Michigan Lupus Information and Resources

Educational Lupus Information - Part 4

2010-03-09T21:12:00.003-05:00

Systemic lupus is a disease that can affect many parts of the body. A lupus symptom that is active for a while is called a lupus flare; if the symptoms go away for a period of time, it's referred to as remission. Some doctors prefer to use the term "quiescence," which means a quiet period, instead of the word remission.

Patients with Systemic Lupus Erythematosus require both medical treatment for controlling their dysfunctional immune system (immunosuppressant medications), and for overcoming the diseases generated by Lupus. People with Lupus are very susceptible to bacterial infections and need continuous medical treatment with antibiotics. Many patients with Lupus also suffer from lung disease (tuberculosis, pneumonia) and cardio-vascular diseases and need medical treatments with antihypertensive medications and anti-inflammatory drugs. Although there are various medical therapies and treatments available nowadays, patients with Systemic Lupus Erythematosus can be affected by the disease for their entire lifetimes. The evolution and the chronic character of Lupus resemble HIV, both involving dysfunctions of the immune system and high susceptibility to other diseases.

While people with discoid lupus erythematosus mostly present recurring skin disorders, patients diagnosed with systemic lupus erythematosus can develop a wide range of diseases: cardiovascular diseases, tuberculosis, pneumonia, disorders of the gastrointestinal tract, diseases of the musculoskeletal or nervous systems.

Becoming overtired or feeling as though your stress level is building up.Having more frequent or higher fevers than usual.Aching in your muscles, or more painful and swollen joints.The development of a rash.The development of any symptoms you have not had before.

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This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Educational Lupus Information - Part 3

2010-02-10T09:09:00.001-05:00

Becoming overtired or feeling as though your stress level is building up.Having more frequent or higher fevers than usual.Aching in your muscles, or more painful and swollen joints.The development of a rash.The development of any symptoms you have not had before

Cytotoxic medications are very powerful and they are prescribed only to patients with severe forms of lupus. Cytotoxic medications and corticosteroids are usually prescribed together in lupus treatments and their aim is to suppress the production of antibodies that are harmful to the organism.

Lupus generates a wide range of symptoms and people with the disease experience them at different intensities. Lupus involves abnormal activity of the immune system. The dysfunctional immune system produces antibodies that turn against healthy body cells and tissues (antinuclear antibodies). Some antibodies produced by the dysfunctional immune system can even alter the body’s genetic material (anti-DNA antibodies). The abnormal activity of the immune system can lead to the occurrence of various internal disorders (heart disease, pulmonary disease, kidney disease), disorders of the musculoskeletal system (arthritis, osteoporosis), disorders of the nervous system (brain disease) and skin diseases (lupus rash, erythematous lesions).

The treatment for systemic lupus erythematosus is mainly targeted at reducing the damage caused by the dysfunctional immune system to the body. Immunosuppressive medications are very common in the treatment for lupus. Although they can generate pronounced side-effect, corticosteroids are often used in the treatment of systemic lupus erythemaosus. However, doctors are trying to minimize the use of harmful drugs such as azathioprine (Imuran) and cyclophosphamide (Cytoxan).

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This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Educational Lupus Information - Part 2

2010-01-04T21:09:00.002-05:00

Subacute cutaneous lupus rash generally occurs in the body areas that are exposed to the sun. The rash increases in size and it forms circular, scaly patches. This type of lupus rash doesn’t involve scarring, but it usually heals with hypo-pigmentation of the skin. Subacute cutaneous lupus rash can occur in both systemic and discoid forms of the disease and it generally fades in the periods of remission. Although it can’t be completely overcome, this symptom can also be controlled through the means of medical treatments. When you have lupus rash, it is very important to avoid exposing the affected skin to sunlight. Also, you should avoid exposing the skin to irritants and chemicals, as they can seriously aggravate the rash.

Systemic lupus erythematosus can affect different parts of the body, sometimes even causing permanent damage. Lupus involves dysfunctions or hyperactivity of the immune system, which begins to attack healthy blood cells and genetic material. Instead of protecting the body from infectious agents and malign organisms, the immune system produces antinuclear antibodies that attack the DNA (deoxyribonucleic acid). Systemic lupus erythematosus can affect the cardiovascular system, the lungs, the gastrointestinal tract, the kidneys, the nervous system and brain, the musculoskeletal system or skin. People with systemic lupus erythematosus commonly suffer from affections of the joints, heart disease, pulmonary disease or skin diseases. Considering the multitude of generated symptoms, people with systemic lupus erythematosus require various medical treatments for each particular disorder.

Corticosteroids are commonly prescribed in lupus treatments. These are powerful drugs that control the activity of the dysfunctional immune system.

Lupus rash commonly occurs on the body regions that are exposed to sunlight: scalp, face, neck and shoulders. However, the rash can also occur in other areas of the body (chest, back, palms and feet), in many cases accompanied by skin lesions. When it occurs on the face, lupus rash has a reddish, burn-like aspect. Sometimes the rash can even affect the moist tissues around the mouth and the nose. In the systemic form of the disease, lupus rash doesn’t generally involve skin scarring and it can ameliorate with medical treatment. Lupus rash tends to aggravate if the affected skin is exposed to the sun for long periods of time.

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This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Educational Lupus Information

2009-12-29T21:06:00.000-05:00

Antimalarials are aimed at reducing the skin lesions and inflammation differentiating to lupus. These drugs are generally used in both discoid and systemic lupus treatments.

The process of diagnosing discoid lupus erythematosus involves physical examination, laboratory another look of graze samples and elaborate blood tests. If laboratory tests distinguish dysfunctions of the immune plan again the skin lesions are linked to discoid lupus erythematosus, the patients will be prescribed an designate medical treatment. Although the disorder can’t be fully overcome since the means of the medical treatments available today, discoid lupus erythematosus can be controlled besides its generated symptoms answerability be ameliorated. Patients diagnosed duck discoid lupus erythematosus need to elude pedantry to sunlight juice order to prevent strain of their skin lesions again the formation of permanent scars.

Statistics indicate that there are around 2 million kinsfolk diagnosed with Lupus each year. An estimated 90 percent of the affected connections are sex. because some reason, Lupus has the prime incidence in young women and many of them show up the disease after tender age. The disorder also occurs credit infants, quite young children and elderly people. African American and Asian womanliness are submerged fresh touchy to developing Lupus than white women. Research results indicate that the incidence of Lupus in black women is advancement to 3 times higher than in white women. Asian and Hispanic women are usually affected by Lupus at a young age again experience more pronounced forms of the malady.

In the discoid parent of lupus, the rash occurs mastery different regions of the body and it affects larger patches of skin. Discoid lupus rash involves hyperpigmentation of the skin, exfoliation and the formation of crust. The skin lesions characteristic to discoid lupus erythematosus can affect deeper layers of graze also they usually heal shroud scarring. When it occurs on the scalp, discoid lupus mange constraint involve temporary or permanent hair loss (alopecia). If the rash is accompanied by intense scaling, papules besides crust, the skin may heal cache pronounced scarring.

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This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Lupus: Treatment, Symptoms and more

2009-09-16T19:43:00.015-04:00

The treatment for systemic lupus erythematosus is mainly targeted at
reducing the damage caused by the dysfunctional immune system to
the body. Immunosuppressive medications are very common in the
treatment for lupus. Although they can generate pronounced
side-effect, corticosteroids are often used in the treatment of
systemic lupus erythemaosus.

However, doctors are trying to minimize the use of harmful drugs
such as azathioprine (Imuran) and cyclophosphamide (Cytoxan).

Discoid lupus erythematosus is a condition of the skin that generates
localized or widespread circular lesions. Discoid lupus erythematosus
is a chronic autoimmune condition. Instead of protecting the body
against infectious organisms, certain dysfunctions of the immune
system cause it to attack healthy body cells and tissues, producing
lesions on the surface of the skin. The skin lesions caused by discoid
lupus erythematosus can aggravate due to prolonged exposure to
the sun.

Most patients have localized skin lesions, predominantly on the body
regions exposed to sunlight: scalp, face, neck and arms. However,
some patients have skin lesions on unexposed regions of the body:
chest, back or legs. These lesions canindicate the development of
systemic lupus erythematosus, which involves serious abnormalities
of the immune system.

Discoid lupus erythematosus is very common in women with ages
between 18 and 50 and it rarely occurs in men. The skin disorder has
the highest incidence in African American women, who commonly
experience more intense symptoms of discoid lupus erythematosus.
Although the actual causes of the disorder have not been identified,
multiple inter-related factors are suspected for triggering the
condition: genetic factors (inherited genetic abnormalities),
hormonal factors (excessive levels of estrogen seem to facilitate the
development of the disorder) and environmental factors (prolonged
medical treatments with antibiotics).

Discoid lupus erythematosus has a pronounced hereditary character,
as the majority of affected people have a family history of the
disorder. Systemic Lupus Erythematosus is an autoimmune disease
that can cause a wide range of dysfunctions.

Lupus involves abnormal activity of the immune system, causing it
to attack the healthy blood cells of the body instead of protecting
them from external infectious agents.

Systemic Lupus Erythematosus can determine various disorders,
affecting the skin, heart, kidneys, lungs, musculoskeletal system,
nervous system and brain. Considering the fact that systemic lupus
erythematosus generates various uncharacteristic symptoms, it is
very difficult to diagnose the disease relying only on physical
examinations and patients’ reports of their symptoms. Many
symptoms of systemic lupus erythematosus can be actually
misleading in the process of diagnosing the disease.

Lupus can be correctly diagnosed only through the means of blood
analyses and laboratory tests. If some of the patients’ experienced
symptoms are linked to systemic lupus erythematosus, the medical
treatment will be established according to the affected persons’
overall health condition.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Work Disability Among People With Lupus

2009-06-17T21:54:00.000-04:00

Being unable to work has a profound impact on chronically ill people and their families. Self esteem, socializing with peers, current income, and retirement assets can all be greatly reduced when a person becomes work disabled. Arthritis Foundation-funded researcher Ed Yelin, PhD, and his team at University of California, San Francisco, assessed the work patterns of people with systemic lupus erythematosus (SLE or lupus) at diagnosis and several years after diagnosis.What Problem Was Studied?Because lupus often begins at a fairly young age, during a person’s career-building phase of life, those people have a lot to lose if they cannot work.

If diagnosed at age 30 and work disabled by age 35, a person with lupus may lose up to 30 years of income and have no money saved for retirement. To determine the levels of work disability and characteristics of people who become disabled, Dr. Yelin and team studied a large group of people with lupus over a number of years.What Was Done In the Study?Participants of a genetic study of lupus were recruited for the Lupus Outcomes Study (LOS). Of those in the genetics study, 982 enrolled in the LOS and answered questions to an initial interview. One year later, 832 of the participants answered the same questions again. The survey gathered data about the following:
demographics and socioeconomic status – age, sex, ethnicity, education, income;

SLE status – disease activity, disease manifestations;
general health – height and weight, smoking status, diseases other than lupus;
mental health – depression, cognitive function, stress;
health insurance – type of coverage, copayments, drug coverage;
health care utilization – number of doctor visits, medications taken, hospitalizations; and
employment – if working, number of hours per week, number of weeks per year, occupation, demands of job.

What Were the Study Results?The LOS participants had lupus for an average of ~12 years. Overall, 74% had been employed in the year of diagnosis, declining to 55% at the time of the first LOS interview and to 54% a year later at the second LOS interview. Among participants who had ever been employed, hours worked per week declined by ~35% between the year of diagnosis and the second interview; weeks worked per year declined by ~24%; and total hours worked per year declined by ~32%. By 5 years after diagnosis, 15% had stopped working; by 10 years, ~36%; by 15 years, 51%; and by 20 years, 63% had stopped working. These numbers represent a much lower employment rate than a similar group without SLE.

What Does This Mean For People With Lupus?Among these people with lupus, diagnosis occurred in their mid-30s. More than half of those lost 20 years of earning potential. As Dr. Yelin notes in the article’s summary “Because much of the accrual of retirement savings occurs in these last two decades of a career, after one’s responsibilities to one’s children have passed, persons with SLE will have to face retirement with a much greater risk of poverty.” This grim reality brings to the forefront a need for occupational therapy and work maintenance programs that can help people with chronic diseases remain in the workforce. To reduce employment loss, Dr. Yelin recommends, “People with SLE must work with their employers to receive the job accommodations that are their due under the Americans with Disabilities Act (ADA). In particular, flexible work schedules have proven helpful so that those with serious illnesses can fit their illness episodes and need to obtain health care in and around work activities.”

Yelin E, Trupin L, Katz P, et al. Work dynamics among persons with systemic lupus erythematosus. Arthritis Rheum (Arthritis Care Res) 2007;57:56-63.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

What Are The Four Types of Lupus?

2009-03-23T18:39:00.001-04:00

There are four types of lupus: discoid, systemic, drug-induced and neonatal lupus.

Discoid
Discoid (cutaneous) lupus is always limited to the skin. It is identified by a rash that may appear on the face, neck, and scalp. Discoid lupus is diagnosed by examining a biopsy of the rash. In discoid lupus the biopsy will show abnormalities that are not found in skin without the rash. Discoid lupus does not generally involve the body's internal organs. Therefore, the ANA test may be negative in patients with discoid lupus. However, in a large number of patients with discoid lupus, the ANA test is positive, but at a low level or "titer."

