Diseases and Conditions When to see a rheumatologist

10 Important warning signs of systemic lupus

February 27, 2018

Systemic lupus erythematosus (SLE) is an autoimmune disease that presents in many ways. The disease is characterized by the production of autoantibodies that deposit onto tissue and fix complement on almost any organ which causes systemic inflammation. Typically it affects women (9:1) aged between 15 and 45 years and it tends to affect people of African-American, Asian, and Hispanic descent more so than Caucasians: 3 to 4 times higher.[1]

This is a very complex condition and we’re still trying to understand the underlying cause and trying to find effective treatments. Even diagnosis remains challenging at times. Today I’d like to go over 10 important warning signs of systemic lupus.

Criteria for the classification of SLE

The following are the criteria for the diagnosis of SLE. To fulfill criteria you need to have at least 4 criteria with at least one coming from the clinical section and one coming from the immunological section. An exception to the rule is if someone has a kidney biopsy that shows lupus nephritis in the presence of a positive ANA or other lupus-related autoantibody.

It’s important to note that there are exceptions to the rule. These criteria are meant to be used in research and we all know that real life sometimes doesn’t fit the mold! Also, as researchers make more discoveries, classification systems change. The Autoimmunity Blog has a great pdf showing how these criteria evolved with time.

Systemic Lupus International Collaborating Clinics Classification Criteria for SLE (2012)

Criterion	Definition
Clinical Criteria
1. ACLE (acute cutaneous lupus erythematosus)	Malar rash, bullous lupus, TEN variant, maculopapular, photosensitive, subacute cutaneous lupus
2. CCLE (chronic cutaneous lupus erythematosus)	Classic discoid, hypertrophic, lupus panniculitis/profundus, mucosal, lupus erythematosus tumidus, chilblains lupus, discoid/lichen panus overlap
3. Alopecia	Non-scarring, diffuse hair thinning or visible broken hairs
4. Oral ulcers	Oral (palate, buccal, tongue) or nasal ulceration
5. Synovitis	Arthritis involving two or more peripheral joints, characterized by tenderness, swelling, or effusion and morning stiffness > 30 minutes
6. Serositis	Pleuritis: convincing history of pleuritic chest pain for >1 days or pleural rub or evidence of pleural effusion, or Pericarditis documented by EKG or rub, or evidence of a pericardial effusion
7. Renal disorder	Persistent protein ≥ 0.5 grams/day or red blood cell casts
8. Neurological disorder	Seizures, psychosis, myelitis, mononeuritis multiplex, peripheral or cranial neuropathy, acute confusional state
9. Hemolytic anemia	Direct Coombs positive
10. Leukopenia	Leukopenia < 4000/mm³ at least once or lymphopenia < 1000/mm³ at least once
11. Thrombocytopenia	Platelets < 100 000/ mm³
Immunological Criteria
1. Positive ANA	Level above laboratory reference
2. Anti-dsDNA	Level above laboratory reference range (or >2-fold ELISA reference range)
3. Anti-Sm	Presence of antibody to Sm nuclear antigen
4. Antiphospholipid antibody – Positive lupus anticoagulant – False positive for rapid plasma regain – Medium titer or high titer anticardiolipin antibody level – Positive anti-β-glycoprotein I
5. Low complements	Low C3, low C4, or low CH50
6. Direct Coombs test	In the absence of hemolytic anemia

RheumDoctor’s simplified lupus criteria

As you can see these criteria are somewhat complicated and use A LOT of “medicalese”. Let’s try simplifying things! Basically, the criteria include clinical features and blood tests that show abnormal changes with the immune system. The clinical criteria do include some blood tests like white cells, blood cells, platelets, and urine, but these are NOT tests that specifically show problems with the immune system. They are abnormal BECAUSE the immune system is affecting them.

10 Important warning signs of systemic lupus erythematosus

Rash
Hair loss
Oral and/or nose ulcers
Autoimmune joint pain
Chest pain
Kidney problems
Neurologic or psychiatry changes
Anemia
Frequent infections
Easy bruising or bleeding

Other symptoms that are not included in the criteria include profound fatigue, fevers, unintentional weight loss, and Raynaud’s phenomenon.

