1 / 36

Does my patient have Lupus?

Does my patient have Lupus?. Jammie Barnes, MD Assistant professor Department of Medicine, Division of Rheumatology. It’s Lupus. http://www.youtube.com/watch?v=bueW1i9kQao. Dr. House or Dr. Warner. LBJ referral: +ANA with aches and pains Dr. Barnes: It’s Lupus Dr. Warner: Wrong

jock
Download Presentation

Does my patient have Lupus?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Does my patient have Lupus? Jammie Barnes, MD Assistant professor Department of Medicine, Division of Rheumatology

  2. It’s Lupus • http://www.youtube.com/watch?v=bueW1i9kQao

  3. Dr. House or Dr. Warner • LBJ referral: +ANA with aches and pains • Dr. Barnes: It’s Lupus • Dr. Warner: Wrong • Another referral: same story • Dr. Barnes: It’s Lupus • Dr. Warner: Wrong • A retrospective chart review at LBJ (1yr) • 104 +ANA referrals…. ONLY 6 cases of confirmed SLE

  4. Objectives • Understand the limitations of sensitivity and specificity of ANA • Determine who needs to be evaluated for SLE • Describe the systemic signs and symptoms of SLE • Apply the American College of Rheumatology criteria for SLE • Apply to cases

  5. ANA is 100% sensitive Lupus Diabetes

  6. Sensitivity & Specificity PPV: 10/400 = 2.5% SnNout: high sensitivity – negative test is good at ruling out the disease Negative ANA – very unlikely to have SLE SpPin: high specificity –positive test good at ruling in disease Sensitivity – 100% Specificity – 60% PPV: 500/700 = 71.4%

  7. The nomogram Reminder: +LR= sens/(1-spec) LR: 2.5

  8. Pretest probability • Consider prevalence • Clinical scenario in your patient • If you order a test – expect a result Positive ANA, now what!!

  9. ANA • Autoabs directed against DNA or snRNP • Positive test: >1:80 • Best to order test by immunofluorescence (IF) • ELISA enzyme linked assays are cheaper but have 80-98% agreement with IF • ACR recommends ordering ANA by IF

  10. Other problems with ANA • 1/3 of healthy people have an ANA 1:40 • 5% of healthy people have ANA 1:160 • 3.3% of healthy people have ANA 1:320 • Healthy 1st degree relatives can have + ANA • Healthy older people increased + ANA • ANA linked to thyroid dz, hepatitis, environmental exposure, cancer, infections and drugs Southern Medical Journal. Vol 105, no 2, Feb 2012

  11. Making the ANA better • 2 possibilities • Raise the threshold of positive test • High titers do warrant more investigation > 1:1280 • Couple the test with more specific signs and symptoms of rheumatic disease • High risk - low occurrence

  12. When to order an ANA

  13. CNS/PNS • Criteria – seizures and psychosis • Both in absence of offending drugs • Question: Have you ever had a seizure or convulsion? Orphanet Journal of Rare Disease 2006 1:6

  14. Skin/Mucocutaneous • 4 criterion for skin: malar rash, discoid rash, photosensitivity and oral ulcers • Do you get sores in your mouth or nose for more than 2 weeks at a time • Rash on your cheek for more than a month • Skin breakout (rash) after being in the sun (not a sunburn) • Others: • Alopecia • Have you had rapid loss of hair • Raynauds • Have your fingers ever shown unusual color changes in the cold • Purpura, urticaria and vasculitis

  15. Hematologic • Hemolytic anemia • Leukopenia <4000 on > 2times or lymphopenia <1500 on > 2 times • Thrombocytopenia <100k in absence of drugs • All meet hematologic criteria (only get 1 point) • Questions: Have you ever been told that you have anemia, low blood count, low platelet count