In approximately 10 percent of patients, discoid lupus can evolve into the systemic form of the disease, which can affect almost any organ or system of the body. This cannot be predicted or prevented. Treatment of discoid lupus will not prevent its progression to the systemic form. Individuals who progress to the systemic form probably had systemic lupus at the outset, with the discoid rash as their main symptom.

Systemic
Systemic lupus is usually more severe than discoid lupus, and can affect almost any organ or organ system of the body. For some people, only the skin and joints will be involved. In others, the joints, lungs, kidneys, blood, or other organs and/or tissues may be affected. Generally, no two people with systemic lupus will have identical symptoms. Systemic lupus may include periods in which few, if any, symptoms are evident ("remission") and other times when the disease becomes more active ("flare"). Most often when people mention "lupus," they are referring to the systemic form of the disease.

Drug-Induced
Drug-induced lupus occurs after the use of certain prescribed drugs. The symptoms of drug-induced lupus are similar to those of systemic lupus. The drugs most commonly connected with drug-induced lupus are hydralazine (used to treat high blood pressure or hypertension) and procainamide (used to treat irregular heart rhythms). Drug induced lupus is more common in men who are given these drugs more often. However, not everyone who takes these drugs will develop drug-induced lupus. Only about 4 percent of the people who take these drugs will develop the antibodies suggestive of lupus. Of those 4 percent, only an extremely small number will develop overt drug-induced lupus. The symptoms usually fade when the medications are discontinued.

Neonatal
Neonatal lupus is a rare condition acquired from the passage of maternal autoantibodies, specifically anti-Ro/SSA or anti-La/SSB, which can affect the skin, heart and blood of the fetus and newborn. It is associated with a rash that appears within the first several weeks of life and may persist for about six months before disappearing. Congenital heart block is much less common than the skin rash. Neonatal lupus is not systemic lupus.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Fertility Preserved in Women With Severe Lupus

2009-01-02T10:47:00.000-05:00

Ovarian function can be preserved and disease activity controlled in women with severe systemic lupus erythematosus (SLE; lupus) when treated with a 6-month course of cyclophosphamide (CYC), a chemotherapy drug, followed by the immunosuppressant mycophenolate mofetil (MMF), according to a new study presented at the Annual Congress of the European League Against Rheumatism. Lupus is most common among women and, although long-term survival has dramatically improved over time with better diagnosis and treatment options, one of the challenges in managing the disease is to minimize the side-effects of treatments such as the disruption of ovarian function and risks to fertility.

Pulsed intravenous CYC is a standard therapy for SLE but may also be associated with ovarian failure in addition to other adverse effects.Dr. Katerina Laskari, the presenting author of the study, led by Professor Athanasios G. Tzioufas in the Department of Pathophysiology of the National and Kapodistrian University of Athens, said: "Although the prognosis for people with SLE has considerably improved over the years, a patient's quality of life can all too often be seriously impaired by the toxicity of many commonly used treatments. Preserving ovarian function is a very important consideration in treating women with SLE of child-bearing age, who are already burdened by the difficult nature and impact of the disease itself."

This article was adapted from a press release issued by EULAR.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Poverty & Lupus

2009-01-02T10:43:00.001-05:00

It is a well-established fact that poor people with chronic disease have poorer outcomes than well-off people with chronic disease. People with lupus have not been able to escape this reality. Research in diseases other than lupus has shown that characteristics of the neighborhood in which people live can also affect a person’s health. For example, studies done by sociologists have shown that living in a poverty-stricken area accentuates the negative effects of being poor yourself.

What Problem Was Studied?
Because of the results of the sociological research, health science researchers – led by Laura Trupin, MPH, and including Arthritis Foundation-funded scientists Jinoos Yazdany, MD, MPH, Lindsey A. Criswell, MD, and Edward Yelin, PhD – decided to examine the joint effects of personal poverty and neighborhood poverty on the health of people with systemic lupus erythematosus (SLE; lupus).

What Was Done in the Study?
The team from University of California, San Francisco, used data from the Lupus Outcomes Study to determine the contribution of neighborhood socioeconomic status (SES) to lupus outcomes over and above the contribution of individual SES. Individual SES was determined using three measurements: educational attainment, annual household income and poverty level. Participants were considered to be living in poverty if their income and number of people in the house put them at or below 125 percent of the federal poverty threshold. For a family of four, this translated to an annual income of less than $23,000.Neighborhood SES was determined by the percentage of households in a neighborhood living at or below 125 percent of the federal poverty threshold. If 30 percent of households are below that level, the neighborhood is considered a high poverty area.As well as obtaining this economic information, the research team also gathered data on the participants’ health. For this study, they measured disease activity, overall physical functioning and symptoms of depression.

What Were the Study Results?
After adjusting for confounding variables, lower education, lower income and poverty all were associated with higher disease activity, poorer physical function and more depression. Likewise, living in a high poverty area was also associated with greater lupus activity, poorer physical function and higher likelihood of depression. When evaluating the simultaneous effect of low individual SES and high levels of neighborhood poverty, however, neighborhood poverty had an adverse impact on only the mental health of people with lupus. Of participants who were personally poor and lived in a poor neighborhood, 76 percent had clinically significant depression, whereas just 32 percent of those who were neither poor nor lived in a poor area had scores indicative of depression.

What Does this Mean for People With Lupus?
Other studies have found that living in a poor neighborhood – even if you yourself are not poor – is linked to greater morbidity and mortality. This study did not confirm that to be the case in people with lupus. The authors do conclude, “However, our finding that community poverty is independently associated with increased rates of depressive symptoms suggests that, in this group of individuals facing the challenges of a potentially severe and complex disease, living in a poor community further jeopardizes mental health status.” Because depression is a distinct manifestation of lupus, indeed a symptom of the disease, the risk for a poor outcome is even greater when poverty compounds the situation. The research team will now turn its attention to uncovering the reasons why the combination of personal and community poverty has such an adverse effect on the mental well-being of persons with lupus. One hypothesis to be tested is that neighborhoods with high concentrations of poor people are stressful places to live because of crime rates and poor access to health care professionals.

Trupin L, Tonner MC, Yazdany J, et al. The role of neighborhood and individual socioeconomic status in outcomes of systemic lupus erythematosus. J Rheumatol 2008; e-pub ahead of print July 15.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Lupus Caregivers - Another Perspective

2008-09-28T11:39:00.000-04:00

Tomiko Fraser and her younger sister, Shneequa, can still communicate, although it is often a struggle. Shneequa, who was diagnosed with lupus seven years ago, has suffered brain damage and can't always come up with the right words.

"My sister has a special language that she uses,” says Tomiko. “For instance, for some reason she refers to the color ‘black’ as the number ’10’ and ‘green’ is the number ‘4.’"
Understanding the code words, combined with hand gestures makes it possible for the sisters to stay close and share each other’s thoughts and feelings.

As a model for Maybelline, an actress, and a spokesperson for the Lupus Foundation of America, Tomiko is surrounded by the glamour that accompanies today’s top models. But, as Shneequa’s guardian and primary caregiver, Tomiko often has to make the glamorous life less of a priority.
For many years, her sister lived in a nursing home on Long Island, New York, and Tomiko, who lives in Los Angeles, was only able to see her about once every month. That all changed last year.
"I became [my sister’s] guardian in December 2003 and finally moved her to a facility in Los Angeles where she has wonderful medical care," says Tomiko. "Now I'm able to see her at least three or four times every week."

Tomiko is just one of millions who each year take on the role of caring for an adult family member or friend who is ill or disabled. It is estimated that more than 50 million people in this country become caregivers.

Shouldering Responsibility
Taking care of a loved one can include a range of activities, from mundane to demanding, from driving the person to a doctor’s appointment or helping with bathing, feeding, and dressing. Also, the task of managing a loved one’s financial and legal matters may fall on the shoulders of the caregiver. Caregiving can be very much like a full-time job—but one that does not come with a paycheck. While the care provided by caregivers is unpaid, at the value has been estimated to be $257 billion a year, according to the National Family Caregivers Association.

Although the value of caregivers can never be disputed, the role often takes an incredible toll on those who take it on. Caregivers can experience emotional stress, physical strain, and financial hardships as they try to balance their roles as caregivers with their other obligations. And often, striking that balance is a heavy task.

Suddenly becoming a caregiver can be hard for anyone. But imagine the difficulty of becoming a primary caregiver at the age of 14 for a mother who has just been diagnosed with lupus.
That’s precisely what happened a decade ago to Michelle Snow. The oldest of five children, Snow found herself taking on the responsibility for cooking and cleaning and getting her mother to her medical appointments.

“I was driving before I even had a license,” says Snow, who today plays for the Houston Comets, a Women’s National Basketball Association team. “I drove my mother to her chemotherapy appointments and took her to dialysis and for other medical appointments.”
Much of the responsibility fell on Snow’s shoulders because, as she puts it, “My father worked from sunup to sundown.”

It was a huge challenge, says Snow, whose mother passed away in the spring of 2004 “We’re not taught how to deal with caregiving, and some children do lose their childhood,” she says.

Self Health
Even the strongest and most determined adult can become overwhelmed by the responsibilities of taking care of someone with a chronic disease. So it is of primary importance for caregivers to take care of their own health as lovingly as they do their family member.

LeAnn Thieman, co-author of Chicken Soup for the Caregiver’s Soul, advises taking care to balance your life physically, mentally, and spiritually. That translates into paying attention to your diet, getting enough exercise, and setting aside a few minutes every day for quiet and reflection.

“We pay so much attention to the person we are caring for we forget to take care of ourselves,” says Thieman. “Often caregivers feel alone and unappreciated. They have to understand that caring for themselves is as important as providing care for others.”

Learn as You Care
One of the best tips for caregivers is to learn as much about the disease as they can. “You might think that you do not want to know, but if you are educated, you’ll find a way to deal with things,” says Suzanne Mintz, president and co-founder of the National Family Caregivers Association.

Mintz, whose husband has multiple sclerosis, has four guiding lights for family caregivers:

Choose to take charge of your life.
Love, honor, and value yourself.
Seek, accept and, at times, demand help.
Be an activist for your disease.

Mintz echoes Thieman and Forte on the importance of looking at the situation from the “glass-is-half-full” viewpoint.

“We really can choose our attitude,” says Mintz. If you focus on the bright side, whether that be the great research on the horizon or you’ve found a wonderful doctor, caregivers will find that an inner strength that they weren’t aware of.

Mintz’s second principle is to take care of yourself, both physically and mentally: get the massage or arrange for lunch and a movie with a friend. Caregivers have a right to do things for themselves and if they don’t take care of themselves, they’ll end up becoming very bitter. Being a martyr is not going to benefit anyone, Mintz points out.

Mintz also advises that caregivers bear in mind that they can’t do it all. “People don’t realize that there has never been a phenomenon like this,” she says. “In 1900 the average life expectancy was 47 years. It used to be that people died from infections or diseases in a short period of time,” whereas today they can live for years with Alzheimer’s or heart disease, so the role of caregiver can be significantly longer than just a couple of months. As a result, the demands on long-term caregivers may be significantly greater than in the past and the toll it can take on their own careers, health, and well-being can be significant.

Seek Support
It’s normal for the strains of caregiving to cause feelings of being overwhelmed, depressed, or discouraged. Considering this, it’s crucial for caregivers to build a support system— whether it consists of paid services, help from friends and neighbors, or members of one’s church or synagogue.

John Forte, whose wife Carole was diagnosed with lupus nine years ago, recommends seeking professional help if the feelings become too much to handle. “Virtually all the caregivers I know have sought mental health counseling for exhaustion, or depression, or because they are getting older and not able to do as much physically as they once were,” he says. Judith Sheagren, D.S.W., a psychotherapist and psychoanalyst in Baltimore, confirms Forte’s point of view.

“I see people all the time who are struggling with their guilt about taking any time for themselves and who feel bad because they are not devoting every minute to a family member who is less fortunate,” she says. “When one feels that she is losing touch with her own life, it really can be beneficial to sit down with a mental-health professional and see what limits need to be set to reclaim one’s life.

“It’s important not to give so much of yourself that there is nothing left for you.”
Support groups are also a rich source of help. “The benefit of a support group is knowledge and having the chance to share information with others,” continues Forte. “These are people who understand what you are going through with doctors and medications and struggling through our very complex medical system.”

Not surprisingly, Forte has been asked more than once: “I can find everything I need on the Internet, so why should I bother attending a support group?” One powerful reason, Forte points out, is that "the computer is not going to reach out and give anyone a hug, a pat on the back, or a shoulder to cry on.”

Of course, even caregivers who themselves have a good support system in place need to be realistic and acknowledge that it is normal to become discouraged. “I get discouraged all the time,” says Tomiko Fraser. “I question why I am the one in my family who was ‘chosen’ to take care of my sister. Still, while taking care of her and being her legal guardian has been an undertaking, I wouldn’t have it any other way. I’d advise other caregivers to try to be strong and have a lot of patience, as well as a heart full of love. I'm trying to keep her quality of life as pleasant as possible ... what keeps me going is my love for her.”