Rash

The first thing that pops up in most people’s mind when they think about lupus is the famous “butterfly” rash, more specifically the malar rash. This type of rash is one of many ways the disease can inflame the skin. DermNet New Zealand has a great selection of examples. People with lupus also tend to get a rash when their skin is exposed to the sun (photosensitivity). Sometimes exposure to the sun can cause a systemic flare, e.g., cause joint pain, swelling, and fatigue.

Hair loss

Unless the hair loss is caused by a rash, e.g., discoid lupus, hair loss tends not to scar. It can happen in patches or simply be generalized.

Oral and/or nose ulcers

Almost everyone gets a canker sore once in a while. People with lupus often get multiple ulcers over and over again. They usually DON’T hurt.

Autoimmune joint pain

Autoimmune joint pain or inflammatory arthritis looks very similar to the joint pain that people have with rheumatoid arthritis. However, joint inflammation caused by lupus is NON-EROSIVE, meaning that people do not get permanent joint deformities. Like rheumatoid arthritis, joints get swollen, tender, and they tend to stay stiff for at least 30 minutes to an hour in the morning.

Chest pain

Lupus can cause pleuritic and pericarditis. Basically, the lining of the lungs (pleuritic) or the lining of the heart (pericarditis) get inflamed. This can cause sharp chest pain and sometimes can cause fluid to accumulate around the lungs or heart. Usually this type of chest pain worsens when you take a deep breath and in the case of pericarditis, improves when you lean forward.

If you are experiencing chest pain, don’t mess around, go to the emergency room. People with lupus have a higher risk of heart disease. In fact, cardiovascular disease is the leading cause of death in people with lupus. So you need to rule out a heart attack.

Kidney problems

Lupus can cause inflammation in the kidneys (lupus nephritis). There are 6 types. It’s important to know what type we’re dealing with when making treatment decisions. Lupus nephritis doesn’t cause “kidney pain”. The symptoms of kidney malfunction include:

Weight gain (water weight)
Uncontrolled high blood pressure
Dark urine
Frothy or foamy urine
Leg swelling
The need to urinate during the night

Neurologic and/or psychiatric changes

These are probably the most difficult to diagnose features of lupus. They vary widely are terribly non-specific. People with lupus who present with neurological symptoms can present with a stroke, limb weakness, small fiber neuropathy, seizures, and even psychiatric changes like schizophrenia or major depression. Close collaboration with a rheumatologist, neurologist, and psychiatrist is often required.

Anemia

Lupus can cause many different types of anemia: anemia of chronic disease, hemolytic anemia, kidney failure, etc. Some symptoms of anemia include:

Loss of energy
Rapid heart beat
Shortness of breath
Headache
Difficulty concentrating
Dizziness
Pale skin
Leg cramps
Insomnia
Hemolytic anemia can also cause yellowing the eyes/sclera (jaundice)

Frequent infections

Many people with lupus get frequent infections. For the most part this is caused by medications used to treat lupus but sometimes it can be the main culprit. Lupus can cause white blood cells and specialized white cells called lymphocytes to decrease in number. These cells are part of the immune system and help your body fight off infection. If they are critically low, you can get frequent infections.

Easy bruising and bleeding

Platelets are specialized cells in your blood that prevent bleeding and help stop bleeding. Lupus can cause a reduction in platelet levels. Some symptoms of low platelets (thrombocytopenia) include:

Easy bruising with minimal trauma
Spontaneous + superficial bleeding into the skin (petechiae)
Prolonged bleeding
Bleeding from the gums after brushing your teeth
Unusually heavy menstrual flow
Blood in your urine or stool
Having a big spleen

I think I may have lupus?

If you think you may have lupus, talk to your primary care physician, your GP, or make a consultation with a licensed rheumatologist. Remember this is not a common disease, so more often than not, it isn’t lupus. Because the condition can affect many organ systems, it can mimic many diseases. Most of these are much more common than lupus.

Get involved

Would you like to get involved? Follow these links!

