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Monday, September 22, 2014
Normal rheumatoid panel means no lupus?
I was diagnosed with fibromyalgia and chronic fatigue syndrome about 4 years ago. Prior to and since the diagnosis, I have had unusual symptoms appear and disappear that no one could offer an explanation for. On occasion, I get swollen, painful joints in my fingers accompanied by small bumps that itch. They come and go in less than a week. I have little red dots (petechiae?) all over my body that never seem to go away and no one knows why. My lymph nodes in my neck, shoulders and down both sides of my sternum become swollen and tender at least once a month. I have frequent chest pain under and around my sternum and have bouts of tachycardia and palpitations. I have had problems with hair loss for years, off and on. I get these clear "bubble" looking blisters on the lining of my mouth that eventually burst and go away. They don`t hurt or anything. I have had flank pain from time to time and the UAs always come back with red cells in them. At one point, one doctor ran some tests on my kidneys to check for function and he said everything was within normal limits. I have the usual FM tender points, migraines, trigger points that give me FITS accompanied by the flare ups and fibro fog. I`m extremely sensitive to cold. The fatigue really gets me too. My doctor has me on Norflex, Ultram, and Prozac. The addition of the Prozac seemed to help for awhile. I`ve also been on Premarin 1.25mg ever since 1985 when I had a complete hysterectomy. About 4 weeks ago, I started the "new" stuff. It began with excruciating pain in the outer joints of my ankles. Then the pain spread up the outer sides of my legs. Next, the inner joints of my ankles started in and it began to spread up the inner side of my leg. Then, I noticed red spots about the size of a dime directly over the areas of greatest pain. They were painful to touch and they itched. I had never had this pain before and I just thought it was a part of the FM. BUT it kept getting worse and spread up the backs and sides of my thighs and into my hips. That was the first week. The next symptoms to pop up were red lumps about the size of a quarter under my skin on the top of my feet where the foot joins the ankle. They were extremely painful and they itched like crazy. The more I scratched, the more I noticed little red bumps around the nodules. To top it all off, my ankles began to swell to the point I couldn`t get my shoes on. By the time I could get in to see a doctor, I was so bad I had to hang on to the handles of my daughter`s wheelchair and SHE had to help ME around the house just to go to the bathroom. I was also running a low grade temp that was between 99.8 and 100.6. I couldn`t get in to see my regular doctor but her partner could see me. He biopsied the nodules, drew blood for a CBC and sed rate, gave me a steroid shot, and put me on Viox. He scheduled me for a follow up with my regular doctor for a week later. By the time I could get in to see her, I was in worse shape than the first visit. The shot had worn off and the Viox couldn`t do the trick. The biopsy came back as erythema nodosun and the CBC was normal. She drew blood for a rheumatoid panel and put me on the 12 day Prednisone pills. Within 6 hours of starting the pills, I felt like a new woman! I called the office back to check out my bloodwork and one of the doctors looked at it and said that it was normal. Does that mean I don`t have lupus? Or could it mean that I might have a drug induced thing going on from the Premarin?
If an antinuclear antibody test was performed as a part of `rheumatoid panel`, and it was negative, then one is less likely to have lupus. Lupus, however, can be present in the absence of antinuclear antibody test in some (less than 5%) patients. Therefore, if one is suspecting lupus on the basis of symptoms or signs, then additional tests such as anti-Ro (also called anti-SSA), anti-La (anti-SSB), anti-DNA and complements should be done. Erythema nodosum that was detected in your skin biopsy can occur in several different diseases, including certain infections, certain diseases of lymphoid system, vasculitis, and certain drugs. Although, hormones can cause erythema nodosum, it is very rare, and appears less likely in your case. Some times, ulcers in the mouth and genital areas, with erythema nodosum and some other problems can occur in a relatively uncommon disease, called `Behcet`s syndrome`. Very rarely, erythema nodosum can be part of a disease called systemic pannicultis (Weber Christian disease) that can cause skin lesions all over the body and fever, joint pains, etc. Some other symptoms such as heat and cold intolerance, tachycardia and palpitation that you have may warrant thyroid tests.
Ram Raj Singh, MD
Associate Professor of Clinical Medicine
College of Medicine
University of Cincinnati