The Advocate’s Role
Finally, Mintz recommends that caregivers must become both activists and advocates. Advocates seek answers to questions, especially when it comes to navigating the health care system, while activists work to make sure that elected officials understand what is expected of them. Tomiko knows about lupus advocacy firsthand and works tirelessly to raise awareness of the disease.

“Since I am a spokesperson for the Lupus Foundation, I make appearances on foundation's behalf, whether that means speaking before Congress or in special events,” she says. “When I'm being interviewed because of my acting or my modeling, I always try to work into the interview what the foundation does, what the disease is and what my role as a spokesperson includes.
“In spite of the difficulties involved in taking care of my sister, what I do for her is nevertheless very important and is very rewarding for me.”

It is a sentiment with which most caregivers would wholeheartedly agree.

Article provided through the Lupus Foundation of America, Inc.

The History of Lupus Erythematosus

2008-05-15T19:51:00.000-04:00

Marc C. Hochberg, MD, MPH
Professor of Medicine, Epidemiology and Preventive Medicine University of Maryland School of Medicine, Baltimore, MD.A selection from the Lupus Foundation of America Newsletter Article Library93-102Revised 6/03

The history of lupus erythematosus (LE) has been reviewed in two of the major textbooks on this disease1,2 and was the subject of an article in a journal in 1983.3 This article concentrates on developments in the present century which have greatly expanded our knowledge about the pathophysiology, clinical-laboratory features, and treatment of this disorder.

The history of lupus can be divided into three periods: the classical period which saw the description of the cutaneous disorder, the neoclassical period which saw the description of the systemic or disseminated manifestations of lupus, and the modern period which was heralded by the discovery of the LE cell in 1948 and is characterized by the scientific advances noted above.
The history of lupus during the classical period was reviewed by Smith and Cyr in 1988.4 Of note are the derivation of the term lupus and the clinical descriptions of the cutaneous lesions of lupus vulgaris, lupus profundus, discoid lupus, and the photosensitive nature of the malar or butterfly rash.

The term lupus (Latin for wolf) is attributed to the thirteenth century physician Rogerius who used it to describe erosive facial lesions that were reminiscent of a wolf's bite.1,3 Classical descriptions of the various dermatologic features of lupus were made by Thomas Bateman, a student of the British dermatologist Robert William, in the early nineteenth century; Cazenave, a student of the French dermatologist Laurent Biett, in the mid-nineteenth century; and Moriz Kaposi (born Moriz Kohn), student and son-in-law of the Austrian dermatologist Ferdinand von Hebra, in the late nineteenth century. The lesions now referred to as discoid lupus were described in 1833 by Cazenave under the term "erythema centrifugum," while the butterfly distribution of the facial rash was noted by von Hebra in 1846. The first published illustrations of lupus erythematosus were included in von Hebra's text, Atlas of Skin Diseases, published in 1856.

The Neoclassical era of the history of lupus began in 1872 when Kaposi first described the systemic nature of the disorder:
"... experience has shown that lupus erythematosus ... may be attended by altogether more severe pathological changes ... and even dangerous constitutional symptoms may be intimately associated with the process in question, and that death may result from conditions which must be considered to arise from the local malady."5

Kaposi proposed that there were two types of lupus erythematosus; the discoid form and a disseminated form. Furthermore, he enumerated various symptoms and signs which characterized the disseminated form including
(1) subcutaneous nodules, (2) arthritis with synovial hypertrophy of both small and large joints, (3) lymphadenopathy, (4) fever, (5) weight loss, (6) anemia, and (7) central nervous system involvement.5

The existence of a disseminated or systemic form of lupus was firmly established by the work of Osler in Baltimore6 and Jadassohn in Vienna7 in 1904. Over the next thirty years, pathologic studies documented the existence of nonbacterial verrucous endocarditis (Libman-Sacks disease)8 and wire-loop lesions in patients with glomerulonephritis;9 such observations at the autopsy table lead to the construct of collagen disease proposed by Kemperer and colleagues in 1941.10 This terminology, collagen vascular disease, persists in usage now fifty years after its introduction.

The sentinel event in the mid 1900s which heralded the modern era was the discovery of the LE cell by Hargraves and colleagues in 1948.11 The investigators observed these cells in the bone marrow of patients with acute disseminated lupus erythematosus and postulated that the cell "... is the result of ... phagocytosis of free nuclear material with a resulting round vacuole containing this partially digested and lysed nuclear material ..." This discovery ushered in the present era of the application of immunology to the study of lupus erythematosus.

Two other immunologic markers were recognized in the 1950s as being associated with lupus: the biologic false-positive test for syphilis12 and the immunofluorescent test for antinuclear antibodies.13 Moore, working in Baltimore, demonstrated that systemic lupus developed in 7 percent of 148 subjects with chronic false-positive tests for syphilis and that a further 30 percent had symptoms consistent with collagen disease.12 Friou applied the technique of indirect immunofluorescence to demonstrate the presence of antinuclear antibodies in the blood of patients with systemic lupus.13 Subsequently, the recognition of antibodies to deoxyribonucleic acid (DNA)14 and the description of antibodies to extractable nuclear antigens (nuclear ribonucleoprotein (nRNP), Sm, Ro, La), and anticardiolipin antibodies; these autoantibodies are useful in describing clinical subsets and understanding the etiopathogenesis of lupus.
Two other major advances in the modern era have been the development of animal models of lupus and the recognition of the role of genetic predisposition to the development of lupus.

The first animal model of systemic lupus was the F1 hybrid New Zealand Black/New Zealand White mouse.16 This murine model has provided many insights into the immunopathogenesis of autoantibody formation, mechanisms of immunologic tolerance, the development of glomerulonephritis, the role of sex hormones in modulating the curse of disease, and evaluation of treatments including recently developed biologic agents such as anti-CD4 antibodies among others. Other animal models that have been used to study systemic lupus include the BXSB and MRL/lpr mice, and the naturally occurring syndrome of lupus in dogs.17

The familial occurrence of systemic lupus was first noted by Leonhardt in 1954 and later studies by Arnett and Shulman at Johns Hopkins.18 Subsequently, familial aggregation of lupus, the concordance of lupus in monozygotic twin pairs, and the association of genetic markers with lupus have been described over the past twenty years.19 Presently, molecular biology techniques are being applied to the study of human lympho-cyte antigen (HLA) Class II genes to determine specific amino acid sequences in these cell surface molecules that are involved in antigen presentation to T-helper cells in patients with lupus. These studies have already resulted in the identification of genetic-serologic subsets of systemic lupus that complement the clinico-serologic subsets noted earlier. It is hoped by investigators working in this field that these studies will lead to the identification of etiologic factors(e.g.,viral antigens/proteins) in systemic lupus.

Finally, no discussion of the history of lupus is complete without a review of the development of therapy. Payne, in 1894, first reported the usefulness of quinine in the treatment of lupus.20 Four years later, the use of salicylates in conjunction with quinine was also noted to be of benefit.21 It was not until the middle of this century that the treatment of systemic lupus was revolutionized by the discovery of the efficacy of adrenocorticotrophic hormone and cortisone by Hench.22 Presently, corticosteroids are the primary therapy for almost all patients with systemic lupus. Antimalarials are used principally for patients with skin and joint involvement on the one hand and cytotoxic/immunosuppressive drugs are used for patients with glomerulonephritis, systemic vasculitis, and other severe life-threatening manifestations on the other.23 Currently, newer biologic agents are being investigated in treating patients with lupus.
Thus, the history of lupus, although dating back at least to the Middle Ages, has experienced an explosion in this century, especially during the modern era over the past forty years. It is hoped that this growth of new knowledge will allow a better understanding of immunopathogenesis of the disease and the development of more effective treatments.

REFERENCES
Lahita RG. Introduction. In: Lahita RG, ed. Systemic Lupus Erythematosus. New York: John Wiley and Sons. 1987; 1-3. (Fourth edition published 2004)
Talbott JH. Historical background of discoid and systemic lupus erythematosus. In: Wallace DJ, Dubois EL, eds. Lupus Erythematosus. Philadelphia: Lea & Febiger. 1987; 3-11. (Sixth Edition published 2002)
Boltzer JW. Systemic lupus erythematosus. I. Historical aspects. MD State Med J 1983; 37:439.
Smith CD, Cyr M. The history of lupus erythematosus from Hippocrates to Osler. Rheum Dis Clin North Am 1988; 14:1.
Kaposi MH. Neue Beitrage zur Keantiss des lupus erythematosus. Arch Dermatol Syphilol 1872; 4:36.
Osler W. On the visceral manifestations of the erythema group of skin diseases (third paper). Am J Med Sci 1904; 127:1.
Jadassohn J. Lupus erythematodes. In: Mracek F, ed. Handbach der Hautkrakheiten. Wien: Alfred Holder, 1904; 298-404.
Libmann E. Sacks B. A hitherto undescribed form of volvular and mural endocarditis. Arch Intern Med 1924; 33:701.
Baehr G, Klemperer P, Schifrin A. A diffuse disease of the peripheral circulation usually associated with lupus erythematosus and endocarditis. Trans Assoc Am Physicians 1935; 50:139.
Klemperer P. Pollack AD, Baehr G. Pathology of disseminated lupus erythematosus. Arch Path (Chicago) 1941; 32:569.
Hargraves MM, Richmond H, Morton R. Presentation of two bone marrow elements: The tart cell and the LE cell. Proc Staff Meet Mayo Clin 1948; 23:25.
Moore JE, Lutz WB. The natural history of systemic lupus erythematosus: An approach to its study through chronic biological false positive reactions. J Chron Dis 1955; 2:297.
Friou GJ. Clinical application of lupus serum nucleoprotein reaction using fluorescent antibody technique. J Clin Invest 1957; 36:890.
Deicher HR, Holman HR, Kunkel HG. The precipitin reaction between DNA and a serum factor in SLE. J Exp Med 1959; 109:97.
Tan EM, Kunkel HG. Characteristics of a soluble nuclear antigen precipitating with sera of patients with systemic lupus erythematosus. J Immunol 1966; 96:404.
Bielschowsky M, Helyer BJ, Howie JB. Spontaneous haemolytic anemia in mice of the NZB/BL strain. Proc Univ Otago Med School 1959; 37:9.
Hahn BH. Animal models of systemic lupus erythematosus. In: Wallace DJ, Dubois EL,eds. Lupus Erythematosus. Philadelphia: Lea & Febiger. 1987; 130-57.
Arnett FC, Shulman LE. Studies in familial systemic lupus erythematosus. Medicine 1976; 55:313.
Hochberg MC. The application of genetic epidemiology to systemic lupus erythematosus. J Rheumatol 1987; 14:867-9.
Payne JF. A post-graduate lecture on lupus erythematosus. Clin J 1894; 4:223.
Radcliffe-Crocker. Discussion on lupus erythematosus. Br J Dermatol 1898; 10:375.
Hench PS. The reversibility of certain rheumatic and non-rheumatic conditions by the use of cortisone or of the pituitary adrenocorticotrophic hormone. Ann Intern Med 1952; 36:1.
Lockshin MD. Therapy for systemic lupus erythematosus. N Engl J Med 1991; 324:189.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Inspiration, Perseverance, and Love

2008-03-08T20:37:00.002-05:00

For several years now, we've tried to make as much information available about Lupus here on the Blog. A deeper insight combined with further education about something is never a bad thing.

Lupus is without doubt a very serious illness, one that touches many more people today, than years ago. In providing all the educational material that has been posted, the focus seems to have been one of the effects, symptoms, and some treatments that have been documented by the medical profession.

You have to realize that Lupus doesn't just affect those who have the illness, but also the people who are held closest in our hearts, our families and loved ones.

Being human we need to communicate with one another, to let others know how we feel, even if it's only a sincere offer of support or a kind word that touches someone deeply. All too often we take those things for granted, but to someone, somewhere it empowers and strengthens.

We are 'highly' encouraging anyone who has Lupus, or who is close to someone with the disease to let their voice be heard.

We want you to share your experiences and stories with everyone around the world. You just never know whose life you can brighten, the strength your words can build, and the courage it could bring about.

Just simply register here at the Blog, it's free and only takes just a few minutes. Tell the 'world' your stories, lend a shoulder for a kind soul and make a difference in someone's life.

So please take the time to register so you can reach out your heart and lighten someone's heavy load.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Living Well with the Losses of Lupus

2008-01-04T21:19:00.000-05:00

Survival – emotional and physical – is tricky business. It involves a balancing act, which centers on the ability to regain a steady state when powerful agents or events throw a person out of equilibrium. Imagine a circus tightrope walker. A sudden shift in the tautness of the line can cause even the most experienced performer to lose her footing and fall off balance. Such loss of control can threaten survival. Indeed, it is that threat which causes us to be mesmerized by the tightrope walker. We are awed by her ability to survive, by her knowledge of how to get balance back when it is lost or, when necessary, how to fall into a safety net without consequence. Survival of both the mind and body often depends not only on maintaining a balanced state but also on regaining control or minimizing damage in the face of unavoidable losses. Living, and especially living well, depends on a little bit of luck and a lot of practice and hard work.