Lupus Foundation of America

Lupus Research Alliance

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

References

[1] West, SG. Rheumatology Secrets 3^rd edition

1 Comments

Diseases and Conditions When to see a rheumatologist

What is a positive rheumatoid factor?

October 17, 2017

Introduction

What does it mean to have a positive rheumatoid factor (RF)? Does this mean that you have rheumatoid arthritis, are you at risk of developing rheumatoid arthritis, is your prognosis worse, or is it completely unrelated to arthritis?

Before answering, what is a positive rheumatoid factor, we need to understand antibodies and how they are made. We can then better understand autoantibodies, and more specifically rheumatoid factor.

What is an antibody?

The goal of the immune system is to protect yourself from bacteria, viruses, as well as cancers. The immune system is made up of many different components, however, in broad terms it can be divided into three categories: physical barriers, the innate immune system, as well as the adaptive immune system. Physical barriers include skin as well as mucous membrane barriers that line your digestive, respiratory, and your reproductive tracts. The innate immune system is the second line of defense. This is the part of the immune system that deals with immediate dangers. For example, the skin reaction you get when you get bitten by a dog or you when you accidently cut your hand with a knife. The third level of defense is called the adaptive immune system. This is the part of the immune system responsible for making antibodies.

Antibodies, also called immunoglobulin (Ig), are specialized proteins that defend against specific invaders. An antigen stimulates your body to make an antibody. For example, if someone gets the chickenpox (antigen) the body will make antibodies directed against the chickenpox virus. So the next time that person is exposed to the chickenpox virus, the body will have chickenpox antibodies to prevent the infection.

Antibody structure

Immunoglobulin are made up of light and heavy chains. They also have two regions, Fab regions and the Fc region. The Fab region is also called the variable region. This is the place where specific antigens attach to the antibody. It is variable, because each antigen has its own antibody. The Fc region helps the antibody communicate with other parts of the immune system. The Fc region is also called the constant region. It’s constant because it doesn’t really vary all that much.[1]

Are there different types of antibodies?

Yes. There are 5 different classes of antibodies: IgG (75%), IgA, IgD, IgE, and IgM. Remember how I said the Fc region “doesn’t vary all that much”? The Fc region determines the class of the antibody and in turn, which immune system cells the antibody will interact with. For example, dust mite particles cause the immune system to make IgE antibodies. When the body is exposed to dust mites for a second time, IgE antibodies interact with mast cells, which release histamine, which cause an allergic reaction.[2]

Every class of immunoglobulin looks different and as I mentioned interacts with different parts of the immune system. IgM antibodies are made very early on during an infection. IgG antibodies are made about 2-3 weeks after an infection and you typically find them in blood. IgA antibodies are made in the gut, nose, lungs, and mammary glands. IgE antibodies are made to parasites and they trigger allergies. Currently, we don’t know too much about IgD.

What is a rheumatoid factor?

A rheumatoid factor is created when an IgM antibody binds to the Fc portion of an IgG antibody. In simple terms, this is a situation where an antibody attacks another antibody. When you have many antibodies doing this at once, they can form large IgM-IgG antibody complexes, which can stimulate the immune system to make some serious inflammation.

My doctor told me my rheumatoid factor was high. What does that mean?

The answer to this question is varies depending which lab your doctor sent your blood. Each lab has their own specific cut off points. Below you will find the cutoff points for Labcorp and Quest Diagnostics.

Labcorp

Methodology: Latex immunoturbidmetry

Negative: < 14.0 IU/mL

Quest Diagnostics

Methodology: Immunoturbidimetric

Negative: ≤ 14 IU/mL

Note: There are many different ways to measure rheumatoid factor and even specific types of rheumatoid factor: IgM, IgG, IgA. These will all have their own cutoff points.

Now, what does having a positive rheumatoid factor mean? The answer to this question depends on your symptoms.

