Friday, September 16, 2005

Is it Lupus - The St Thomas' Hospital "Alternative Criteria"

Is it Lupus - The St Thomas' Hospital "Alternative Criteria": "Is it Lupus? - The St. Thomas' Hospital 'Alternative Criteria'"

1. Teenage "growing pains" yes
2. Teenage migraine yes
3. "Glandular Fever" prolonged periods off school due to putative "glandular fever" sore throats, fatigue - yes
4. Severe reaction to insect bites - yes
5. Recurrent miscarriages - no
6. Septrin (and sulphonomide) allergy ?
7. Agoraphobia - varying from panic attacks in shops to fear of motorway driving - yes
8. Finger Flexor Tendonitis - maybe
10. Family history of autoimmune diseases?
11. Dry Shirmer's test
12. Borderline C4 ?
13. Normal CRP with raised ESR - one of the most important diagnostic aids. It is 20 years since we reported the persistently low CRP (C-Reactive Protein) levels seen in SLE. CRP zero and ESR (Erythrocyte Sedimentation Rate) 100?
14. Lymphopenia - Cytopenias (a deficiency of some cellular element of the blood) are included in the ACR classification criteria. They are also in my diagnostic criteria. For the purposes of the "diagnostically difficult" case, I have focussed on lymphopenia. In the patient with very non-specific complaints and essentially unremarkable blood tests, a borderline or low lymphocyte count is often overlooked. Common in lupus (although obviously not in any way specific), it is certainly worth including among the minor criteria.

All of us can diagnose lupus in the presence of a butterfly rash, nephritis and alopecia. the challenge comes at the other end of the spectrum. The atypical case. The mild case. The differential between real disease versus no organic disease whatsoever.

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