No one of us walk a perfect tightrope. We are daily required to alter how we go about things as the imperfections of life present themselves to us. Adaptation to change is a constant in all our lives. Those who live with lupus are especially challenged to stay in equilibrium and remain balanced, as this is a disease that requires more than adjustment at the time of diagnosis. Lupus demands a lifetime of refining or redesigning path and destination, as the disease remits and relapses, over and over. With each new flare or newly emerged disability comes another time or arena of loss. Living well with the losses of lupus is a tricky act to perform.

The losses of lupus are as many and varied as the people who have it. Each of us is unique, not fully like any other, and so our experience is often idiosyncratic. Nonetheless, some losses are common to lupus patients, and they can be placed into one of two categories. First, there are the tangible losses – e.g., those that may come from an appearance changed by disease or medications, from an income decreased by lost work time, or from restrictions on outdoor activity. Second, there are the intangible losses – e.g., those that come from diminished self-confidence, from the necessity of confronting one's mortality, or from feeling dependent on others. Coping successfully with the losses of a life with lupus takes a great deal of time, courage and effort. And because of the chronic, up-and-down nature of the disease, it is a process that never fully ends. Living with lupus can feel, at times, like an endless tightrope walk on a bad day at the circus!

Just as we each have our own unique losses, we also develop our own special ways of coping, of regaining our balance, of surviving. But there are some universal truths about adapting to loss. The model of successful coping that I find most useful (see footnote) is based on two critical ideas – that losses must be mourned and that the grieving process is actually a group of tasks, each of which must be carried out over time and with considerable expenditure of energy. In other words, adjusting to loss is long, hard work. It is no wonder that some shy away from doing grief work and choose instead to cope in ways that are less effective in the long run but much easier and less painful in the short-term.

Mourning losses, thereby reinstating emotional equilibrium, requires grief work. This work can be divided into four different tasks which may be accomplished in any order and may be worked on simultaneously. In that sense, what is described here is not a stage theory of mourning. One does not proceed in lockstep fashion through a series of stages to reach an adaptation to losses. Human beings like to think in terms of stages but we don't function in such a rigid way. Instead, we tend to work on an issue for awhile, move on to other concerns, and then revisit the issue when we are ready to proceed with it.

One of the tasks of successful grief work is to accept the reality of the loss. The losses of lupus can be numerous and initially overwhelming. It is not unusual for a caller to our office to say that she has had a diagnosis of lupus for several months but is only now ready to educate herself about the disease and seek support. It takes time to get over the disbelief that follows shocking news and to acknowledge the losses and changed needs that accompany chronic disease. How is this accomplished? Primarily by talking, by “telling the story” of the loss, articulating what has happened, and how and when it occurred. This telling must be done over and over and it must be heard by willing listeners. With each recounting of the tale, what has changed or been lost becomes more real and integrated into the person's self-concept. Individuals who are reluctant to talk about themselves or who are surrounded by well-meaning others who won't discuss upsetting topics are often stuck on this task. By not telling the story to others, they are able to maintain their denial of a changed reality. This not only precludes completion of grief work; it can also keep patients from taking care of their medical needs. Denial can easily set in periodically for people who live with lupus, since disease activity may subside for long intervals, allowing for a false sense of total wellness. Whether through regular participation in formal support groups or informal discussions with friends, the losses of lupus must be given “air time” to be accepted as reality.

Another task of grief work may be the hardest of all. It entails expression of the many feelings that accompany major loss. This can be a great challenge, as many of us are taught from an early age to hide our feelings. We may have had few role models to show us how to safely and fully ventilate painful emotions such as anger (“I hate that this is happening”), guilt (“I did something bad to make this happen”), anxiety (“I feel that I have no control over what is happening”) and deep sadness (“I am utterly without joy since this has happened”). Responses such as these are normal in the face of significant loss, yet we may believe that they should be stifled. Inhibiting the expression of feelings does not destroy them, it simply insures that the feelings will be expressed in unhealthy, indirect ways. Each of us has a unique way of ineffectively coping with emotions – e.g., drinking too much to dull the pain, not taking good care of ourselves so as to feel punished, becoming demanding and rigid to feel in control The person who lives well with lupus works to find or create a therapeutic environment where the emotions that accompany loss may be fully felt and safely expressed on an ongoing basis.

The tasks of grief work also include adapting to an environment in which the lost entity is missing Simply put, the challenge is to figure out how to live joyfully and productively now that things are different. What adaptations – in the routines of daily life, in the ways you feel good about yourself, in the manner by which you make others happy – have to be made? Change requires learning to do things differently or learning to do without certain things. We usually embrace change which we have sought but resist change thrust upon us. So the new learning which follows loss often occurs slowly. It takes time and diligence to identify the inner resources (e.g., coping style, maturity, intelligence, belief system) and the external supports (e.g., quality and quantity of relationships) which will undergird the new structure of life.

The last of the tasks is one of moving forward and becoming emotionally invested in life again. When a major life change – such as the emergence of chronic disease – happens, one has to say good-bye to a way of life that can no longer be. When such loss first occurs, there is little else about which one can think or feel. It absorbs attention and emotions completely. Being a person with lupus is the only way in which one sees oneself and one sees little else but the losses that this entails. But over time, and with work on the three tasks mentioned previously, one is able to focus on and become absorbed by other things. You come to believe that having lupus is only one of the many aspects of your identity. You learn that it has a place in your life but does not define your life. This happens when the losses of lupus are real to you, and you experience the feelings around those losses and you are adapting to the changes they've created. A sense of equilibrium and a realistic perspective return. You move through and beyond your grief. You never forget what you have lost; at the same time, you recognize that you can live well with what you've got and what is yet to come.

Like the seasoned tightrope walker who has finished a performance plagued by unexpected gusts of wind and loosely tied line, you know you'll go on another day. You know the trick to regaining your balance and insuring your survival.

By Jeri L. Falk
Executive Director, Maryland Lupus Foundation
Associate Professor of Psychology, Adjunct, University of Baltimore

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Living With Pain

2007-11-20T12:13:00.000-05:00

Managing life today can be difficult. Managing life with pain is even more challenging, but it is possible. There are ways to balance your life so that you can live the way you choose, rather than your illness dictating. The key is for you to become an active member of the treatment team. It is important to understand what your responsibilities are to ensure a near normal life style. Your health care team will do all they can to provide the necessary medical care, but you will be responsible for much of the day-to-day routine.

First you must clearly understand what your needs are. Personal needs can range from a balance between getting the proper rest and physical exercise to taking medications and reducing stress. While managing illness and pain are complex issues, the majority of the key components are simply common sense and good living skills. Things such as good nutrition, open communication with family and friends, asserting yourself so that your needs are met, and finding balance between activity and rest are all key components in successfully managing pain.

It is important to recognize your limitation to prevent becoming overly tired or risking increasing pain levels. Staying within your limits can enhance your ability to think clearly and concentrate on important tasks. Understanding personal needs will provide a means to develop a workable plan so that you can incorporate important tasks into your daily routine.

Journaling is an excellent way to ensure necessary tasks are completed while brining you one step closer to independence. Balancing daily activities with necessary rest periods is easier when you have a written overview of your endurance.

Your journal can also provide you with insight into daily stressors. Reducing stress is vital in the fight against pain. Muscles that are already painful will experience increased pain as your stress level increases and your muscles tighten. There are relaxation exercises and audiotapes available to teach ways to recognize stress and reduce tension.

Recognizing and understanding feelings are another important component to successful pain management. When you ignore feelings, they do not go away, but can show up as increased tension, feeling out-of-sorts, or even anger. Dealing with feelings as they occur can greatly reduce both stress levels and pain. Your journal, with its daily entries, can become your road map to wellness and provide you with a sense of empowerment.

Daily exercise should also become a routine activity. Simple stretches can strengthen muscles, improve circulation and improve energy levels. Ask your doctor about an exercise program designed to fit your ability. Invite your family to exercise with you or try exercising to some lively music.

When you plan your day, keep in mind your need to pace activities according to your ability for that particular day. A simple way to remember the importance of pacing is with the word PACE.

P is for prioritizing your tasks to ensure that the most important ones get done first.

A is for planning your actions to ensure the best result.

C is to remind you of your physical comfort. If a task creates increased pain levels, then perhaps you need to ask for help.

E is for energy. Energy levels are never the same from day to day.

You need to consider how much energy you have at the beginning of each day to ensure you are working and playing within your ability.

By combining PACE – Priorities, Actions, Comfort and Energy – with your personal commitment to a near-normal life, you can begin to feel like a person rather than a patient.

By Penny Cowan, Founder and Executive of the American Chronic Pain Association. Reprinted with permission from NewSLEtter, the Bay Area Lupus Foundation newsletter.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Looking Your Best with Lupus

2007-11-19T12:09:00.000-05:00

It's difficult to be confident when you're self-conscious about the way you look. Many people with lupus experience changes in appearance due to the medications they take or the lupus itself, everything from weight gain to hair loss. The following suggestions are not intended to make you feel more self-conscious about yourself; they're just ideas to make you more comfortable with your appearance and boost your self esteem when lupus is wearing you down physically.

It's a Skin Thing

Malar (butterfly) rashes or stretch marks can make you feel pretty self-conscious. The malar rash, which appears in a lot of lupus patients, spreads across the cheeks and the bridge of the nose like a rosy butterfly. There are products out there that you can use to minimize the appearance of this rash. More than just makeup (and a little more pricey than most drugstore brands, too), the products are specifically designed to cover hard-to-hide skin problems. Look for Dermablend or ask a cosmetician to recommend some products. As for stretch marks, you can use these products on those too, but if you have too many to cover, stick to concealing clothes instead. There are anti-stretch creams on the market and eventually those red and purple marks will fade into a paler shade of white. If you're having trouble getting the makeup just right, book yourself a makeover – it might even be fun!

Rapunzel No More

Your hair's falling out! While this can be awful, there are ways to deal with it. First of all, be nicer to the hair you do have. Avoid any products that irritate your scalp or any products that may make you lose more hair, e.g., stick to coated elastic, not rubber, bands. . . on second thought, pony tails can be stressful to your hair. While brushing, be gentle. To cover up thinner hair, experiment with hats or scarves. If hair loss is severe, you can find great synthetic or real hair wigs and they're easy to take care of.

Wait, Now I'm Growing Hair in Other Places!

Strange, isn't it? The hair on your head falls out while hair elsewhere - say, your upper lip – grows like a weed. This is a side effect of certain medications. To get rid of the fuzzy stuff, get your hands on some hair removal products like creams, waxes, natural sugar or honey, bleach, electrolysis – all dedicated to making you fuzz free. If you're not a do-it-yourselfer, visit a salon; they're pros at this kind of thing.

Indulge Yourself

Don't forget the most important part of yourself to cultivate; your inner beauty, of course! All the makeup in the world won't help you if you don't believe in your inner beauty. Don't let lupus (or anything else) make you think otherwise.

Edited for clarity; reprinted from Work Out, the employment newsletter for people living with lupus and other chronic illnesses.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Young People Beware: Alcohol and Lupus Don't Mix

2007-11-19T11:59:00.000-05:00

There's no way to soften the bad news about drinking alcohol. While anyone is at risk from alcohol's negative side-effects, people who take prescription medications (and also some over-the-counter-ones) put themselves at an even greater risk of suffering health troubles.

The problems occur because alcohol can change the way the body uses, or metabolizes, certain medications. Alcohol is absorbed through the intestinal tract and shuttled to the liver, where chemical "knives" called enzymes break it into smaller molecules. Trouble is, alcohol causes the body to make more of these enzymes, especially when someone drinks regularly (even so-called "social" amounts of alcohol). Some of these enzymes are the same "knives" that break down medications so the body can use them. In producing more enzymes, the liver metabolizes medications faster. The bottom line: medications are sent into the bloodstream much faster and to a larger extent than when you don't drink. This can be dangerous, intensifying both the positive and negative side-effects of medications.

It is a myth that you can avoid these alcohol medication side-effects by taking medications while you are not drinking: the liver is still in "over-drive," producing more of these enzymes for some time after you drink. Another myth: "You have to drink hard liquor to suffer dangerous consequences." Beer and wine are just as likely to cause problems.

Of the 50 most frequently proscribed drugs, more than half contain ingredients that react adversely with alcohol. Among the negative effects are seizures, headaches, nausea, vomiting, mental confusion and coma. Don't forget that medications that are available without a prescription can also react adversely with alcohol. People with lupus, for example, often take Tylenol to alleviate pain. Drinking any amount of alcohol can cause Tylenol to be toxic to the liver at much smaller doses. Alcohol mixed with aspirin can lead to bleeding in the stomach. If you are taking methotrexate or other immunosuppressive medications, drinking greatly increases the chance that you will suffer liver damage.

Young bodies demand good nutrition. Teenagers and young adults need relatively more protein and nutrients to support growth and development. In addition, anyone with a chronic disease like lupus needs even better nutrition to also fight the chronic disease. Alcohol interferes with good nutrition in a couple of ways. Alcohol causes the body to waste some nutrients, basically by burning them up at a faster rate. In addition, the body's first priority is to metabolize or use alcohol, rather than the type of calories a person (especially teenagers) needs to grow. Anyone with lupus should avoid alcohol, particularly when taking medications, or restrict their alcohol intake as much as possible.

By Kristine M. Napier, N.P.H., R.D., L.D.