Rheumatoid factor and rheumatoid arthritis

About 70% to 80% of people that have rheumatoid arthritis have a positive rheumatoid factor. Not having a positive rheumatoid factor doesn’t necessarily rule out the disease, but rather, it makes it less likely. Having rheumatoid arthritis AND having a positive rheumatoid factor is associated with a more severe form of the disease and having non-joint symptoms like nodules or lung involvement (interstitial lung disease). Unlike lupus, rheumatoid factor doesn’t really go up or down depending how active rheumatoid arthritis, so we don’t follow it if you have an established diagnosis.[3]

What are some other diseases that cause a positive rheumatoid factor?

Rheumatoid factor has an 86% specificity for rheumatoid arthritis. That being said, if you test positive for rheumatoid factor, there’s a pretty good chance that you have or will have rheumatoid arthritis in the future, but this is by no means set in stone. It’s very important to realize that someone can test positive for rheumatoid factor, AND NOT have rheumatoid arthritis because many diseases can cause the immune system to form antibodies directed towards the Fc portion of an IgG antibody. However, in most non-autoimmune conditions the rheumatoid factor tends to be lower than in rheumatoid arthritis. Moreover, when one finds more than one different type of rheumatoid factor particular in the fluid of a joint (e.g., IgM RF and IgA RF), this indicates that we are dealing with rheumatoid arthritis.

Category	Disease
Rheumatic diseases	Rheumatoid arthritis Systemic lupus erythematosus (SLE) Scleroderma Mixed connective tissue disease Sjogren’s syndrome
Viral infections	HIV/AIDS Mononucleosis (Epstein-Barr virus) Hepatitis Influenza
Parasitic infections	Malaria Schistosomiasis Trypanosomiasis Kala-azar Filariasisis
Chronic bacterial infections	Subacute bacterial endocarditis Tuberculosis Syphilis Salmonellosis Brucellosis Leprosy Yaws
Cancers	Lymphoma Leukemia Multiple myeloma
Hyperglobulinemic diseases	Sarcoidosis Chronic liver disease Chronic pulmonary disease Cryoglobulinemia Hypergammaglobulinemic purpura[4]

It is also important to mention that approximately 5 – 25% of individuals aged 60 years and older have a positive rheumatoid factor without any underlying causative disease.

I have a positive rheumatoid factor, but I have no symptoms

This is where it gets a little tricky. Here are the following possible scenarios:

You may develop rheumatoid arthritis in the future.
It may be that you actually have another non-rheumatic disease that is causing you to test positive for rheumatoid factor.
The rheumatoid factor is not clinically significant.

When faced with a positive rheumatoid factor, it’s important to rule out other conditions that cause positivity. If the workup is negative, care monitoring is recommended. Knowing the symptoms of autoimmune joint disease is of utmost importance as well.

Can you predict who will develop rheumatoid arthritis?

We cannot predict with 100% certainty, who will and who won’t develop rheumatoid arthritis. There are a few factors that increase the odds like having both a rheumatoid factor AND anti-citrullinated peptide antibodies (anti-CCP)[5]. This is particularly true for people that have high levels of anti-CCP antibodies.[6]

The time between the formation of autoantibodies and rheumatoid arthritis is called preclinical rheumatoid arthritis. Other terms include: pre-RA, autoantibody-positive arthralgia, probable RA, very early RA, and early undifferentiated arthritis progressing to RA.

Phases of preclinical rheumatoid arthritis

Preclinical RA goes through many phases. Not everyone progresses so smoothly and some people can even skip steps.

Phase I

People with certain genetic predispositions are exposed to environmental factors that trigger an immune response. Smoking is a known trigger.

Phase II

The immune system starts making rheumatoid factor and/or anti-CCP antibodies.

Phase III

People start experiencing some joint pain and stiffness, but no swelling or over autoimmune joint pain.

Phase IV

There is some joint swelling, but it’s limited to 1-2 joints. We can now call this undifferentiated arthritis but it’s not rheumatoid arthritis yet. If it happens on and off, we sometimes call it palindromic rheumatism. We think that 30 – 50% of people with undifferentiated arthritis will go into remission, 30-40% will progress to other diseases, and 30 – 40% will evolve into rheumatoid arthritis.

