Beverly Johnson MD Rheumatologist Urban Health Plan 1
In the US, it is estimated as many as 1.5 million people have lupus. 1.8 to 7.6 people per 100,000 are diagnosed with lupus each year. Most cases are diagnosed between age 15 and 40. Primarily women are affected (6-10 F:1 M) African Americans (and possibly Latinos, Asians and Native Americans) are affected more than whites. (1, 2) 2
No. This is a common misconception. A blood test alone does not mean a diagnosis of lupus. Having lupus is a combination of symptoms and blood tests. 3
Lupus is an autoimmune disease, its cause is not well known. What is an autoimmune disease? Normally the immune system has cells in the body that attack viruses and colds. In patients with autoimmune disease like lupus the immune system is overactive and starts to attack its own body. 4
Skin rash and photosensitivity Joint pain and swelling Tiredness Fever Shortness of breath Hair loss Sores in the mouth 5
It is a rash that appears on the cheeks but spares the nose. It is a classic rash in lupus. It often occurs after being in the sunlight. 6
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A discoid rash is also a classic rash in lupus. This rash is often red, raised and can cause scarring. The rash often looks like small circles or discs. 8
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Joint tenderness, swelling and redness; usually worse in the morning. Deformities of the joints can occur. Typically on x-ray the bones are not damaged. 10
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American College of Rheumatology Criteria for Classification of Lupus (4 or more of 11= lupus) 1-Butterfly rash 2-Discoid rash 3-Photosensitivity 4-Oral ulcers 5-Swollen/painful joints 6-Pleuritis or pericarditis (water around lungs/heart) 7-Kidney problems 8-Seizures or psychosis 9-Anemia 10-Special positive labs: Anti-dsDNA, Anti-Sm or APL 11-Positive ANA lab (Anti-nuclear antibody) 12
ANA=Antinuclear antibody Antibodies=cells that normally fight a virus or a cold. Anti=against. Nuclear=Nucleus of a cell. 95% of lupus patients have a positive ANA. However 5% of healthy people have a positive ANA and do not have lupus; having a +ANA does not mean you have lupus. (1,2) 13
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Erythrocyte Sedimentation Rate (ESR) C-reactive protein(crp) Complement (C3/C4) Anti-double stranded DNA (anti-dsdna) Anti-Smith antibody (anti-sm) Anti-Ro antibody Anti-La antibody Blood clotting tests (Lupus anticoagulant, etc.) 16
Anemia is when your red and white blood cells are low; it can make you very tired. In lupus your body does not recognize that your cells are part of your body. The lupus cells attack and kill your own blood cells and this makes you anemic. 17
What is ESR/CRP (Erythrocyte sedimentation rate or C-reactive protein)? These are markers of general inflammation in your body in the blood. They can be elevated for a number of reasons including infection like pneumonia or from lupus. Your doctor is looking to see if this lab value is HIGH; if so your lupus may be active. 18
Lupus can damage your kidneys and in checking the urine we look for protein. Healthy people have no protein in the urine, so we are looking for proteinuria, i.e. protein in the urine. 19
More specific to lupus. If these tests are high it means that your lupus is more active. 20
Complement is something in your blood that fights infection, or in the case of lupus it can attack your own cells. If complement (C3/C4) is LOW then your lupus may be active. If your lupus is in good control this value will be normal or high. 21
These are not positive in all patients. However, if these are positive it can mean that you are more likely to have symptoms of dry eyes or dry mouth. It also means that if you are pregnant the baby is at higher risk of heart problems. 22
Some, but not all lupus patients are more likely to get blood clots. Your doctor will send special tests to see if you have this problem. Lupus anticoagulant B2-glycoprotein antibodies Anti-cardiolipin antibodies 23
In general if you have lupus your doctor will check your labs every three to six months. Your doctor wants to see in your labs if your lupus is active: Signs of inflammation (elevated ESR/CRP) Signs of active lupus (anemia in the blood) Signs of active autoimmune disease (elevated ANA or dsdna, or low complement (C3/C4) Signs of kidney problems (urine test) 24
If your family member does not have any signs or symptoms of lupus then testing can lead to needless anxiety. Without symptoms you cannot have lupus. However, if your family member does have signs or symptoms of lupus then testing would be appropriate. 25
A positive ANA does not mean that you have lupus; lupus is a combination of labs and symptoms. Active lupus= ESR/CRP-high, ANA/dsDNA-high, complement-low, +anemia and protein in urine. Your doctor will check your blood and urine periodically; how often depends on your symptoms but in general every 3 months. Following with your doctor is important and so is understanding what your doctor is looking for in the labs so you can work together to feel your best. 26
1-Pisetsky DS, Buyon JP, Manzi S. Chapter 17. Systemic lupus erythematosus. In: Klippel JH, Crofford LJ, Stone JH, Weyand CM. Primer on the Rheumatic Diseases. Edition 12. Arthritis Foundation, Atlanta, GA., 2001. Rus V, Hajeer A, 2-Hochberg MC. Chapter 7. Systemic lupus erythematosus. In: Silman AJ, Hochberg MC (eds.) Epidemiology of the Rheumatic Disease. 2nd edition. Oxford University Press, New York, 2001. 27
Yasmin Santiago and the S.L.E. Lupus Foundation for inviting me to speak. Urban Health Plan and my assistant Santa Mena for all their help with my lupus patients. My colleagues at Hospital for Special Surgery who specialize in lupus, in particular Dr. Michael Lockshin and Dr. Doruk Erkan. 28