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Does my patient have Lupus?. Jammie Barnes, MD Assistant professor Department of Medicine, Division of Rheumatology. It’s Lupus. Dr. House or Dr. Warner. LBJ referral: +ANA with aches and pains Dr. Barnes: It’s Lupus Dr. Warner: Wrong

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Does my patient have lupus

Does my patient have Lupus?

Jammie Barnes, MD

Assistant professor

Department of Medicine, Division of Rheumatology

It s lupus
It’s Lupus


Dr house or dr warner
Dr. House or Dr. Warner

  • LBJ referral: +ANA with aches and pains

  • Dr. Barnes: It’s Lupus

  • Dr. Warner: Wrong

  • Another referral: same story

  • Dr. Barnes: It’s Lupus

  • Dr. Warner: Wrong

  • A retrospective chart review at LBJ (1yr)

    • 104 +ANA referrals…. ONLY 6 cases of confirmed SLE


  • Understand the limitations of sensitivity and specificity of ANA

  • Determine who needs to be evaluated for SLE

  • Describe the systemic signs and symptoms of SLE

  • Apply the American College of Rheumatology criteria for SLE

  • Apply to cases

Ana is 100 sensitive
ANA is 100% sensitive



Sensitivity specificity
Sensitivity & Specificity

PPV: 10/400 = 2.5%

SnNout: high sensitivity – negative test is good at ruling out the disease

Negative ANA – very unlikely to have SLE

SpPin: high specificity –positive test good at ruling in disease

Sensitivity – 100%

Specificity – 60%

PPV: 500/700 = 71.4%

The nomogram
The nomogram




LR: 2.5

Pretest probability
Pretest probability

  • Consider prevalence

  • Clinical scenario in your patient

  • If you order a test – expect a result

Positive ANA, now what!!


  • Autoabs directed against DNA or snRNP

  • Positive test: >1:80

  • Best to order test by immunofluorescence (IF)

  • ELISA enzyme linked assays are cheaper but have 80-98% agreement with IF

  • ACR recommends ordering ANA by IF

Other problems with ana
Other problems with ANA

  • 1/3 of healthy people have an ANA 1:40

  • 5% of healthy people have ANA 1:160

  • 3.3% of healthy people have ANA 1:320

  • Healthy 1st degree relatives can have + ANA

  • Healthy older people increased + ANA

  • ANA linked to thyroid dz, hepatitis, environmental exposure, cancer, infections and drugs

Southern Medical Journal. Vol 105, no 2, Feb 2012

Making the ana better
Making the ANA better

  • 2 possibilities

  • Raise the threshold of positive test

    • High titers do warrant more investigation > 1:1280

  • Couple the test with more specific signs and symptoms of rheumatic disease

  • High risk - low occurrence

Cns pns

  • Criteria – seizures and psychosis

    • Both in absence of offending drugs

  • Question:

    Have you ever

    had a seizure

    or convulsion?

Orphanet Journal of Rare Disease 2006 1:6

Skin mucocutaneous

  • 4 criterion for skin: malar rash, discoid rash, photosensitivity and oral ulcers

    • Do you get sores in your mouth or nose for more than 2 weeks at a time

    • Rash on your cheek for more than a month

    • Skin breakout (rash) after being in the sun (not a sunburn)

  • Others:

  • Alopecia

    • Have you had rapid loss of hair

  • Raynauds

    • Have your fingers ever shown unusual color changes in the cold

  • Purpura, urticaria and vasculitis


  • Hemolytic anemia

  • Leukopenia <4000 on > 2times or lymphopenia <1500 on > 2 times

  • Thrombocytopenia <100k in absence of drugs

  • All meet hematologic criteria (only get 1 point)

  • Questions: Have you ever been told that you have anemia, low blood count, low platelet count

Cardio pulm

  • Criteria:

    • Pericarditis – documented by ECG, rub or pericardial effusion

    • Pleuritis – convincing h/o pleuritic chest pain, rub or pleural effusion

    • Question: Do you get chest pain with deep breath?