Reprinted, with permission, from Lupus World, Patient Empowerment Through Information, a publication of the University of Massachusetts Medical School, Worcester, MA 01655. Vol.1, No.2. With special thanks to Henrietta Aldjem, Editor.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Substance Abuse in Chronic Illness - A Challenge to Young Adults

2007-10-20T09:24:00.000-04:00

Lupus is a disease that usually afflicts women between the ages of 15 and 45. The important word here is "usually" because, as most of you know, lupus can be found in children who are but a few years old up to those who are 15 years of age. Childhood lupus can range from an inconvenient to life-threatening problem.

This is not very different from the adult variety; however, the emotional aspects of it are very different. Children and adolescents suffering from lupus at times may feel severely restricted in what they are allowed to do and in what they are able to do. They may feel suffocated by their parents whose only "crime" is caring too much. Young people with lupus are often required to grow up well before their time. They must possess a certain responsibility that does not allow them to be children, to be teenagers. This leads to a certain sense of frustration and anguish.

However, with appropriate thought, guidance and consideration, such individuals will function quite normally and learn to develop a perspective on how best to view their disease. I think that it is most important that people afflicted with this or any other chronic illness not be "disease oriented" but rather be "life oriented." There are times when their lupus will dominate their day-to-day lives, but there are many times when it should not be so dominant.

There are those, however, who try to take the fact that they must live with a chronic disorder such as lupus and try to forget about it. In these instances, people with this attitude will expose themselves to unnecessary peril.

There are a number of things that go on in a teenager's world that are not necessarily good for anyone, let alone people who have lupus. This includes experimentation with alcohol, smoking and even illegal drugs. No matter who you are, you may be taking chances with your life by using these. Young people with lupus may be in a much more difficult position and fail to realize that the chances they are taking far outweigh those of the average teenager.

Lupus itself is a disease that can affect many organ systems. It is also a disease that can affect the circulation or blood flow to the body. If we look at smoking, for example, the risks taken by someone with lupus are different and more severe than those taken by someone who does not have this disease. One merely has to look at the problems of Raynaud's phenomenon. Smoking aggravates this problem, in which the fingers become white or blue upon exposure to cold.

Cigarettes contain nicotine, a very powerful chemical that causes blood vessels to constrict or clamp down. In people who have problems with circulation to the fingers and toes, clamping down can become so serious that they lose blood supply to the fingers and toes. In extreme cases, they could even lose fingers and toes because of lack of blood supply.

Street drugs can have a similar effect; indeed, their effect on blood flow may be even more severe. Furthermore, street drugs may have very serious effects on the liver and kidneys. In some people living with lupus, these organ systems are already affected, so by taking street drugs a person with lupus adds more poisons and exposes these already damaged organs to further injury. This could lead to loss of organ function to the extent that the liver may deteriorate and put life at risk. In the case of kidneys, the damage may be severe enough to make dialysis necessary.

It is also important to remember that there are various medications that may be necessary for people with lupus to take on a regular basis. Some of these drugs have side effects affecting various organs such as the liver, kidneys and bone marrow. The combination of such drugs as Imuran, Methotrexate or Cyclophosphamide with alcohol may exaggerate the known side effects of these drugs, putting organ systems at greater risk of permanent damage. Such damage could even lead to a life-threatening situation.

For example, it is well known that Methotrexate and alcohol are a very bad combination. Methotrexate is being used with increasing frequency in treating people with lupus. In many individuals the benefits of this drug have been surprisingly good. However, one of the problems with Methotrexate is that it may have some degree of liver toxicity. If an individual who is taking Methotrexate drinks alcohol, that liver toxicity is no longer a "maybe" but is almost a "definite." Persons who have responded extremely well to Methotrexate and possibly are even in remission with lupus may drink themselves into a situation where the Methotrexate must immediately be discontinued. They then may fall out of remission and suffer a lupus flare that could result in hospital admission or worse.

The easy answer to these problems is simply to stop taking the prescribed medications. In this way, I suppose you could say that experimentation with alcohol, cigarettes or street drugs becomes a less risky proposition. Unfortunately, discontinuing your medications makes risks much greater than you can imagine. I agree that it is frustrating, it is annoying and may cause you a tremendous amount of anger that you have lupus. Unfortunately, it is a problem that you may not deserve, but you've got anyway.

I think it is important to make that problem as small an aspect of your life as possible. Exposing yourself to needless risk will suddenly make lupus a problem in your entire life. So, in order for you to live your life, and not let lupus live your life think very carefully before you light that cigarette, drink that drink or try the latest "designer drug."

Dr. C. A. Laskin, a Rheumatologist who works in Toronto.

Minnesota Lupus News, August / September 1998, reprinted with permission from the Taking Life as a Challenge newsletter, Ontario Canada. TLC, geared to young people with chronic illness is supported by the Ontario Lupus Association.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Explaining Chronic Illness to Your Child

2007-09-01T21:50:00.000-04:00

Explaining Chronic Illness to Your Child

As a parent, if you become ill, your illness has a profound impact on the entire family system. In spite of your own increased stress, confusion and anger, your children will look to you to maintain or return to normal family routines as soon as possible. If you, or your spouse, present an image of feeling overwhelmed or being consumed with the illness, your children will feel as if life is spiraling out of control.

As parents, it is often instinctive to want to protect our children from hurt or pain. We want them to be carefree and experience the joy and happiness that only childhood can offer. However, as much as we don't want to acknowledge it, children do experience the same kinds of losses and disappointments that we, as adults, experience.

We, as the nurturers and protectors, must explain and "normalize" these experiences in the best way that we can.

No matter what the age of your child, it is helpful to know and understand the developmental stages and how children at each stage can be expected to respond to stress and change. Developmental refers to the concept that a child's behavior, like his physical growth, develops in patterned and predictable ways. The age and goals of your child at each stage will guide you in how and when you need to intervene when your family goes through a crisis.

The first developmental stage -- infancy up to age two -- is probably the easiest in terms of knowing how to respond. The primary developmental goal is to establish trust. The child is completely dependent on the mother (or primary caretakers) to have basic physical and emotional needs met. With love and nurturing, the infant (and older baby) will thrive and grow.

Adults generally assume that a baby is too young or unaware to notice a change in a parent or family. However, infants and babies are extremely intuitive and can sense when a parent is upset or anxious. Any change in daily routine can throw a baby into a fretful state. When crisis occurs, you may see the following behaviors: increased crying and irritability, changes in appetite and sleep schedules, clinging behaviors and regression. Separation anxiety, which occurs routinely, becomes exaggerated. The baby will develop offensive behaviors. Treat regressive behaviors casually and return to a normal routine as soon as possible.

If your toddler asks a question about your illness, answer openly and honestly. A rule of thumb is never offer more information than the child has requested. Concealing the illness or whispering about what is happening will not help. Children always suffer more from the tension of not knowing than from knowing the truth. Allowing the child to act out fears and frustration through play or art is also an excellent help.

Preschool, ages four to five years, is the age of expansion. Preschoolers are ready to move out of the safety zone of the home and into a broader social arena. There is an increased reliance at this stage on "magical thinking." To a preschooler, anything that happens, good or bad, is related to them and their behavior. If a parent becomes ill during this stage, the preschooler's view will be: "Mommy is sick because I told her she was mean."

In response to stress and change, preschoolers often present with extremes, either being all good or all bad. This is the child's attempt to maintain a sense of control and to feel less frightened. Regressive behaviors are likely to occur, especially an increased reliance on a favorite security object (blanket, teddy bear, thumb-sucking).

To help preschoolers, it is essential to assure them that the illness is not their fault. Returning to a security object should be encouraged, rather than discouraged. Answer all questions honestly, including those about death. This is a good time to rely on books which help you help your child work through complex and often frustrating feelings about illness.

The primary development goal of the school-age stage (six to ten years) is achievement. The focus is school, outside activities and developing strong peer relationships. While parents and family are still central, the biggest concern is: "What will happen to me if you are ill?" This self-centeredness is normal.

Although there is still some overlap with magical thinking, by the age of eight children realize that illness may not be their fault. However, they still are not mature enough to remove themselves completely from the situation. The thinking now is: "If I'm good, Mommy will feel better and things will be fine."

School-age children tend to show strong emotions in reaction to change. They may show anger at both parents: "Why did you let this happen?" They tend to have a lot of somatic complaints (headache, stomach pain, fatigue), especially when leaving for school. The child is often fearful to leave the ill parent; he or she often assumes a protective role. Earlier in this stage, children are fearful that if they leave, the parent may die. As such, preoccupation and fear of death may be common.

When attempting to help school-age children, it is important to recognize that angry outbursts are an attempt to grieve or release fearful feelings. The opposite reaction, denial, may also occur as the child hopes that the illness will just disappear. Children will have many more questions and concerns at this stage. However, only the simplest explanations need be given. Information they don't understand will only frighten them and increase anxiety. Questions about death must be answered directly; evasion leads to more fear.

Changes in school performance, either for better or worse, are common. It is essential to let teachers know about the changes at home and to establish a feedback loop.

Our final stage of development is adolescence. The primary goal is to develop a self-identity that is capable of independent action. Adolescents work to achieve separation from parents and to become independent of the family system. This stage is a painful one for both parent and child, as both struggle in this journey toward separation.

Under normal circumstances, adolescents are known for their emotional volatility and moodiness. When a crisis occurs, you may see and hear even more expressions of anger, hurt and confusion. The opposite extreme is also common -- they may withdraw completely and not want to discuss your illness or their feelings about what's happening. There will be ambivalence about helping you. If you have an adolescent who is willing to do his or her part in helping the family, this will not extend to outside the home. Fitting in and acceptance by peers will be much more important than appearing helpful to the family. It is normal for them to be embarrassed by the illness and not want to discuss it with friends or teachers.

This is an essential time for parents to fine tune their communication skills. It is imperative to listen to and understand the volatile outbursts of the adolescent. Accept these feelings without overreacting to their tone. Continue to set limits, rules and boundaries, but keep the task of separation in mind. These outbursts are often fear-based.

At a time when they often feel out of control, teenagers cling to the hope that parents and family will remain structured and safe. Remember, even though he or she appears grown, your adolescent needs as much love and reassurance as your younger children.

In discussions about your illness, be prepared to give much more detailed information, especially all the facts about the illness. A major concern or fear will be: "Will I get it too?"

Some adolescents (the withdrawing ones) may not want to hear about or discuss your illness. They may express anger or disappointment toward the ill parent. These behaviors serve to diffuse their own fears or feelings of inadequacy in controlling the changes that are occurring or may occur in the future. Honest and open discussion of your own feelings may help them to express their own feelings.

One of the most difficult obstacles for parents of the adolescent is to overcome the expectation that he or she will be mature enough to handle the situation and to provide support. In actuality, they are overburdened with their own concerns and too vulnerable to carry the adult concerns.

In conclusion, the following reminders are offered to help you during times of crisis:

- Your children, like mirrors, reflect adult stress and behavior.
Be assured that most children experience times of high stress, confusion and frustration, yet still manage to develop and maintain a healthy sense of personal worth.

- Your children still need limits, rules and structure. Be the same parent you were before the illness.

- Discuss plans and decisions with your children commensurate with age and level of understanding. The more a child is included in planning, the more your relationship will be safeguarded.

- Do not assume the problem behaviors that a child exhibits in times of high stress will be permanent. However, if behaviors persist or worsen over time, seek professional help for the child and the family.

Jan Buxton-Truffer, MS, CEAP, is a counselor with the Sheppard Pratt Health Plan Employee Assistance Program.

Minnesota Lupus News, February / March 1998, reprinted with permission from Lupus Update, Maryland Lupus Foundation Newsletter, LFA, March 1997.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Heart Problems in Children with Lupus

2007-07-01T11:43:00.000-04:00

Introduction
It has been well established that accelerated atherosclerosis, or hardening of the arteries, occurs in adults with lupus, along with its eventual clinical outcomes-myocardial infarction (heart attack) and stroke.

However, atherosclerotic heart disease is emerging as one of the most serious concerns in children and adolescents with lupus. Young, premenopausal women with lupus are up to 50 times more likely to have a heart attack than women of the same age who do not have lupus (1). Our research and that of other investigators indicate that these clinical outcomes are generally related to accelerated atherosclerosis (2,3).

Evidence of heart problems in children with lupus Children with lupus are known to experience myocardial infarction and stroke. Although the frequency of atherosclerosis in these young patients is not fully known, emerging evidence suggests the incidence may be similar to that in premenopausal women with lupus.

It is not unreasonable to suspect atherosclerotic development at young ages, as evidence of fatty streak formation-an early step in plaque formation-has been noted in healthy children as young as two to three years of age.

Atherosclerosis-promoting patterns of cholesterol, triglycerides, and other lipoproteins in children and adolescents with lupus have been documented (4). Coronary blood flow abnormalities were found in 16 percent of children and adolescents with lupus who had no cardiac symptoms. This suggests that there may be a significant percentage of young lupus patients with undiagnosed heart disease.

In addition, evidence of carotid atherosclerotic plaque and abnormal coronary blood flow have been detected two to five years after the onset of lupus, indicating that atherosclerosis may develop very early in the course of disease (5,6).

What causes heart disease in lupus? We do not completely understand the underlying biological cause for accelerated atherosclerosis in young patients with lupus, probably because we do not yet completely understand the underlying biological cause of lupus. One thing we do know is that two key factors are the disease of lupus, itself, and its treatment.