Phase V

It’s spreading! Now we can call this rheumatoid arthritis.[7]

Is there anything I can do to prevent rheumatoid arthritis?

The following are some modifiable risk factors that can help prevent rheumatoid arthritis.

Avoid/quit smoking
Maintain good dental hygiene
Eat a balanced diet containing fish oil, antioxidants, and vitamin D
Avoid excess coffee and foods with high salt content
Keep a healthy body weight
Prevent infections[8]

Conclusion

If you’ve tested positive for rheumatoid factor and have more questions, I highly urge you to speak with your physician or local rheumatologist. And remember, doctors treat people not numbers.

Medical Disclaimer

References

[1] L Sompayrac. How the Immune System Works 4^th edition

[2] L Sompayrac. How the Immune System Works 4^th edition

[3] Rheumatology Secrets 3^rd edition

[4] Adapted from Kelley’s Textbook of Rheumatology, 8^th edition

[5] Sun J, Zhang Y, Liu L, Liu G. Diagnostic accuracy of combined tests of anti cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis: a meta-analysis. Clin Exp Rheumatol. 2014 Jan-Feb;32(1):11-21.

[6] Heidari B, Firouzjahi A, Heidari P, Hajian K. The prevalence and diagnostic performance of anti-cyclic citrullinated peptide antibody in rheumatoid arthritis: the predictive and discriminative ability of serum antibody level in recognizing rheumatoid arthritis. Ann Saudi Med. 2009 Nov-Dec;29(6):467-70.

[7] Paul BJ, Kandy HI, Krishnan V. Pre-rheumatoid arthritis and its prevention. Eur J Rheumatol. 2017 Jun; 4(2): 161–165.

[8] Paul BJ, Kandy HI, Krishnan V. Pre-rheumatoid arthritis and its prevention. Eur J Rheumatol. 2017 Jun; 4(2): 161–165.

Immunoglobulin image By Fvasconcellos 19:03, 6 May 2007 (UTC) [Public domain], via Wikimedia Commons

2 Comments

Overcoming Inflammation When to see a rheumatologist

How to prepare for your rheumatology consultation

October 3, 2017

Rheumatologists treat well over 100 different types of diseases. These diseases are complex and affect many organ systems. Diagnosing a rheumatic disease is like solving a complex puzzle. Every first consultation includes a detailed history, a physical examination, and a review of past blood work, x-rays, and documentation from your other doctors. All these help your rheumatologist solve the puzzle.

Preparing for a rheumatology consultation is a bit like preparing for a meeting with your accountant. You want everything organized in advance: W-2, investment income statements, IRA/pensions distributions, child care costs, etc. You want everything neatly laid out in advance, so that your consultation is as productive as possible.

Laying the groundwork

Make sure your rheumatologist has all the information at his or her disposal well before your appointment.

The progress note from your referring physician. What is the question that’s being asked?
Your primary care physician’s (PCP) last progress note.
The results of any blood tests.
The results of any x-rays or any other imaging.
If you had a biopsy that relates to your symptoms (e.g., skin biopsy, kidney biopsy, lung biopsy), your rheumatologist will want to see the pathologist’s interpretation.
If you are transferring care from another rheumatologist, your current rheumatologist will definitely want to see that information.

Bring an updated list of your medications and allergies

It’s always a good idea to have a written updated list of all your medications and allergies. Make sure you bring this along to your first consultation. Do not assume that your PCP’s updated medication list is up-to-date. Some people see more than one doctor and they’re all making changes independently.

Anticipate questions your doctor may ask

Rheumatologists certainly have access to high specialized blood tests and imaging, but the medical history is by far the most important part of the consultation. Before your visit, try to expect some questions your doctor may ask and then write them down. Here are a few that may help you get started.

When did you first notice something was wrong or had changed?
Describe your symptoms.
Has this ever happened before? If so when?
Do the symptoms come and go or are they continuous?
Is there a particular time of day where they are worse?
What makes your symptoms worse? What makes them better?
Have you taken any over-the-counter medications for your symptoms? If so, which ones and did they help?
Do you think you have other symptoms besides joint or muscle pain that seem connected?
Have your symptoms caused you to make changes to your daily routine?

