Lupus or not

Hello,

Thank you for choosing DoctorSpring.

Lupus diagnosis has to be confirmed and there pretty reliable tests for this.
I would like some additional information from you so that I can provide my best opinion.

1. Is there any joint pain ? If so which joints are involved ?
2. Does she have fever now
3. How is her blood pressure ?
4. Any pain in eyes while looking to eyes ?
5. Any ulcers in mouth or elsewhere ?
6. What about her blood tests specifically - CBC, ESR, ANA tests ? Do you have these values with you ?
7. What about her urine studies ?

You can reply as followup. Any additional information will help me forming a more learned and solid opinion.

Thank you

Dear Dr Deepu Sebin,

1. Is there any joint pain ? If so which joints are involved ?

Yes, my mother has had some join pain since she was 30. It appears and disappears again and again. Now she doesn't feel so much pain from joints. She said if the pain can be measured from 1 to 10, pain from her joints now is around 1 or 2. When she had pain, normally it was from finger, knee, shoulder, nape, toe.

2. Does she have fever now?

Yes, she does have fever one or two a day (normally in evening or early morning). I would like to tell a bit history about her sickness. In 2010, she had fever for about two weeks. Doctor thought she had tuberculosis. But then using medicines for tuberculosis didn't help. Doctor gave her corticoid, then there was no fever. She took corticoid 60mg/day in 10 days. After that she took 32mg/day. Until the end of 2012, she took 4mg/day. But now she get lots of pain from top of the head to face, eye socket, jaw bone. Doctor gave her Medexa (corticoid) 32mg/day and Cellcept (6 tablets (6x250mg)/day then reduce to 2 tablets/day). But now doctor said to stop taking Cellcept, only Medexa (32mg/day) at the moment.

3. How is her blood pressure ?

From her left hand around 98/68 or 100/70. My mother has blood deficient, but doctor hasn't mentioned about taking iron. I don't know why.

4. Any pain in eyes while looking to eyes ?

Yes she has pain in eye socket.

5. Any ulcers in mouth or elsewhere ?

She has no ulcers.

6 + 7. Test results

Below are test results I translated from orignal documents (I also attached to this reply). My mother is having pain so the speed of dianogsis is important. But please take your time to have your best diagnosis.

Thanks a lot in advance!


Name of test Unit Value Conclusion
ANA OD 0.58 NEGATIVE (< 1.0) [positive > 1.2]
dsDNA U/ml 24.00 NEGATIVE (< 60) [positive > 60]

Name of test Unit Value Normal range
Ure mmol/l 2.0 Male: 1.7-8.3; Female: 1.7-8.3
Glucose mmol/l 4.7 Male: 4.1-6.7; Female: 4.1-6.7
Creatinin umol/l 56 Male: 62-106; Female: 44-80
Calci mmol/l 2.20 Male: 2.15-2.55 Female: 2.15-2.55
Calci ion mmol/l 1.15 Male: 1.17-1.29 Female: 1.17-1.29
Protein total g/l 73.1 Male: 66-87 Female: 66-87
Albumin g/l 38.5 Male: 34-48 Female: 34-48
ASAT(GOT) U/L 26 Male: < 37 Female: < 31
ALAT(GPT) U/L 35 Male: < 41 Female: < 31
CK-MB U/L 9 Male: < 24 Female: < 24
Cholesterol total mmol/l 3.74 Male: < 5.2 Female: < 5.2
Triglycerid mmol/l 2.58 Male: < 2.26 Female: < 2.26
HDL-C mmol/l 0.76 Male: >= 0.9 Female: >= 1.15
LDL-C mmol/l 1.81 Male: <= 3.4 Female: <= 3.4
HbA1c % 6.2 Male: 4.8-6.0 Female: 4.8-6.0

Natri mmol/l 136 Male: 133-147 Female: 133-147
Kali (P) mmol/l 3.2 Male: 3.4-4.5 Female: 3.4-4.5
Clo mmol/l 97 Male: 94-111 Female: 94-111

Urine
LEU cells/ul NEG
PRO g/l NEG
SG 1.016 Male+Female: 1.003-1.030
GLU mmol/l NORM
NIT NEG
PH 7 Male+Female: 5.5-6.0
KET mmol/l NEG
UBG umol/l NORM Male+Female: 3.2
ERY cells/ul 50 (??) Male+Female: NEG
BIL umol/l NEG

Blood
RBC T/l 4.27 Male: 4.3-5.8 Female: 3.9-5.4
HGB g/l 106 Male: 140-160 Female: 125-145
HCT l/l 0.338 Male: 0.38-0.50 Female: 0.35-0.47
MCV fl 79.2 Male: 83-92 Female: 83-92
MCH pg 24.8 Male: 28-32 Female: 28-32
MCHC g/l 314 Male: 320-360 Female: 320-360
PLT G/l 535 Male: 150-450 Female: 150-450
RDW-CV % 16.0 Male: 10-15 Female: 10-15
MPV fL 8.5 Male: 5-20 Female: 5-20
WBC G/l 15.36 Male: 4.0-10.0 Female: 4.0-10.0
NEUT% % 73.7 Male+Female: 45-75
EO% % 1.9 Male+Female: 0-8
BASO% % 0.1 Male+Female: 0-1
MONO% % 4.6 Male+Female: 0-8
LYM% % 19.7 Male+Female: 25-45
LUC% % Male+Female: 0-4
NEUT# G/l 11.32 Male+Female: 1.8-7.5
EO# G/l 0.29 Male+Female: 0-0.8
BASO# G/l 0.01 Male+Female: 0-0.1
MONO# G/l 0.71 Male+Female: 0-0.8
LYM# G/l 3.03 Male+Female: 1-4.5
ESR 1hour mm 56
ESR 2hour mm 99

Best regards,
Trung

Hello Trung,

There are the core finding in the blood tests :

Low inonised calcium, ALAT +, triglyceride high, HDL-C low, HbA1C higher, potassium low, in urine sample erythrocytes+, Hb, HCT,MCV,MCH,MCHC low, PLATELETS and WBC slightly high, ESR raised.

