Symptoms of SLE Continued

3. Discoid lupus is a scaly, raised rash that appears on the face, scalp, ears, chest or arms in 25% of SLE patients. The rash, if untreated, may leave permanent scars. Involvement of the hair roots on the scalp may also cause permanent damage in the form of bald spots but widespread or total baldness is rare. The rash is photosensitive (it will get worse after being in the sun) but this can be avoided if the proper sunscreens are used. In Canada, patients typically experience the reappearance or worsening of discoid lesions during spring and summer. The use of a sunscreen for protection and appropriate treatments can usually reduce or control this problem. It is important to be aware that approximately 10% of discoid lupus patients will eventually develop a usually mild form of SLE. As a result, discoid lupus patients are tested for SLE from time to time.



4. Mucosal ulcers are small sores that occur on the mucous lining of the mouth or nose in as many as 40% of SLE patients. Mouth ulcers most often occur on the roof of the mouth and, because these are usually painless, the patient may not notice them except, perhaps, when eating spicy foods. Painful canker sores happen to lupus patients too but are different from lupus ulcers. Nose ulcers are usually painless but they may cause nosebleeds which, if frequent, should be brought to the physician's attention.



5. Arthritis is very common in SLE. In fact, it is unusual for patients with SLE not to have arthritis sooner or later. It causes pain in the joints of the hands, wrists, elbows, knees or other joints in the arms and legs. (Lupus arthritis does not cause back pain although patients may experience back pain from other causes.) The pain may be migratory, meaning that it goes from one joint to another, and it may occur in the same joint on both sides of the body. Signs of inflammation (swelling, redness, heat) may not show up but, when SLE is very active, the inflammation and pain may be severe.Both the patient and the physician can become very frustrated by the arthritis of SLE. Because the pains move from joint to joint and can appear and disappear quite quickly, the patient may not have any signs of arthritis at the time of their appointment. As a result, diagnosing arthritis in the patient can take quite a long time.
Lupus arthritis is usually not crippling and patients should not fear becoming wheelchair bound (although the use of a wheelchair is sometimes necessary in SLE due to causes other than arthritis). Changes (deformities) in the fingers do sometimes happen as a result of arthritis but this does not usually cause a major loss of function.



6. Pleuritis is inflammation of the pleura, the lining of the lungs, and pericarditis is inflammation of the pericardium, the lining of the heart. These problems may occur alone or together and affect at least 50% of all SLE patients. Pleuritis, and sometimes pericarditis, cause a particular type of chest pain that gets worse when breathing in and gets better or goes away when breathing out. Patients may also have less pain when sitting or standing and more pain when lying down. If the pain is severe, the person may be limited to shallow breathing only. Lupus patients who experience a second bout of pleuritis or pericarditis later in the course of their disease often readily point out that "...the pain is like it was the first time...".
While there are many benign (not serious) causes of chest pain, it is wise to inform your doctor immediately if you experience such a pain. By examining you, and performing tests such as a chest x-ray, heart ultrasound and electrocardiogram (ECG), your physician will be able to make a diagnosis and, if necessary, start treatment.



7. Kidney involvement ranges from very mild to very serious. It is believed that most, if not all, patients with SLE have at least some mild degree of kidney (or renal) involvement. When mild, this involvement is usually not a problem. However, in 50% of patients, kidney damage may occur and this is of concern because it may lead to a loss of the kidney's ability to clean the blood. An upsetting feature of SLE kidney involvement is that it tends to remain silent (the patient will not have any symptoms) until damage has already occurred. Then the patient will complain of weight gain and swelling, particularly in the feet and legs. Doctors call this fluid retention or oedema and it is the most common symptom of major kidney involvement.
It is very important to detect kidney involvement early because some of the deaths caused by SLE are related to severe kidney involvement. For this reason, regular tests of kidney function (simple urine and blood tests) will be ordered by your physician. Urine analysis and tests of kidney function are best performed from time to time, even when lupus seems to be quiet. Regular testing of the kidneys is absolutely necessary whenever lupus is active. Urine analysis can show various signs of inflammation in the kidney such as clumps of red blood cells (called cylinders or casts) or the presence of an excessive amount of protein. To determine how much involvement is present, doctors measure the amount of protein and the performance of the kidneys on all your urine collected over a 24 hour period. In this way, early involvement of the kidneys can be discovered and, if necessary, treatment can be started.Although most patients with SLE never develop kidney involvement that requires the use of artificial blood filtration (dialysis), some patients clearly will. Because kidney involvement can be so serious, affected patients should be evaluated by a nephrologist, a physician who specializes in treating diseases of the kidney.