Anticipate questions you may have for your doctor

Based on what you know, what could be causing my symptoms?
What tests do I need to have done to help decide what my diagnosis is?
Are there any symptoms that I should be looking out for?
What kind of interventions could I do now, to help ease some of my symptoms?
What kind of activities should I avoid at this time? (e.g, get pregnant, run a marathon, prolonged travel, etc.)

Actively listen and participate

You may feel overwhelmed when your doctor is giving you a new diagnosis, let alone giving you a complex set of recommendations. You’re not alone. A study looked at how much information (when prescribing a new medication) patients retained after their doctor’s appointment. They found that only 64% of people were able to recall all the information that they discussed during the visit[1]. Not bad, but not great.

We know that recall of information improves health outcomes in people suffering from chronic diseases like rheumatoid arthritis and lupus. Another study looked at aspects of doctor-patient communication that lead to higher recall. They found that active patient engagement and explicit conversations about medications improved recall.[2] Here are a few tips about becoming a better active listener.

Pay attention
Show that you’re listening
Provide feedback
Defer judgement
Be candid, open, and honest in your response.

You may also want to write things down in a journal (highly recommended) or maybe you may want to bring an advocate to your consultation. This could be a trusted friend or family member.

Conclusion

Being ready for your appointment, active listening, and asking questions to understand your symptoms is central to not only making the most of your rheumatology consultation but also, becoming an empowered patient.

Please follow this link to request a rheumatology consultation.

[1] Tarn DM, Flocke SA, New prescriptions: How well do patients remember important information? Fam Med. 2011 Apr; 43(4): 254–259.

[2] Richard C, Glaser E, Lussier MT. Communication and patient participation influencing patient recall of treatment discussions. Health Expect. 2017 Aug; 20(4): 760–770.

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Diseases and Conditions When to see a rheumatologist

10 Warning signs you could have Sjögren’s syndrome

March 1, 2017

Sjögren's syndrome can cause dry eyes and dry mouth as well as many other symptoms. Read on to learn more!

Today is a most bizarre weather-related day. It’s warm, like you don’t need a coat warm, and there’s a raging thunderstorm. Did I mention it’s February in upstate New York? In honor of this most bizarre day, I’d thought I’d write a few words on a somewhat bizarre and illusive autoimmune disease called Sjögren’s syndrome.

Henrich Sjögren gave Sjögren’s syndrome its name. He was a Swedish physician who first described the disease in 1933. Sjögren’s syndrome is a common autoimmune disease that primarily causes dryness. But it’s a lot more complicated than that because Sjögren’s syndrome can involve almost any organ so can present with a myriad of symptoms. The symptoms arise from infiltration of lymphocytes into glands and affected organs. Simply put, Sjögren’s syndrome is on the differential diagnosis in any person who has a positive ANA presenting with unexplained symptoms.

10 Warning signs you may be suffering from Sjögren’s syndrome

The following are some of the common manifestations of Sjögren’s syndrome. Believe me, there are A LOT more but these are some of the common ones.

Dry eyes
Dry mouth
Swollen cheek(s) i.e., parotid gland enlargement
Profound tiredness
Joint pain, sometimes with swelling
Swollen glands
Numbness, tingling, burning of the skin
Raynaud’s
Shortness of breath with minimal work
Having a child that suffered from congenital heartblock

Dry mouth symptoms

The following are some common symptoms of dry mouth.

Difficulty swallowing dry foods
Inability to talk continuously
Change in taste
Burning sensation
Large dentist bill! – Cavities, cracked teeth, loose fillings
Problems with your dentures
Worsening heartburn
Thrush

As you can see the symptoms are a little all over the place and quite frankly are kind of vague. Furthermore, many different conditions can mimic some of these symptoms: dehydration, depression, various medications, uncontrolled diabetes, multiple sclerosis, hepatitis C, sarcoidosis, etc etc. Literally.

Classification criteria

Now it’s important to note that the following classification criteria are used for research purposes, and not necessarily for the day-to-day clinic. Although they are important, there is such a thing called the art of medicine.