Along with these she has fever + joint pain + ? photo-phobia. It is possible that she is having an aunto immune disease like SLE. But it cannot be confirmed by these test results alone. A main finding in SLE is a Postive ANA. In your mothers case it is negative . (ANA negative SLE is rare).

She has been treated with steroids and mycophenolate mofetil - So for sure your Doctor must be having a standing diagnosis. A single diagnosis at this point is not possible - There are two possibilities 1. An infective cause (if the fever is still persisting ) 2. An autoimmune disease . Both will require extensive evaluation. I understand that this could be frustrating, but unfortunately there is no other way to go. I suggest a complete fever work up in consult with your Doctor. This could be considered as a case of Fever of Unknown origin and followedup. I do not recommend steroid treatment unless a specific diagnosis is on the table .

Hope this helps
Feel free to ask followups
Thank you

Dear Dr Deepu,

Thanks a lot for your opinion. I also think using steroid treatment (in my understanding is using Medexa and Cellcept) is very risky when the root-cause is still unclear.

My father is looking for help everywhere to find out a right treatment, but so far we haven't got one yet. You mentioned about 2 possibilities, please advice us what tests we can do to make it clearer.

I don't know how many follow-up questions I can ask given one main question. Please also advice me on this.

Any help is really appreciated. I am looking forward to hearing from you.

Best regards,
Trung

Hello,

Feel free ask follwoup questions till all your queries are answered :
Rather than tests I would suggest an approach which would be more meaningful. She needs to be under the care of a experienced Physician (Internal Medicine). She will also require a Rheumatologist Consultation.

First step would be a analysis of the medical history and a Physical examination.
If the fever is persisting first it has to be investigated - This should include (but not limited to ) Chest Xray, Blood and Urine culture, TB (Sputum AFB), Liver function and Hepatitis Panel , CT/MRI Brain, Ultrasound abdomen, Brucella Antibody, Peripheral Smear, Bone Marrow Smear and Biopsy.

In consult with a Rheumatologist evaluation for connective tissue disorder has to be done. This should include repeat testing of Anti nuclear antibodies and urine tests.

This approach should hopefully establish a diagnosis. Also you should discuss with your current Doctor whether she fits for the SLE criteria (refer SLE criteria online). Also what does she/he think the diagnosis and may be ask for a reference.

As you can see, the next step is not very simple, but it not impossible either. I would recommend you to leave all these concerns to your Doctor.

Hope this helps
Feel free to ask followup questions
Thank you

Hi Dr Deepu,

Regarding medical history, I have listed below the progress of the unknown disease:

- In 2010, my mother traveled for a week. She had a bath then she had fever (38-39 C) for about 5 days continuously.

- She felt very hurt from the knees and below and got fever for about 2 months.

- She had tests for throat, lung, breast. They were all good.

- Doctor gave her corticoid, she had no fever about 6 hours a day. But after 6 hours of having corticoid, she had fever again.

- She felt hurt in eyes (doctor said she had Glaucoma), from chest to back.

- Sometimes she felt hurt in half-body, sometimes in shoulder, nape, fingers, toes. Increasing corticoid reduced her pain. The most recent problem was headache.

- She started using 32mg corticoid per day 10 days ago, now she's using 16mg corticoid. When reducing corticoid she feels a bit more pain than using 32 mg.

- The problem right now is she cannot sleep much (4-5hours per day).

- She's taking "medicine food" http://translate.google.com/translate?sl=vi&tl=en&js=n&prev=_t&hl=en&ie=UTF-8&u=http%3A%2F%2Fteresa.vn%2Fthuoc%2Fthuoc-an-than-gay-ngu%2F1425636-bonihappy.html to help her to sleep (still 4-5 hours a day, a bit better than before).

Below is the list of medicines my mother is taking at the moment:

- Medexa 16mg: first 10 days: 2 tablets/day; last 10 days 1 tablet/day.

- Chloroquine 0.25g: 1 tablet/day.

- Montair 10mg: 1 tablet/day.

- Medicine for liver: http://translate.google.com/translate?hl=en&sl=vi&tl=en&u=http%3A%2F%2Fduocphamnganha.com%2Fproduct%2Fview%2F33%2FGantiso.html&sandbox=1

- Tavanic 0.5g: 1 tablet/day.

- Albonzoi: 1 tablet/day.

- Prasocare - 20: 1 tablet/day. (I think it is Gastrointestinal Drugs)

When taking this medicines, my mother feels better than before (much less pain in head and eyes).

The current problem is sleeping.

Base on medical history, current medicines and the reaction of the body (feel better, still hard to sleep) to the medicines, do you have any idea about the disease and its root cause?

Thank you in advance.

Best regards,
Trung

Hello Trung,

Hope you would understand that without a Physical examination it is really difficult to come to a diagnosis. However with the available information an autoimmune disease (like Lupus) is possible. However we cannot say for sure it is Lupus. I am sure that your Doctor will have specific diagnosis in mind since she on these medications.

Except for fever, all the symptoms need to be managed symptomatically only. For the lack for sleep she can take a TCA / SSRI medication (kind of sleeping pills, but much better). Fever as I said if persists need further evaluation.

Hope this helps
Feel free to ask followups questions
Thank you