8. Seizures (epilepsy) and psychosis are serious problems caused by central nervous system (CNS) involvement in SLE, and occur in 15-25% of patients. These problems can be caused by many disorders other than SLE so doctors must take the time to rule out other conditions before deciding that SLE is the true culprit. It is important to be aware that, with CNS involvement, other types of problems may occur which are not as serious as seizures or psychosis.Seizures most commonly involve loss of consciousness and involuntary body movements. The person does not usually recall what happened and descriptions by relatives or friends who witnessed the seizure are most helpful. Seizures can usually be confirmed by performing an electroencephalogram (EEG) which is a reading of the electrical activity of the brain. Fortunately, several drugs are available to control seizures in SLE patients.When seizures are the first symptom experienced by the patient, SLE may not be suspected until other lupus problems appear. This can cause confusion, as physicians may wonder if the other symptoms were triggered by the anti-epileptic drugs. In other words, is this drug-induced lupus? In most cases the answer is no and the seizures will begin again if the anti-epileptic drug is stopped.Psychosis is a serious mental condition where thinking and behavior are disturbed, often including hallucinations (seeing or hearing things that aren't there) and delusions (false notions or ideas, for instance the belief that one is being poisoned). Relatives may say that the person has partly or completely lost contact with reality. Other symptoms may be present such as confusion (the person does not know where he/she is, what the time and date are and may not recognize family members or close friends). Many doctors think that SLE psychosis is best treated with prednisone or a steroid drug.



9. Disorders of the blood cells are caused by autoantibodies that attack one of the blood cells or particles, usually the red or white cells or platelets. It is important to understand that these problems may have causes other than SLE. In all cases, doctors must rule out the other possible causes before treating these problems as related to lupus. Red blood cells may be attacked, resulting in a large number of cells being destroyed and removed from the body in the spleen, a process called hemolytic anemia. This destruction may be slow and relatively mild or may be very quick and cause an emergency. Prednisone is effective in treating this anemia in most people but sometimes the spleen must be removed to bring the anemia under control.
SLE commonly causes a decrease in the white blood cells called leukopenia. In most instances this is not dangerous and by itself does not require treatment.Platelets are cell particles that control the clotting of blood. Autoantibodies to platelets may cause the platelet count to drop, a situation called thrombocytopenia. Some SLE patients continue to have, over time, lower than normal platelet counts which do not require treatment but do need to be checked regularly. In others, a severe decrease in the platelet count can cause bleeding in various parts of the body such as the digestive tract, the urinary tract, the uterus or the brain. This is a serious situation that requires treatment with prednisone and, sometimes, removal of the spleen. Easy bruising of the skin may be a sign of a decreased platelet count but it also occurs in normal individuals or can be caused by prednisone. In my experience, these explanations account for far more cases of bruising than does a low platelet count.



10. Immunologic disorders refer to four autoantibodies found in the blood which, when taken with other symptoms, point to SLE.The lupus erythematosus cell preparation (doctors say LE prep) test is positive when a particular cell (the LE cell) is found in the blood of patients with active SLE. However, the LE cell is sometimes found in disorders other than SLE and most doctors have stopped using this test simply because better tests are now available.Anti-native DNA autoantibodies are common in SLE and it would be unlikely that they would be seen in other diseases. This test is repeated often because the amount of anti-native DNA autoantibodies seems to increase when lupus is active and the test can help the physician measure the degree of disease activity.Anti-Sm autoantibodies refer to the name of the first patient in whose blood they were found (her name was Smith). These antibodies point to SLE.A false-positive test for syphilis, which happens in approximately 20% of SLE patients, suggests that patients have the venereal disease called syphilis when, in fact, they don't. This is another of SLE's sneaky thousand faces and one that has caused a lot of fright and upset. When a diagnosis of SLE is suspected, doctors simply request this blood test for syphilis (V.D.R.L.) and, if it is positive, further tests are done that can show whether or not syphilis is actually present.



11. Antinuclear antibodies, or ANA, are found in the blood in almost every patient with SLE. This test has made the diagnosis of SLE more certain, as it is very accurate, but three cautions must be kept in mind. The first is that ANA may be present as a reaction to various drugs, may be present in diseases other than SLE and may be present in healthy individuals, particularly the elderly. Therefore, a positive ANA must always be looked at in light of other symptoms of SLE. The second caution is that the improved methods of testing for ANA have found small amounts of ANA in the blood of many apparently healthy people. Therefore a positive ANA does not necessarily mean a diagnosis of SLE. The third caution is that a positive ANA test should be repeated to be absolutely sure.In rare cases, a diagnosis of SLE will be made even when the ANA test is not positive. Some patients with several specific symptoms of lupus will not develop a positive ANA until later on in their disease. Other patients may have a particular autoantibody in their bloodstream called anti-Ro (from Robert who was the first person identified with this antibody) which is poorly detected by standard ANA tests. In these cases, there is a specific test for anti-Ro that is available at University Hospitals.