It was initially thought that the increased risk of heart disease in patients with lupus might be due to traditional risk factors, such as:

hypertension
diabetes
obesity
elevated cholesterol levels.

But recent evidence indicates that the presence of lupus itself, or the treatment for lupus, contribute more than those risk factors alone (2,7). The task now is to identify the biological processes occurring in lupus or resulting from its treatment that promote atherosclerosis.
It was once believed that excess cholesterol built up as plaque inside the blood vessels and obstructed blood flow. Investigators now know that fewer than 20 percent of heart attacks are due to restricted blood flow in progressively narrowed coronary vessels. More commonly, heart attacks occur when an atherosclerotic plaque ruptures and a blood clot forms around the plaque (8).

There are several potential parallels between lupus and the formation and rupture of atherosclerotic plaques (9).

A. For instance, damage to the lining of the blood vessels provokes an inflammatory response, which leads to deposits of immune cells containing fat droplets into the arterial wall. This in turn leads to plaque formation.

B. Inflammation is also responsible for thinning the fibrous cap that covers a plaque, making it more vulnerable to rupture. The inflammatory substances known as cytokines that drive the formation of atherosclerotic plaques and increase the vulnerability of the plaques to rupture are the same substances that play a major role in the inflammatory processes seen in lupus. This may explain why cardiovascular disease is accelerated in lupus.

C. Another factor related to lupus as a prime suspect as sources of damage to the lining of the arterial wall is high levels of circulating immune complexes. Although immune responses are important in the body's normal response to damage and microbial infections, in systemic lupus-and perhaps in atherosclerosis in general-these normally protective immune responses become dysregulated, leading to a high degree of inflammation and tissue damage.

D. A wide variety of autoantibodies may also hold responsibility. Elevated levels of antiphospholipid antibodies, which are often found in people with lupus, have traditionally been linked to an increased risk of blood clotting and may increase the risk of clot formation at the plaque site. More recent evidence suggests that these antibodies may also facilitate the uptake of oxidized low density lipoprotein, the "bad cholesterol," into inflammatory cells in the vessel wall. This is a key step in the formation of atherosclerotic plaque (10).

E. The amino acid homocysteine is another agent that is often elevated in lupus patients and is a likely source of arterial injury. Elevated levels of homocysteine have been linked to thrombosis in lupus patients (11) and to coronary heart disease and stroke in non-lupus patients. The reasons for elevated homocysteine in lupus are not entirely known, but may be related to kidney disease, diet, or treatment.

Is there a link between corticosteroids and atherosclerosis?With the advent of glucocorticoids (prednisone) in the 1950s, there has been a significant improvement in the lifespan of young people with lupus. Yet there is concern that these agents may actually contribute to the development of atherosclerosis, either directly by promoting plaque formation or indirectly by intensifying risk factors such as:

weight gain
hypertension
elevated serum glucose and lipid levels.

In contrast, some evidence indicates that the anti-inflammatory effects of glucocorticoids may actually provide protection against atherosclerosis, suggesting that poorly controlled lupus activity may contribute to cardiac disease, with corticosteroid treatment providing a degree of protection.

Perhaps with the use of newer biologic therapies with similar anti-inflammatory and immunomodulatory effects as corticosteroids, but fewer adverse side effects, we will begin to see a reduction in heart disease.

How can atherosclerosis be managed in young people? It is of critical importance that physicians and patients be aware of the increased risk of cardiovascular complications in lupus. Young people generally view their risk of heart disease as negligible, yet cardiovascular disease intervention and prevention has the potential to significantly lengthen and improve the quality of their lives over many years.

Chest Pain.

Any physician treating a young person with lupus, regardless of the patient's age or sex, should be suspicious of chest pain. Because the patients are young and because chest pain in lupus may be attributable to other causes, physicians may overlook conditions, such as angina (chest pain due to myocardial ischemia). Yet often there are no warning signs for an impending heart attack. For these reasons, a major focus on management strategies should rest on preventing the development of atherosclerosis.

Diet.

There have been reports on the potential benefits of diet modification in controlling abnormal lipid levels in children with lupus, but diet alone is not always sufficient, and pharmacologic therapy may be necessary. However, the type, timing, and dosage of such therapy in children have not been well established by large studies.

Blood clots.

Measures to reduce potential blood clots, such as anticoagulation or antiplatelet therapy, should be considered in patients at increased risk, such as those with kidney disease, antiphospholipid antibodies, and other coronary disorders.

There are few clinical data on the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on atherosclerosis. However, some evidence suggests that the selective inhibitors of the prostaglandin-producing enzyme COX-2 might actually enhance blood clot formation in some non-lupus populations. Further investigation in this area is currently underway.
Aspirin. There is strong evidence from clinical trials to support the use of low-dose aspirin therapy in preventing heart attacks in the general population. At low doses, aspirin is probably reducing the clotting risk but not reducing inflammation.

Dietary supplements.

There is some evidence that the antioxidant vitamins E and C may improve arterial dilatation in children with familial hypercholesterolemia or combined hyperlipoproteinemia. However, the long-term benefit of antioxidant therapies in reducing cardiovascular risks in lupus is unknown. Measures to reduce homocysteine levels with folate supplementation may be beneficial; again, however, the effects on prevention of coronary events are unproven.
Steroids. Based on the possible opposing effects of corticosteroids-increasing traditional risk factors and controlling inflammation-there are no established recommendations about the use of corticosteroids concerning cardiovascular risk in lupus. In general, judicious use of these agents to control the underlying disease and to minimize the proven long-term side effects is recommended.

Table 1 (below) illustrates suggested strategies to manage and/or prevent atherosclerosis in young patients with lupus. These strategies are targeted at both traditional cardiovascular risk factors and at potential lupus-specific factors. Physicians should communicate these potential risks to patients and their parents, and provide relevant information and resources for patient education.

Table 1. Strategies For Managing Cardiovascular Disease Risk In Children With Lupus

Step 1: Physician awareness
Recognize increased risk in young population.
Conduct a thorough cardiac evaluation if there is any suspicion of heart disease.

Step 2: Patient education
Make patients and parents aware of increased risk.

Step 3: Minimize traditional cardiovascular risk factors
Encourage a regular aerobic exercise program.
Establish guidelines for a heart-healthy diet.
Assist with weight loss program, if necessary.
Start a smoking cessation program.
Control hypertension and diabetes, if present.
Treat hyperlipidemia.

Step 4: Address potential lupus-specific risk factors
Use corticosteroids judiciously.
Reduce homocysteine levels (folate supplementation).
Consider aspirin or anticoagulant therapy for patients at high risk for blood clotting.

Physicians also should work together with the patients and parents to encourage a heart-healthy diet, a regular exercise program that involves aerobic activity, and weight loss, if necessary. Patients should be advised not to start smoking and to quit if they have already started. Hypertension and diabetes should be managed aggressively.

Bottom line

It is clear that premature atherosclerosis in children, adolescents, and young, premenopausal women with lupus is a substantial medical concern. The reasons that atherosclerosis is accelerated in lupus patients likely involve the inflammatory and immune-mediated mechanisms shared by these two disease processes.
Until new biologic therapies are available that can halt the immune dysregulation and resulting inflammation and vascular damage in lupus, we must promote aggressive approaches to reducing traditional cardiovascular risk factors.

Noninvasive methods for specifically identifying vulnerable plaques might also pinpoint those lupus patients at greatest risk for heart attack and those most likely to benefit from intervention. Investigations into the pathways that lead to premature heart disease in lupus may provide an ideal model for examining the role of inflammation in all populations with cardiovascular disease.

About the Authors Susan Manzi, MD, M.P.H., is an Associate Professor of Medicine and Epidemiology at the University of Pittsburgh School of Medicine in Pennsylvania.
Janice M. Sabatine, Ph.D. is a medical writer and editor.
Laura E. Schanberg, MD is an Assistant Professor of Pediatric Rheumatology at Duke University Medical Center in Durham, NC.

References
1. Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger TA, Jr., Jansen-McWilliams L et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Am J Epidemiol 1997;145:408-415.2. Manzi S, Selzer F, Sutton-Tyrrell K, Fitzgerald SG, Rairie JE, Tracy RP et al. Prevalence and risk factors of carotid plaque in women with systemic lupus erythematosus. Arthritis Rheum 1999;42:51-60.3. Selzer F, Sutton-Tyrrell K, Fitzgerald S, Tracy R, Kuller L, Manzi S. Vascular stiffness in women with systemic lupus erythematosus. Hypertension 2001;37:1075-1082.4. Ilowite NT. Premature atherosclerosis in systemic lupus erythematosus. J Rheumatol 2000;27 Suppl 58:15-19.5. Gazarian M, Feldman BM, Benson LN, Gilday DL, Laxer RM, Silverman ED. Assessment of myocardial perfusion and function in childhood systemic lupus erythematosus. J Pediatr 1998;132:109-116.6. Falaschi F, Ravelli A, Martignoni A, Migliavacca D, Sartori M, Pistorio A et al. Nephrotic-range proteinuria, the major risk factor for early atherosclerosis in juvenile-onset systemic lupus erythematosus. Arthritis Rheum 2000;43:1405-1409.7. Esdaile JM, Abrahamowicz M, Grodzicky T, Li Y, Panaritis C, du BR et al. Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus. Arthritis Rheum 2001;44:2331-2337.8. Libby P. What have we learned about the biology of atherosclerosis? The role of inflammation. Am J Cardiol 2001;88:3J-6J.9. Manzi S. Systemic lupus erythematosus: a model for atherogenesis? Rheumatology (Oxford) 2000;39:353-359.10. Vaarala O. Autoantibodies to modified LDLs and other phospholipid-protein complexes as markers of cardiovascular diseases. J Intern Med 2000;247:381-384.11. Petri M, Roubenoff R, Dallal GE, Nadeau MR, Selhub J, Rosenberg IH. Plasma homocysteine as a risk factor for atherothrombotic events in systemic lupus erythematosus. Lancet 1996;348:1120-1124.

Eating More Fish – The Answer To Lupus?

2007-06-06T10:06:00.000-04:00

Eating More Fish – The Answer To Lupus?
11th March 2003

Press Release from the University of Ulster , Ireland

New research from the University of Ulster today offered hope to millions of lupus sufferers worldwide.

Dr Emeir Duffy, from the School of Biomedical Sciences, and Dr. Gary Meenagh, from Musgrave Park Hospital , have discovered new evidence to suggest that fish oil can greatly reduce the symptoms of the disease.

Systemic Lupus Erythematosus (SLE) or Lupus is a disorder of the Immune System, where the body harms its own healthy cells and tissues. The body tissues become damaged causing painful or swollen joints, unexplained fever, skin rashes, kidney problems, complications to the cardiovascular system and extreme fatigue.

There are approximately 500 diagnosed cases of SLE in Northern Ireland and it is most common in women of child-bearing age.

At present there is no cure but a key to managing lupus is to understand the disease and its impact. Steroids are the main drug used in the treatment of lupus and they should be administered for the shortest period possible to reduce side-effects.

But recently researchers have been looking specifically at its management through diet. Fish oils contain long-chained polyunsaturated fatty acids which are essential for normal growth and development but also have anti-inflammatory and anti-autoimmune properties.

Dr Duffy said: “We have been investigating how fish oil can improve the quality of life for lupus sufferers.

“In lupus, the body's immune system does not work as it should. Antibodies, which help fight viruses, bacteria and other foreign substances, are not produced effectively. The immune system actually produces antibodies against the body's own healthy cells and tissues. These auto-antibodies contribute to inflammation and other symptoms of the disease.

“Participants in the study who were taking fish oil supplements, three times per day for twenty-four weeks, saw a reduction in disease activity, an improvement in quality of life and reported an overall feeling of improved health by the end of the study compared to those taking a placebo supplement. Participants taking the fish oil also showed a reduction in fatigue severity, the most debilitating symptom for lupus sufferers.

“From our study and from other work, there is evidence that increasing dietary intake of the polyunsaturated fats found in fatty fish can have beneficial effects for lupus sufferers. Good examples of fatty fish include mackerel, lake trout, herring, sardines, tuna and salmon”.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

New Research Shows Certain Vegetables May Delay the Onset and Reduce the Severity of Lupus

2007-06-06T10:02:00.000-04:00

New Research Shows Certain Vegetables May Delay the Onset and Reduce the Severity of Lupus:

Scientists find that a compound abundant in broccoli, cauliflower and cabbage may help fight disease that affects 1.5 million Americans

A team of scientists from the North Shore-Long Island Jewish (LIJ) Research Institute have discovered that a compound found in abundance in the cruciferous family of vegetables delays the onset of systemic lupus erythematosus (SLE) in mice and reduces the severity of the disease once it has developed. This could be good news for individuals at risk for lupus, especially women, as well as those already affected by it.

Published today in the Journal of Nutrition, the study led by Karen Auborn, PhD, evaluated the effect of a supplement of indole-3-carbinol (I3C) - the compound found in broccoli, cauliflower, cabbage and similar vegetables - on the outcome of SLE in mice that are bred to develop the disease genetically. The results showed that mice with lupus lived significantly longer when fed the supplemented diet than did diseased mice fed the normal diet. Some even lived the normal lifespan.

