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Could patient who is 'tired all the time' have lupus?

Thirty-eight-year-old Sarah has been complaining of tiredness and various aches and pains for months. When you suggest she may be depressed following a miscarriage last year, she asks whether she could possibly have lupus as her cousin has the disease. Dr Melanie Wynne-Jones advises.

Is lupus a likely cause of tiredness in a

38-year-old woman?

Tiredness is a common presenting complaint at all ages, and for Sarah possible causes include:

 · Anaemia ­ various aetiologies, including coeliac disease

 · Thyroid disease, diabetes and other endocrine disease

 · Liver or renal disease

 · Post-viral syndrome

 · Autoimmune disease including lupus

 · Premature menopause

 · Occult malignancy

 · Substance abuse

 · Depression

Lupus is not the most likely cause but its two most frequent symptoms are joint/muscle pains and extreme tiredness/weakness, so it should always be considered in the differential diagnosis of these complaints.

What is lupus?

An immunological disease which is part of a 'family' of autoimmune diseases that includes rheumatoid arthritis and scleroderma. Cell-mediated immunity is impaired, and pathogenic auto-antibodies and immune complexes are produced, leading to widespread tissue.

There are about 50,000 sufferers in the UK. Lupus affects nine times as many women as men and natural or external oestrogens can exacerbate the disease. The disease is multigenic; having an affected family member increases personal risk by 3-10 per cent (if an identical twin is affected, the other's risk may be as high as

30 per cent). Lupus is four times commoner in Afro-Caribbeans, and drug-induced lupus (DIL) for example, from hydralazine or chlorpromazine, is increasingly recognised.

Lupus occasionally occurs in childhood but usually starts in young or middle age. However, the diagnosis may be delayed because symptoms are often transient or non-specific.

Migraine, 'growing pains' or prolonged glandular fever in the teenage years may be pointers to the condition, as may recurrent miscarriage.

What symptoms does lupus cause?

The commonest presentations are:

 · Joint or muscle pains (often without signs of inflammation)

 · Fatigue/weakness

 · Rashes (not always the typical red butterfly rash over nose and cheeks)

 · Weight gain or loss

However, part of the reason that lupus is hard to diagnose is that as a multisystem disease it may produce few or many symptoms that initially seem unconnected:

 · Fever may be a sign of increased disease activity

 · Skin/mucous and serous membranes ­ butterfly rash, vasculitis, mouth/genital ulcers, discoid LE, hair loss, photosensitivity, Raynaud's syndrome, pericarditis, pleurisy, endocarditis, peritonitis

 · Eyes ­retinal exudates, blindness, Sjogren's syndrome

 · Kidneys ­ renal failure, proteinuria, hypertension, oedema

 · Nervous system ­ convulsions, paralysis, neuropathies, psychiatric disorders, headaches

 · Immune system ­ lymphadenopathy, hepatosplenomegaly

 · Reproductive system ­ repeated miscarriages, amenorrhoea, prematurity and stillbirths

 · Blood ­ haemolytic anaemias, abnormal platelets, neutropenia

 · Heart and lungs ­ breathlessness, chest pains, tachycardia

How is it diagnosed?

The key is to remember lupus as a differential diagnosis for many symptoms. Tests used for diagnosis and monitoring include:

 · Urinalysis for proteinuria

 · Full blood count ­ the classic triad is anaemia, neutropenia and thrombocytopenia. Anaemia may be due to chronic disease (normocytic, normochromic), haemolysis, or NSAID-induced gastrointestinal bleeding

 · ESR ­ raised

 · C-reactive protein ­ usually normal, but goes up in intercurrent infection or serositis.

 · Urea and electrolytes ­ may be deranged if kidney involved

 · Liver function test ­ important if azathioprine used

 · Anti-nuclear antibodies ­ positive in 90-plus per cent of untreated patients

 · Rheumatoid factor ­ positive in 40 per cent of adults with lupus (compared with 10 per cent of population)

 · Antiphospholipid antibodies ­ positive in up to 40 per cent of affected patients, putting them at greater risk of thrombosis or miscarriage

 · Other immunological tests including lupus anticoagulant test, complement assay (low C3 and C4) antibodies to double-stranded DNA, anti-C1q and anti-histone antibodies.

If Sarah's tests are positive, what are the implications?

Lupus is a chronic disease which can cause widespread and ongoing damage. The need for regular monitoring and treatment, as well as the disease itself, will impact significantly on Sarah's life, including work, leisure and starting a family.

Her reaction will in part depend on her perception of how lupus has affected her cousin. She may want to discuss the implications in depth, or avoid this if she is not yet ready to handle them. She may become depressed, requiring counselling or medication.

How should she be managed?

Sarah should be referred to a rheumatologist who will confirm the diagnosis and monitor her disease activity long-term, although if she is unlucky she may eventually also need to see a renal physician, ophthalmologist, gynaecologist and so on.

Regular blood counts and urine analyses are needed, plus tests relating to drugs used in treatment which may include steroids, anti-malarials, azathioprine, methotrexate, cyclosporin, cyclophosphamide and others.

She may also require physiotherapy (joint protection, hydrotherapy, splints) pain management, and practical assistance from an occupational therapist (aids and appliances, home and workplace adaptations) or social worker (benefits). The national support group, Lupus UK, can also provide information and general advice.

As her GP, your role is to offer ongoing support and to act as Sarah's advocate in co-ordinating this extended team.

Key points

 · There are many physical causes of aching and fatigue which should always be thoroughly investigated

 · Lupus is a multi-system autoimmune disease with serious complications

 · Diagnosis may be delayed because the symptoms seem vague

and unconnected

 · Lupus should be managed holistically by a multidisciplinary team

References and resources

Lupus : a GP Guide to Diagnosis. Available free ­ send a brief request on practice-headed notepaper to Lupus UK (see below)

Lupus UK ­ Factsheets, information, support and raising both awareness and funds.

St James House, Eastern Road, Romford,

Essex RM1 3NH

Arthritis Research Campaign. Information for professionals and patients, plus practical advice on lupus. Copeman House, St Mary's Court, St Mary's Gate, Chesterfield, Derbyshire S41 7TD.

Tel: 0870 850 5000

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