As we all know, not everyone fits into a neat little box.

Recently the American College of Rheumatology and the European League Against Rheumatism came up with a new system to classify Sjögren’s. Basically, a group of hot-shot Sjögren’s specialists got together, looked at the literature, probably had more than one heated discussion, and came up with the following.

To test positive you need to have a score ≥4. There are five items but they are weighted differently.

3 Points – Anti-SSA/Ro antibody positivity
3 Points – Focal lymphocytic sialadenitis with a focus score of ≥1 foci/4 mm²
1 Point – Abnormal Ocular Staining Score of ≥5 (or van Bijsterveld score of ≥4)
1 Point – Schirmer’s test result of ≤5 mm/5 mi
1 Point – Unstimulated salivary flow rate of ≤0.1 mL/min, each scoring = 1

The sensitivity of this score is 96% and the specificity is 95%. The sensitivity tells you how likely you are to detect all cases of Sjögren’s syndrome and the specificity tells you how accurate you are with the diagnosis using these set of diagnostic criteria. These are pretty good figures.

What does this mean?

As you can see, the diagnosis favors objective findings, NOT symptoms. This is a huge change from the previous set of diagnostic criteria. You’ll also note that positive ANA, rheumatoid factor, and positive anti-SSB/La antibody positivity are not included in the new classification criteria.

Now I don’t want people thinking that I think symptoms are unimportant. They are VERY important. It’s just that symptoms should prompt a workup looking for objective features of the disease.

Now, try to remember the 10 warning signs. If you find yourself checking a few of these items, check-in to your local rheumatologist.

References

Rheumatology Secrets 3rd edition

Shiboski CH, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren’s syndrome: A consensus and data-driven methodology involving three international patient cohorts.Ann Rheum Dis. 2017 Jan;76(1):9-16.

5 Comments

Diseases and Conditions When to see a rheumatologist

What is autoimmune back pain?

December 26, 2016

Let’s face it, back pain is terrible and unfortunately for us, very common. According to the 2016 Global Burden of Disease Study, low back pain is the number one cause for disability globally.

So we know back pain is common and debilitating, but the question is, what is the difference between regular and autoimmune back pain?

There are two broad categories: mechanical back pain and inflammatory or autoimmune back pain. Many but not all autoimmune diseases cause back pain. For example, rheumatoid arthritis usually does not cause back pain. Sometimes these disease are very difficult to diagnosis because they progress very slowly. Often times it takes years to decades to diagnose. Yes you heard me, DECADES. Unfortunately, if left untreated, it can cause irreversible spinal damage: joint erosions and spinal fusion also known as ankylosis. Prompt treatment with a disease modifying anti-rheumatic agent (DMARD) often can slowdown or prevent joint damage.

Autoimmune back pain

As I was mentioning before, mechanical and autoimmune back pain are completely different. Mechanical back usually improves with rest, worsens with strenuous activity, and usually begins later in life. People that have autoimmune back pain experience the opposite. Here are some of the key features.

Usually pain starts during the 2^nd or 3^rd decade of life. People usually experience symptoms before the age of 45
Onset is gradual for the most part
Symptoms have been ongoing for more than 3 months
Exercise improves the pain
Rest really doesn’t help. The pain usually worsens with rest
Anti-inflammatory medications like naproxen or ibuprofen helps the pain
Pain wakes you up during the second half of the night
Pain and prolonged stiffness in the morning. Typically, stiffness lasts more than one hour
Alternating deep buttock pain

Risk factors

Autoimmune disease rarely occur in isolation. The following are some of the risk factors pointing towards a diagnosis of autoimmune back pain.

Personal history of uveitis. This is a type of inflammatory condition that affects the eye.
A personal history of psoriasis.
Having a history of dactylitis in your finger or your toes, aka “sausage digitis”.
History of inflammatory arthritis: redness, swelling, and stiffness in any joint
Any first degree relative with any spondyloarthritis (SpA)-associated condition? This means mom, dad, siblings, or your children. SpA-associated conditions include:
- Axial spondylitis also known as ankylosing spondylitis
- Psoriasis
- Psoriatic arthritis
- Reactive arthritis
- Crohn’s disease
- Ulcerative colitis

If you think you could be suffering from autoimmune back pain, please seek your local rheumatologist. But do not jump to conclusions. There are many other diseases that can mimic inflammatory back pain that are not autoimmune in nature.