Whether the mice were started on the I3C diet before or after the onset of the disease, the result was the same: there were fewer kidney problems (kidney disease is one of main complications of SLE) and they lived much longer than the control group.

"Mice are not people, of course, but the implication is that a diet rich in cruciferous vegetables could do much to ameliorate the disease," said Dr. Auborn. The findings support the view that I3C may benefit people at risk for SLE as well as those in the early stages of the disease. SLE is often treated with immunosuppressive drugs, which can have serious toxic side effects. By reducing the severity of the disease, I3C may allow a decrease in the dose of immunosuppressive drugs required, thereby reducing toxicity. It may even help prevent the recurrence of the disease.

A person could get the human equivalent dose of I3C tested in the study from about a third to a half of a head of cabbage. So getting the proper amount of I3C from food is realistic, although I3C also is available on the market as a dietary supplement.

According to the Lupus Foundation of America, approximately 1.5 million Americans suffer from some form of lupus, of which SLE is the most common. While it is unknown why women are nine times more likely to develop the disease than men, it is suspected that estrogen plays a role. Research has shown that women with SLE have abnormal estrogen metabolism. In many cancer prevention studies, I3C has been shown to exhibit antiestrogenic activity in the body. The North Shore-LIJ investigators had theorized that because I3C is an antiestrogen, it may prevent, delay, or even represent an adjunct treatment for lupus. They were right, at least for mice that genetically develop lupus.

The North Shore-LIJ Research Institute is planning a human study of the effects of I3C on SLE. Nicholas Chiorazzi, MD, a world-renowned rheumatologist and member of the study team, is working closely with Richard A. Furie, MD, chief of rheumatology at North Shore University Hospital in Manhasset, to make this a reality.

"It will be essential to determine if I3C can have similar effects in patients with SLE. Such studies are more difficult in humans because individual patients with lupus differ in their genetic backgrounds and also because the effects of lupus vary greatly from person to person, at least as far as the organs targeted by the problem," said Dr. Chiorazzi, who is also director and CEO of the North Shore-LIJ Research Institute.

This research was supported by grants from the Ryan Caulfield Foundation, the Willa and Robert Bernhard Fund, and the National Institutes of Health.

About the North Shore-Long Island Jewish Research Institute The North Shore-LIJ Research Institute is among the top seven percent of institutions nationally that receive funding from the National Institutes of Health. Building on its strengths in immunology and inflammation, oncology and cell biology, human genetics, and neurodegenerative and psychiatric disorders, its goal is to understand the biological processes that underlie various diseases and translate this knowledge into new tools for diagnosis and treatment.

===========================================================
This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

2007-04-30T07:10:00.000-04:00

Lupus: Its Impact on Young People
By Robert H. Phillips, Ph.D.

Introduction
Most of the books and articles written about lupus are targeted for adults with lupus. There is a lot of information about the disease, such as its symptoms, treatment and lifestyle changes necessitated, all of which is very valuable. But there is a unique population that is not addressed often enough in this written material: the young person with lupus.

Lupus is most commonly diagnosed in women of childbearing age, and men are diagnosed as well, although in smaller numbers. But it is important to remember that boys and girls before childbearing years also can be diagnosed with lupus. And although they may experience many of the same problems that adults do (such as pain, other physical symptoms and medication side effects), certain problems are more “exclusively theirs.”

This article will address a sampling of the problems that may affect young people with lupus. (It is not the scope of this article to discuss medical facts. Rather, it focuses on the psychosocial issues that may appear). Rarely will a young person with lupus experience every psychological problem due to lupus. However, it's important for everyone involved – the young person, other family members, friends, educators and healthcare professionals – to be aware of, and sensitive to, these difficulties.

Denial
It is interesting that adolescents, more than virtually every other age group, have a common, non-verbalized (and sometimes loudly verbalized) belief about their medical status: “I'm fine!” They don't want to feel sick; they don't want to be sick; and they don't want to be different. But lupus may throw a monkey wrench into that.

What makes it especially difficult, though, is that unless lupus is affecting the young person so aggressively that they are virtually unable to move, in many cases the young person's attitude will continue to be “I'm fine.” This can be frustrating for other family members, who are trying to be protective and helpful, and for healthcare professionals, who have more difficulty treating a young person if the answers to questions about symptoms are evasive or denying.

School
Adults who work generally have a clear sense of their responsibilities and obligations at their jobs; they know that if they don't work, changes will result – many of which can be difficult and unpleasant. Young people, whose primary job is to go to school, may go because they want to and because they know they are expected to. Yet they may not be aware of the far-reaching implications of inconsistent school attendance.

For young people with lupus, the attitude about school varies. Some are upset and frustrated if lupus interferes with consistent school attendance and schoolwork performance. Others see school as less important and may have few or no qualms about missing excessive time in school.

Young people with lupus may have a more difficult time in school if they have to deal with the cruelty of other children (“What is that ugly rash on your face?”) or the ignorance of teachers (“You've missed too much school work; either get with the program or you're going to fail.”) In addition, because of lupus, young people may find themselves ostracized and even excluded from activities that were once within their physical capabilities.

Peer pressure
Peer pressure may also affect young people with lupus. The need to “fit in” – at its strongest during childhood and adolescence – can be devastating to someone who has a chronic illness with noticeable physical effects (e.g., rashes, bloating, etc.) and behavioral effects (slower, more painful movements, etc.).

It is heartwarming to hear stories of young people with lupus whose friendships continue despite their illness. Yet it is sad to hear of other stories in which the person with lupus is ridiculed and even abandoned by former friends.

Parents
Young people with lupus may have difficulties with parents being overprotective (“Stay inside, the sun is out”), not protective enough (“You want to go to the beach? Do whatever you want”), or insensitive to their needs (“Stop complaining about your pain, already. Get up and finish your school work”).

Parents may be concerned about the effects their child's lupus will have on the family, such as financial issues, problems with or neglect of other children, or even feeling like their independence is being inhibited. Any of these concerns can likewise affect the young person with lupus. Already unhappy because of having lupus, but feeling responsible for problems within the family or with the parents, a young person may feel guilty to the extent that it interferes with their physical and emotional health.
For example, the young person may not tell parents about a serious lupus symptom, knowing it might mean another trip to the doctor or even the possibility of hospitalization.

Siblings
Brothers and sisters of a young person with lupus may be very resentful. Being less able to understand the physical impact of the disease, they may dislike the added “attention” being directed at their sick sibling. They also may not like getting less attention, and may act out in an attempt to regain their “share” of parental interactions. Their resentment toward their sick sibling may be manifested in many hurtful ways, such as anger, ignoring instructions, spiteful behavior, concealing important information from their parents, etc.

A final note
It is difficult enough for anyone to live with lupus, but the young person with lupus has added, age-related problems. Being aware of the potential impact of lupus in young people does not eliminate these problems. But increased awareness can pave the way to a better understanding of the unique needs of young people, and can lead to methods for better alleviating the problems that may occur.

Some Helpful Suggestions for Parents and Other Adults Dealing with Young People
Be Sensitive to the young Person's unique needs. Lupus can be a difficult disease to live with, especially for a child who has fewer “coping strategies” in place. Don't assume that the young person has the emotional strength or the social support network to handle lupus-related problems successfully.

Communicate appropriately. Try to look at any lupus-related issues through the eyes of the young person. See what they see. Feel what they feel. Using anger and aggressiveness in “forcing issues” is rarely productive. Calm, constructive discussion is a much more positive way to address lupus-related issues.

As much as possible, treat the young person like an adult. Plan together the appropriate ways to treat, and live with, lupus. Demonstrating adult-like behavior in interactions with young people is more likely to generate adult-like behavior in return.

Educate significant others. Any individuals who are not familiar with lupus, including family members, friends and teachers, can be obstacles to successful living with lupus. This is especially important in school, since the young person is going to spend a good number of hours there each day. Provide pamphlets and other information to teachers, guidance counselors and even classmates, so that school can truly be a “home away from home.”

Reprinted with permission of the Lupus Foundation of America, ©2001. Dr. Robert H. Phillips is founder and director of the Center for Coping in Long Island, NY ( www.coping.com) . He has been in private practice as a licensed psychologist since 1975 and has published and spoken widely on coping with physical ailments and other psychological topics. He has appeared on dozens of television and radio programs and currently is the host of “Coping Conversations, “ a weekly radio talk show on WKJY-FM (98.3) on Long Island .

Dr. Phillips is the published author of more than 20 books, including the highly popular Coping With Lupus (now completely revised and updated for its third edition); Lupus: Everything You Need to Know (with co-author Dr. Robert Lahita); and his new Successful Living With Lupus: An Action Workbook, published last year. These books, as well as several others, are available for sale from the Lupus Foundation of Minnesota (952-746-5151).

Dr. Phillips has served on the National Board of Directors of the Lupus Foundation of America and currently is a member of the Lupus News Advisory Board.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Kids Adapting to Lupus

2007-04-30T07:08:00.000-04:00

Kids Adapting to Lupus

About 25 percent of lupus begins in childhood and adolescence, posing special problems. Pain, fatigue, the interruption of school and sports activities, limitations of mobility, change in appearance, and the feeling of being different are all particularly difficult for kids.

Lupus in childhood threatens the normal development process of gaining social and academic skills, the formation of a solid identity, and the development of independence and separation from parents. Very young children have rather concrete notions of disease, essentially that it is a result of accidents or catching germs from someone else. The more abstract reasoning required to understand lupus as an autoimmune disease does not usually develop fully before adolescence. In addition, children are focused on the immediate aspects and consequences of their disease, such as whether or not they can go to school or spend time with their friends or engage in any particular activity that day or that week. It's not until adolescence that children begin to understand the way in which their disease might interfere with their future goals. Depression stemming from this perception of future loss may be more of an issue for adolescents.

Lupus in children is essentially the same disease as that which occurs in adults. Some newborn infants of mothers with SLE experience abnormally slow heart rhythms and temporary skin rashes, the so-called "neonatal lupus syndrome", this is caused by antibodies that originate in the mother, but affect the newborn. This is not true lupus. In childhood, as in adulthood, true lupus can cause joint pain, fever, fatigue and butterfly rash as well as serious organ dysfunction, such as kidney or central nervous system involvement. Test results are similar, and treatment recommendations for childhood lupus are essentially the same as that for adults.

In most parts of this country, children with lupus are treated by pediatricians and often by a rheumatologist with special training in pediatric lupus. Generally, by the time patients reach adolescence, their care is transferred to an adult rheumatologist. However, the timing of this transfer may vary considerably and should be managed sensitively. Another significant difference with the treatment of lupus in children has to do with the effects of prednisone and other corticosteroids; calcium and vitamin D supplements are used to avoid or delay future problems with osteoporosis.

Over time, the adolescent patient should assume an increasingly autonomous role in her or his own care. They should be expected to do the talking in an appointment and have answers directed to them rather than to their parents. They should gradually gain responsibility for handling medications and scheduling their appointments while parents monitor the situation. They also have a right to confidentiality that should be respected.

However, as much as kids want to become independent from their parents, they are anxious about taking these steps, whether it be going away to college, or communication directly with their doctors, making appointments, or generally assuming responsibility for this aspect of their lives. They may forget their medications, appointments, and their need for rest and sleep. These are opportunities to provide additional guidance, reminders, and encouragement and not to usurp control of their healthcare. These are also good opportunities for open dialogue about the issues of independence and expectations of support. Studies of other chronic childhood diseases, such as asthma and diabetes, suggest that kids often fail to take their medications in the prescribed dosage. It is very important to involve children as active participants in their own health care.

Within the family, it is important to not treat the child with lupus differently than other children. For example, kids should not be over-sheltered or protected from the usual expectations or developmental challenges. Parents commonly feel guilty about their children with lupus because of the influence of genetic factors in its onset. However, they need to manage that guilt in such a way as not to become over-involved in the life of their ill child to the point of suspending their lives or neglecting the need of their other children.

Kids benefit from having some contact with adults who have had lupus and yet managed to live full and gratifying lives. One patient, Vicki Croke, now a journalist for the Boston Globe, has written about the importance of discovering the example of Henrietta Aladjem. When Vicki was quite ill she met "Hennie", whose disease by then had been in remission for many years, Vicki's hope was restored. Kids above all need a vision for themselves in the future and adult role models to help provide it. They also benefit from having contact with other kids with illness, either in support groups or in chat groups on the Internet. One nine year-old with lupus, Jessica, has a web site in which she described her illness, the disruption in her activities, the teasing about prednisone-related weight gain and her recovery. The teasing improved when her mom, a nurse, came to school and explained the illness to her class.

Fortunately, children and adolescents are extremely resilient. With the support of their family, friends, and doctors, most manage to negotiate the extra challenges imposed by illness. Sometimes counseling or psychotherapy can be helpful as well. At times parents need counseling even more than their children. If more difficulties or anxiety persist, psychiatric intervention and / or referral are recommended.

By Malcom P. Rogers, MD.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

The Genetic Basis of Lupus

2007-03-13T12:10:00.000-04:00

The Genetic Basis of Lupus

Lupus is an illness in which the immune system appears to have gotten confused. Instead of attacking viruses, bacteria or cancer cells – which is what it's there to do – the immune system attacks the person's own body.

