The symptoms of lupus can span to any part of the body. There are different symptoms of patients. Some patients can present with oral ulcers, hair loss, rashes in the sun, swollen joints, or morning stiffness in their joints. Other patients will have inspiratory chest pains, fevers, swollen glands, low white blood cell counts, protein in the urine.
Other patients will have fatigue associated with any of these symptoms, but it’s very important that this fatigue in lupus is not chronic. It’s a fatigue that accompanies the activity of lupus and generally resolves once the activity resolves itself. Any kind of symptom can be a sign of lupus and one symptom alone shouldn’t raise suspicion for lupus. There are some manifestations that are very common like cognitive dysfunction.
Not all cognitive dysfunction is a sign that somebody has active inflammation of the brain. That is a common misconception. Cognitive dysfunction is commonly seen in lupus, even at the time of diagnosis. About 80% of the patients will have it even during their first visit with their rheumatologist to a mild degree and it may not progress over time. Lupus can affect the brain by causing seizures, by causing inflammation of the lining of the brain, by inflaming the brain itself.
It can affect the spinal cord and cause something called myelitis and paralyze patients. It can affect peripheral nerves and cause footdrop or wrist drop. It can affect the lungs by causing bleeding in the lungs or affecting the lining of the lungs and inflaming it, something called pleuritis. It can affect the lining of the heart or the heart itself. It can affect the valves of the heart.
Gastrointestinal involvement is relatively rare but can happen. It can also inflame the peritoneum, the lining of the abdomen. Very rarely, the blood vessels of the bowels, something called vasculitis, mesentery vasculitis. It can affect the joints, but mostly small joints, not the large joints like the hips or shoulders. It can affect the skin by causing either inflammatory rashes or ulcerations. It can affect the fingers. The Raynaud’s I mentioned when they change colors. Sometimes that can lead to ulcers, although it’s very rare. It can cause clots.
Patients with lupus have a higher risk of thrombosis when they make so-called antiphospholipid antibodies. Very rarely it can affect the eye too and people can get inflammation of the sclera or the uvea or the retina. So there’s really no part of the body that is always spared. Something can always be affected. Patients that go into these long remissions where they don’t have flares and flares are rare, but on average, flares occur about once a year. And by a flare, we generally mean clinical evidence of activity or laboratory evidence of activity.
Some flares will not require changes in management. Like I said, if somebody has low white blood cell count or suddenly drops their compliment levels, that will count as mild disease activity, but doesn’t necessarily require that we change their management. Some flares though do require changes in management like if somebody has inflammation of the lining of the lungs or inflammation of the lining of the heart or the joints.
To the severe flares that I mentioned before. Inflammation of the brain, kidneys, or bleeding in the lungs, which require hospitalization and very aggressive treatment of high dose of IV steroids and immediate immunosuppressants. About 30% of patients with lupus will develop fibromyalgia and that is the most common course of chronic pain and fatigue. Exactly why this high percentage of lupus patients develop it is unknown.
But it does affect their quality of life in a manner that is even more significant than lupus itself. It’s a common misconception that chronic fatigue alone is a sign of lupus activity. Chronic fatigue is usually a sign that somebody has developed fibromyalgia and doesn’t require changes in immunosuppression or any of the lupus medications.
Developing this fatigue and pain does require a rule out of other things that can mimic it like thyroid dysfunction or inflammation of the muscles, which can rarely cause widespread pain, but the context of fatigue, unrefreshed sleep, widespread pain, cognitive dysfunction generally accompanies fibromyalgia and requires a completely different approach rather than immunosuppression. In outpatient settings, a lot of times chronic pain is worked up with an ANA and that’s a very important misconception because lupus does not cause chronic pain. Lupus does not cause hip girdle or shoulder girdle pain. It does not cause chronic neck or low back pain. So whenever somebody has that kind of pain, checking an ANA without having other signs of lupus doesn’t really make any sense, but I do evaluate a lot of patients who have chronic pain and end up getting a positive and then nobody knows exactly what the cause is and they think it’s lupus. So yes, I do see fibromyalgia patients in that context, but lupus symptoms do not follow fibromyalgia patients. (slow music)