    • 1 point

  • Others:

    • Endo and myocarditis, pulmonary arterial hypertension, valvular, CAD

    • Chronic interstitial pneumonitis, acute lupus pneumonitis, acute alveolar hemorrhage, acute reversible hypoxemia, PE, shrinking lung syndrome


  • Criteria:

  • Persistent proteinuria >0.5gm per day or 3+ on dipstick or cellular cast

  • Have you have been told you have protein in your urine

  • Class 1-6 of lupus nephritis

  • Microangiopathic glomerular disease

  • Renal vein thrombosis


  • No criteria for diagnosis

  • None specific abd pain, nausea and vomitting

  • Rare mesenteric vasculitis


  • Not a criteria

  • LAD

  • HSM


  • Criteria:

  • Arthritis – tenderness, swelling or effusion in 2 or more joints witnessed

  • Typically non-erosive

  • Jacoudsarthopathy

  • Others:

    • Myositis


  • Not a criteria

  • Profound fatigue (disabling fatigue) – in absence of depression

  • Fever (no signs of infection)

  • Weight loss


  • Criteria:

  • Positive ANA >1:80

  • Positive anti-dsDNAOR Anti-Smith OR antiphospholipid antibody

    • AbnlIgG or IgMcardiolipin, + lupus anticoagulant, false positive RPR

  • Others:

    • SSA/B (anti-Ro and La), RNP

Applying signs and sxs
Applying Signs and Sxs

  • Upon screening:

  • Two or more organs systems involved – order CBC, CMP, UA to evaluate for systemic disease

  • If above reveals possible systemic disease then order an ANA and possible other antibodies

  • If 4 or more criteria by ACR or suspect SLE refer to Rheumatology


  • 21 y/o college student with two months of joint pain worse in AM

  • Notices faint rash on face for last month

  • Very tired and finds it difficult to concentrate in class

  • Denies fevers, abd pain, chest pain, diarrhea or constipation

  • On exam: malar rash, decreased breath sounds at bases, no murmurs, diffuse cervical LAD and mild synovitis in the MCPs and PIPs

What next
What next

  • Order labs/studies: CBC, UA, CMP, CXR

  • What other labs do you want?

  • ANA, RF, CCP and TSH

  • WBC count 3.2, nlHgband platelets, neg RF and CCP, UA 2+ proteinuria, no cast or red cells, UPC 0.3, ANA 1:640, +dsDNA, +smith and chest xray with effusions

  • Does she meet criteria?

  • YES!


  • 36 y/o stay at home Mom presents with joint pains for 3 months

  • She has no swelling, but she has tenderness all over in the upper and lower body

  • She tells you she has anemia, severe fatigue but she can still take care of her children

  • She has occasional HA, some weight gain, but other ROS is negative

  • On exam she is overweight with BMI of 32, multiple tender points but no synovitis

What next1
What next

  • Order CMP,CBC, UA and TSH

  • Her labs are normal with exception of HGB of 10.2 and MCV of 76

  • What next:

  • Iron studies

  • Low ferritin, smear: hypochromic RBCs, low iron and high TIBC

  • Do you need to do more?

  • Treat IDA


  • 32 y/o man with long standing history of epilepsy. He has been on anti-seizure medication for many years. Initially he was on phenytoin and now on oxcarbazepine

  • He has developed a photosensitive rash and joint pain

  • In ROS he also has pleuritic chest pain

  • On exam he has a erythematous rash on the face and upper chest, synovitis of the bilateral wrist but rest of exam is normal

What next2
What next

  • CBC, CMP, UA, CXR and ANA

  • He has positive ANA, nl CMP, CMP, UA and chest xray

  • What does he have?

  • Drug induced lupus

  • Do you need histone antibodies?

  • No

  • How do you proceed?

  • Discuss changing anti-convulsant medication, may add NSAIDs, steroid cream for rash and hydroxychloroquine

Thank you for time
Thank you for time

  • Remember ANA does not equal lupus

  • Need careful history and physical

  • Lupus is RARE disease but high morbidity and mortality if missed

  • Please remember your packet!!

  • I need to contact you again in 3months for post test!!!