One component of medicine in reverse

This patient of mine had recently followed up with a rheumatologist for a checkup to see where her disease activity had been. She’s carried a diagnosis of lupus for 20+ years, by the way.

She had concerns that she wasn’t feeling her best, but there were no obvious signs that anything was going on.

Her rheumatologist and the PA tagging along reviewed her labs with her which revealed:

Normal blood chemistry and CBC.

A negative ANA.

Normal complement levels.

An elevated double stranded DNA.        

The specialist’s verdict

The rheumatologist concluded that she never really had lupus (an entirely different discussion) because apparently there is no such thing as ANA negative lupus.

Whatever, man. What happened to hiccams dictam. What happened to the “no 100%s in medicine?”

Let’s pretend she has lupus anyway, because she was told by several rheumatologists in the past twenty years that she did in fact have lupus.

She was told at her recent appointment that if she did have lupus, her disease was in remission because her complement levels weren’t low. We expect them in lupus to be low because your body is using up complement levels in the disease process. But the key word there is expect, because nothing is 100% in medicine, and there are several explanations as to why complement levels could be this way in a flare.

Another interpretation of the labs

But what about her double stranded DNA? Turns out it does track with disease activity. And what’s interesting about this particular patient, who has a 20-year history of lupus, is that she recalls this particular metric being elevated whenever she hasn’t felt well in the past.

So, she was sent away, told there was nothing to be concerned about. A few weeks later, she ended up in the ER feeling pretty unwell and with what was determined to be signs of vasculitis. She was re-evaluated in an outpatient setting and told by three different docs that her vasculitis was likely secondary to autoimmune disease.

There was arguably some laboratory evidence of that. But more importantly, she told us so!

There are different philosophies on this order of operations, and yes there’s a ton of gray area when dealing with complex issues like lupus, but it’s important your doc is listening to what you’re saying first and then tying that into lab and imaging studies. Not the reverse.

Dr. Mitchell is a Naturopathic Physician practicing in Gilbert, Arizona. His interests include rheumatology and environmental medicine