  16. Cardio/Pulm • Criteria: • Pericarditis – documented by ECG, rub or pericardial effusion • Pleuritis – convincing h/o pleuritic chest pain, rub or pleural effusion • Question: Do you get chest pain with deep breath? • 1 point • Others: • Endo and myocarditis, pulmonary arterial hypertension, valvular, CAD • Chronic interstitial pneumonitis, acute lupus pneumonitis, acute alveolar hemorrhage, acute reversible hypoxemia, PE, shrinking lung syndrome

  17. Renal • Criteria: • Persistent proteinuria >0.5gm per day or 3+ on dipstick or cellular cast • Have you have been told you have protein in your urine • Class 1-6 of lupus nephritis • Microangiopathic glomerular disease • Renal vein thrombosis

  18. GI • No criteria for diagnosis • None specific abd pain, nausea and vomitting • Rare mesenteric vasculitis

  19. Reticuloendothelial • Not a criteria • LAD • HSM

  20. MSK • Criteria: • Arthritis – tenderness, swelling or effusion in 2 or more joints witnessed • Typically non-erosive • Jacoudsarthopathy • Others: • Myositis

  21. Constitutional • Not a criteria • Profound fatigue (disabling fatigue) – in absence of depression • Fever (no signs of infection) • Weight loss

  22. Immunologic • Criteria: • Positive ANA >1:80 • Positive anti-dsDNAOR Anti-Smith OR antiphospholipid antibody • AbnlIgG or IgMcardiolipin, + lupus anticoagulant, false positive RPR • Others: • SSA/B (anti-Ro and La), RNP

  23. Applying Signs and Sxs • Upon screening: • Two or more organs systems involved – order CBC, CMP, UA to evaluate for systemic disease • If above reveals possible systemic disease then order an ANA and possible other antibodies • If 4 or more criteria by ACR or suspect SLE refer to Rheumatology

  24. Case • 21 y/o college student with two months of joint pain worse in AM • Notices faint rash on face for last month • Very tired and finds it difficult to concentrate in class • Denies fevers, abd pain, chest pain, diarrhea or constipation • On exam: malar rash, decreased breath sounds at bases, no murmurs, diffuse cervical LAD and mild synovitis in the MCPs and PIPs

  25. What next • Order labs/studies: CBC, UA, CMP, CXR • What other labs do you want? • ANA, RF, CCP and TSH • WBC count 3.2, nlHgband platelets, neg RF and CCP, UA 2+ proteinuria, no cast or red cells, UPC 0.3, ANA 1:640, +dsDNA, +smith and chest xray with effusions • Does she meet criteria? • YES!

  26. Case • 36 y/o stay at home Mom presents with joint pains for 3 months • She has no swelling, but she has tenderness all over in the upper and lower body • She tells you she has anemia, severe fatigue but she can still take care of her children • She has occasional HA, some weight gain, but other ROS is negative • On exam she is overweight with BMI of 32, multiple tender points but no synovitis

  27. What next • Order CMP,CBC, UA and TSH • Her labs are normal with exception of HGB of 10.2 and MCV of 76 • What next: • Iron studies • Low ferritin, smear: hypochromic RBCs, low iron and high TIBC • Do you need to do more? • Treat IDA

  28. Case • 32 y/o man with long standing history of epilepsy. He has been on anti-seizure medication for many years. Initially he was on phenytoin and now on oxcarbazepine • He has developed a photosensitive rash and joint pain • In ROS he also has pleuritic chest pain • On exam he has a erythematous rash on the face and upper chest, synovitis of the bilateral wrist but rest of exam is normal

  29. What next • CBC, CMP, UA, CXR and ANA • He has positive ANA, nl CMP, CMP, UA and chest xray • What does he have? • Drug induced lupus • Do you need histone antibodies? • No • How do you proceed? • Discuss changing anti-convulsant medication, may add NSAIDs, steroid cream for rash and hydroxychloroquine

  30. Thank you for time • Remember ANA does not equal lupus • Need careful history and physical • Lupus is RARE disease but high morbidity and mortality if missed • Please remember your packet!! • I need to contact you again in 3months for post test!!!

More Related