogeneity such as potential interactions between genetic susceptibility and environmental factors.

First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus: Latin American Group for the Study of Lupus (GLADEL, Grupo Latino Americano de Estudio del Lupus)-Pan-American League of Associations of Rheumatology (PANLAR)

Systemic lupus erythematosus (SLE), a complex and heterogeneous autoimmune disease, represents a significant challenge for both diagnosis and treatment. Patients with SLE in Latin America face special problems that should be considered when therapeutic guidelines are developed. The objective of the study is to develop clinical practice guidelines for Latin American patients with lupus. Two independent teams (rheumatologists with experience in lupus management and methodologists) had an initial meeting in Panama City, Panama, in April 2016. They selected a list of questions for the clinical problems most commonly seen in Latin American patients with SLE. These were addressed with the best available evidence and summarised in a standardised format following the Grading of Recommendations Assessment, Development and Evaluation approach. All preliminary findings were discussed in a second face-to-face meeting in Washington, DC, in November 2016. As a result, nine organ/system sections are presented with the main findings; an 'overarching' treatment approach was added. Special emphasis was made on regional implementation issues. Best pharmacologic options were examined for musculoskeletal, mucocutaneous, kidney, cardiac, pulmonary, neuropsychiatric, haematological manifestations and the antiphospholipid syndrome. The roles of main therapeutic options (ie, glucocorticoids, antimalarials, immunosuppressant agents, therapeutic plasma exchange, belimumab, rituximab, abatacept, low-dose aspirin and anticoagulants) were summarised in each section. In all cases, benefits and harms, certainty of the evidence, values and preferences, feasibility, acceptability and equity issues were considered to produce a recommendation with special focus on ethnic and socioeconomic aspects. Guidelines for Latin American patients with lupus have been developed and could be used in similar settings.

Acute Hepatic Failure and Epididymitis in a Hispanic Patient With Active Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease known to affect a variety of organ systems. Patients with SLE are more prone to developing common infections that can mimic the complications of SLE. As such, it is essential to differentiate complications of SLE from infection to ensure appropriate management and to improve morbidity and mortality of this patient population. Here we present a 24-year-old, Hispanic male, with SLE complicated by dialysis-dependent end-stage renal disease and dilated cardiomyopathy. The patient presented to the emergency room with nausea, vomiting, and abdominal pain and admitted to the medicine service. Initial evaluation showed hypoalbuminemia coupled with elevated transaminases, INR, and total bilirubin consistent with acute liver failure. Further evaluation was negative for viral, toxic, metabolic, or vascular causes of acute failure. The patient was diagnosed with lupus hepatitis and associated acute hepatic failure, and started on high dose prednisone (60 mg daily). Complete resolution of liver function and symptoms was observed within 1 week at follow-up. The patient was readmitted 2 weeks after discharge with left scrotal pain and swelling after abruptly decreasing the prescribed prednisone dose 3 days after discharge. Physical exam and scrotal ultrasound in the emergency department were consistent with epididymitis. Urinalysis, urine culture, and gonorrhea and chlamydia PCR were all negative. Without evidence of infection, and upon reconfirmation of low serum complement levels, the patient was diagnosed with lupus epididymitis and restarted on high dose prednisone. Complete resolution of symptoms was attained within 1 week at follow-up. This case emphasizes the importance of differentiating the clinical manifestations of SLE from infection and the complexity of disease presentation in Hispanic patients.