References

Vos T, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016 Oct 8;388(10053):1545-1602.

Sieper J, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009 Jun; Suppl 2:ii1-44.

http://www.asas-group.org/publications/ASAS-handbook.pdf

Medical Disclaimer

Diseases and Conditions When to see a rheumatologist

Signs you may be suffering from autoimmune joint pain

December 5, 2016

Pretty much everyone at some point in their lives is going to experience some form of joint pain. But when does joint pain become more than just your typical, “I over did it” joint pain? When does it become, “I think there is something really wrong” type of joint pain? Is this joint pain caused by an autoimmune disease?

Here are a few typical scenarios.

Scenario #1

Mr. B is a 65-year-old man who presents to clinic with bilateral knee pain. He first noticed the pain a few years ago. He used to take some over-the-counter ibuprofen when it got real bad and that used to relieve the pain. Over the past few months he has noticed worsening. His left knee sometimes swells up. The ibuprofen isn’t really cutting it anymore. He tells me that the pain is worse after particularly active days. When he sits down he feels pretty good but when he stands up, he feels pretty stiff but generally loosens up after a few steps. He used to work construction and played football in college.

Scenario #2

Mrs. M is a 53-year-old woman who comes to the clinic for joint pain. About 3 months ago, she noticed that she was having a lot of difficulty removing her rings. She really didn’t pay much attention to it. She told herself, “I must be eating too much salt”, “I must be getting old”. Over the course of the next few weeks she began developing pain and swelling involving her knuckles. The pain is particularly worse first thing in the morning and sometimes wakes her up in the middle of night at times. She also states, “My hands feel like a claw in the morning”. The stiffness last well over one hour in the morning and typically, by noon she’s as good as she is going to be for the rest of the day. She’s tried ibuprofen, naproxen, and acetaminophen but nothing seems to work. She also remarks that her hot flashes have gone completely out of control recently.

Sounds familiar?

Inflammatory vs. Non-inflammatory joint pain

In scenario #1, we have a man presenting with non-inflammatory joint pain. This is your common wear and tear arthritis or osteoarthritis. It can involve pretty much any joint you can think of. What is important to note, is that it tends to progress slowly over time. The joint pain tends to worsen with increasing activity and it typically responds, although maybe not completely, to over-the-counter anti-inflammatory medications. Usually there is no joint swelling, but when it comes to the knees, swelling often does occur. A phenomenon called “gelling” can also occur with osteoarthritis. This occurs when the joint has been in a resting position for a while and then becomes active. The joint stiffens up or gels, but then loosens up pretty quickly.

In scenario #2, we have a woman presenting with joint pain that develops over the course of 3 months, or what we call a subacute presentation. She’s experiencing joint swelling involving small joints and it’s associated with prolonged morning stiffness. What I mean by prolonged is over one hour. Her symptoms also are worse in the morning. She also experiences constitutional symptoms, i.e., hot flashes. These are all hallmarks of inflammatory joint pain. There are MANY different autoimmune diseases that present with inflammatory joint pain and they all have their own particular flavor. Some like the knuckles, some like the ankles, some like the knees, some have a symmetrical distribution, and some are simply just random. But they all share these specific key characteristics. Rheumatoid arthritis and psoriatic arthritis are two common types. Please follow the links to learn more about these.

Another important note about autoimmune joint pain. It doesn’t go away. This is very important. There are A LOT of different things that can cause a joint to swell, but most of them get better with time. When it doesn’t, then you have to start wondering.

Summary

Why is this important?

So why should you care? Well, first, walking around with swollen joints isn’t exactly the most pleasant thing in the world. It turns out that it isn’t exactly healthy for your joints either. Autoimmune joint disease at times can cause permanent joint damage and it can happen in as little as 3 months.