The evidence that lupus is a genetic disease is quite clear. Lupus runs in families. If you have lupus, there's a five percent chance that one of your siblings will get the disease.

If you are a non-identical twin, the chances are about the same as for a sister, suggesting that nothing major happens in the womb to cause lupus. But if you are an identical twin – and your twin has lupus – the chances go up to 57 percent that you will develop the disease. Thus, there is strong evidence for a genetic basis, but it is clearly not a simple genetic basis.

If just one gene you could inherit always caused lupus, at least one out of four siblings should get lupus, considering the classic laws of genetics. Some people who are related to lupus patients have various lupus-like symptoms, suggesting that they have acquired “incomplete lupus” without developing the full-blown disease.

So how do we explain that? And, since identical twins are genetically identical, why does lupus affect only 57 percent of identical twins? We're just beginning to understand that there are several possible explanations.

Multiple Genes Involved
The first important concept is that more than one gene may be involved. One-fourth of your siblings should inherit any one gene, but if three, four or more different genes need to be inherited together, this doesn't explain why both identical twins don't get the disease, since they inherit the same genes.

A concept that could explain why some identical twins of lupus patients are spared is called gene penetrance. This means that you can have a gene – and that gene may cause you to be susceptible to a disease – but the illness still doesn't show up. This is possible because something in the environment is needed to get the disease started. This environment can be either outside your body or inside your body, which is greatly influenced by infections or toxins, or even your other genes. The idea that a certain gene could be there – but not expressing itself completely – is called “incomplete penetrance.”

A third concept, developed in recent years, is that there are cases where genes actually change or rearrange themselves in the body after the first cell divides at the moment of creation. So even identical twins can end up with somewhat different genes that develop later, after they have separated from each other in the womb, or after birth. This can be true for certain genes that have to do with the immune system.

The Role of Genes
What do we know about lupus that helps us to understand the roles of genes? First, there is the predominance of women to men who get the disease. It seems likely that this has to do with a direct effect of hormones on the immune system. Female hormones may help create the environment that allows a lupus gene to penetrate.

Much research is being done to identify the genes that lupus patients share. The ones that are best understood are a series of genes which regulate how the immune system works and where and when it might attack.

These genes are part of the network that is involved in tissue typing. They allow the immune system to recognize and attack foreign invasions from viruses, bacteria, or cancer cells, and to distinguish them from things that should not be attacked, such as parts of the body or tissue-typed organ transplants.

If you were looking for a defective gene that causes lupus, major histocompatibility complex (MHC) genes, whose normal function is to regulate immune responsiveness, would be good candidates since the immune system in lupus gets confused into attacking a person's own body. And, in fact, MHC genes are shared by many lupus patients.

How Genes Work
How do these genes work? They make proteins that act very much like the Lord Chamberlain to a very paranoid queen. Imagine a world in your bloodstream that is rather like medieval times with lots of small castles, each inhabited by a different queen, each queen waited on by a special court made up of one Lord Chamberlain and a lot of little soldiers.

If an infection enters the bloodstream, an invading particle will be picked up by a special Lord Chamberlain, who is genetically programmed to recognize it. He takes the particle back to his own castle and formally presents it to the queen as if it were the ambassador from a foreign country. The queen takes one look at the particle, shouts, “Off with its head!” – and all sorts of things start to happen.

First, immune-fighting cells get made. Then little proteins called antibodies get made. These are like little soldiers who specifically know how to recognize that original invading particle. So they leave cells and run around the blood stream attacking anything that looks to them like the particle.

If they get confused and think your kidney or joints look like an invading particle, then you might develop lupus. But the antibodies would never have started attacking if the Queen hadn't started shouting. And the Queen would have kept quiet if the Lord Chamberlain hadn't brought the particle into her castle.

The Lord Chamberlain (who is an MHC molecule) may be shared by many lupus patients and may be one of primary genes that put people at risk. The Queen (who is called the I Cell Receptor) and the antibodies are examples of immune genes that can rearrange themselves after the beginning of life, so they may or may not be shared exactly in families, even by identical twins. This could explain why an identical twin of a lupus patient might have more risk of developing lupus than another sister, but not a 100 percent risk.

Self-Attacking Genes
But why do lupus patients carry these genes that can start an attack on their own bodies – and what prevents other people from doing the same thing? In order to have a diverse ability to recognize and protect the body from diverse infections over a lifetime, everybody has some genes capable of making proteins that attack their own organs.

However, immune cells go through a complex educational process early in life in the thymus gland, where they are taught to recognize the difference between “us” and “them” – and what sorts of invaders it is appropriate to attack. Those that misbehave and threaten to attack parts of their own bodies are usually simply killed off by a process called apoptosis. But the well-behaved immune cells “graduate” from the thymus and are allowed to enter the bloodstream.

A gene which regulates the system that eliminates self-attacking cells in the thymus gland is defective in some mice with a lupus-like illness. The jury is still out on whether this is the fact in human lupus – but many researchers are now considering the possibility.

I cannot go into all the other genes that seem to put people at increased risk for lupus. But one important set of genes gives rise to special inflammatory proteins called complement proteins. These proteins act something like the artillery used by the antibody soldiers when they attack, and defects to some of the complement genes have been described in lupus and lupus-like illnesses.

Continued Research Needed
In summary, lupus is a complicated disease with a complicated genetic basis. It involves several genes we know of, and probably more not yet identified, that are important to regulating appropriate immune activity.

There are two reasons why continued research into the causes and genetic basis of lupus is very important – first and foremost, to improve the care of lupus patients. Although treatments are better than 20 years ago, and we encourage lupus patients to have optimism for a fairly normal life, people still die from lupus or from side effects of the medications. And others become very ill and suffer major organ damage. Patient care could be better if we knew more.

Second, what we learn by studying lupus has profound implications for better understanding and treatment for many other diseases. This point should not be forgotten when writing to Congresspersons or fundraising for the Lupus Foundation.

Lupus research provides a large picture window into the mysteries of the immune system and will very likely contribute to the understanding and treatment of AIDS, heart disease, cancer, diabetes and many other diseases. This research includes the one disease that costs more than any other – and affects everyone on earth – the process of aging itself.

By Joan T. Merrill, MD, St. Luke's-Roosevelt Hospital Center, New York City. Reprinted with permission from the newsletter of the SLE Foundation, New York.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Difficult-to-Manage Lupus

2007-03-13T12:09:00.000-04:00

Difficult-to-Manage Lupus

Having treated over 2,000 lupus patients over the last 20 years, I was intrigued when the editor of Lupus Update asked me to write about “Difficult to Manage Lupus.” After all, isn't all lupus difficult to manage? However, there are certain situations that are more difficult to manage than others. Ten patient cases are presented here:

When not to overtreat? Resistant non-organ-threatening disease?
A patient with Systemic Lupus Erythematosus (SLE) has persistently active rashes, fevers, fatigue and pain on taking a deep breath despite nonsteroidals and Plaquenil. There is no evidence for heart, lung, liver, central nervous system, hematologic or renal involvement. There are circumstances when certain treatments often do more harm than good if oral steroids or methotrexate are added in this situation, so I might try a few other things first. Consider increasing Plaquenil, consider DHEA, use very high dose nonsteroids or a local one-time only steroid boost.

Cyclophosphamide (Cytoxan) resistant lupus nephritis
Fifteen to twenty percent of all individuals with SLE have lupus in their kidneys and biopsies showing proliferative disease. With no treatment, they will be on dialysis within 2-3 years. Although Cytoxan is the treatment of choice for them, this toxic therapy does not work or wears off 30-40 percent of the time. What do I do? My options include: consider adding azathioprine (Imuran) to the Cytoxan and continue treatments; add plasmapheresis or pulse-dose steroids; or substitute nitrogen mustard for Cytoxan. Consider rebiopsying the patient and make sure that the renal lesion is reversible. Sometimes, it's better to let a patient go on to dialysis and transplant them than treat them further. Newer treatments may be utilized: cyclosporin, mycophenolate mofetil (CellCept) or tacrillimus (Prograf, FK 506). Drug trials with LJP394 and Biogen's antiCD40 ligand are available at selected medical centers.

Refractory chronic cutaneous lupus with no systemic disease
A patient has lupus rashes covering 70 percent of the body, but their ANA is negative and all blood work is normal. Plaquenil has not helped. I have had some success with: switching from Plaquenil to Chloroquine and adding quinacrine, retinoids such as Accutante or Soriatene; antileprosy drugs including thalidomide, clofazimine or dapsone; topical nitrogen mustard or BCNU.

Lifestyle-altering central nervous system (CNS) symptoms with a normal MRI scan of the brain and blood tests showing slight activity
When my patients complain about not thinking clearly, severe headaches and profound fatigue, the issue is raised as to whether it could be vasculitis of the CNS. True CNS vasculitis in SLE is usually obvious (e.g., fevers, meningitis-like picture, psychosis, seizures), and responds to high dose steroids. But could the patient have “subclinical vasculitis?” In fact, this is rare and most often the symptoms are due to abnormal blood flow to the brain due to a dysfunction of the autonomic nervous system and / or the dysfunction of chemicals known as cytokines (interleukins, interferons, etc.). I frequently order a SPECT scan (which might include antineural antibodies) and antiribosomal P antibodies and a spinal tap. Make sure that your doctor obtains LE cells, oligoclonal bands, antineuronal antibodies and IgG synthesis rate in addition to the usual determinations.

Cognitive impairment in patients without CNS vasculitis
How do we treat the patient in number 4 (above) who does not have vasculitis? Interventions are useful that improve the blood flow to the brain regulated by the autonomic nervous system (which controls the dilation or constriction of blood vessels, thus regulating our pulse and blood pressure), such as: biofeedback, relaxation techniques, cognitive therapy and counseling. Additionally, serotonin boosters (Prozac, Zoloft, Paxil) may help give a patient more energy and clarity. Antimalarials (Plaquenil, quinacrine) and DHEA can be useful. Steroids may seem to help at first but make things worse in the long run and should be avoided unless there is evidence for inflammation.

More than one miscarriage in a patient without anticardiolipin antibodies
Antiphospholipid antibodies and the circulating lupus anticoagulant can cause miscarriages. Most primary care doctors stop the workup after obtaining a negative anticardiolipin antibody and circulating anticoagulant test and don't treat the patient. On the other hand, aggressive reproductive immunologists unnecessarily treat patients with expensive and toxic approaches such as heparin, prednisone and intravenous gamma globulin for subsequent pregnancies which would be successful in any case. Active lupus by itself can cause miscarriages. I'm in the middle. I check for three to four different phospholipid antibodies, Protein C, Protein S, antithrombin III, Factor V Leiden mutation, BDRL and kaolin PTTs.

Is the muscle and joint aching a lupus flare or fibromyalgia?
Fibromyalgia can be as discomforting as lupus-associated inflammation but is made worse by corticosteroids. It is important not to inappropriately treat. I generally only treat symptoms of lupus with higher doses of anti-inflammatory medicine when there is objective evidence of joint swelling (synovitis), a high CPK (muscle enzyme), a high sed rate or CRP (blood tests for inflammation), low C3 complement or high anti-DNA. Lacking this, sometimes I have had to resort to obtaining a bone scan to assess if somebody with profound musculoskeletal discomfort and SLE is inflamed or experiencing a flare or fibromyalgia. The latter is treated with tricyclics, serotonin boosters and muscle relaxants and is seen in 25 percent of lupus patients.

The patients with non-organ threatening disease who want to treat their disease “naturally”
Twenty percent of patients with non-organ threatening disease will evolve organ threatening disease over five years, but this percentage decreases to five percent with two years of Plaquenil. No herb or spice has been shown to be specifically effective for SLE, and studies are sorely needed. None of these preparations, marketed as nutritional supplements to avoid FDA regulation, are standardized. Avoid believing testimonials and only rely on peer-reviewed published controlled studies. Let the buyer beware.

My eight-year-old daughter has aches and a positive ANA. Should I be worried?
Ten percent of women with SLE will have a daughter with the disease, and two percent a son with it. Twenty percent with SLE will have an offspring with an autoimmune disorder (most commonly autoimmune thyroid disease). Fifty percent of children of lupus patients have a positive ANA. Girls who are prepubertal develop lupus very rarely. Their positive ANA is inherited and their aches are usually due to growing pains. We usually advise against ANA or antibody testing unless there is objective evidence for a problem such as a fever, swollen joints or rash.

The 70-year-old woman with a diagnosis of new-onset lupus
Ten percent of the population develops ANAs as they age. When senior citizens are found to have a positive ANA and have a high sedimentation rate and joint aches, they often come to rheumatologists with a diagnosis of lupus. In reality, the overwhelming majority do not have the disease. Polymyalgia rheumatica, fibromyalgia, rheumatoid arthritis and particularly Sjogren's syndrome need to be ruled out.

By Daniel J. Wallace, MD, Clinical Professor of Medicine, UCLA School of Medicine. Reprinted with permission from the Maryland Lupus Foundation. Dr. Wallace is the author of “The Lupus Book: A Guide for Patients and their Families”.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Diagnosis Can Be Difficult

2006-12-20T09:24:00.000-05:00

A selection from the Lupus Foundation of America Newsletter Article Library
ApprovedLFA Patient Education Committee
92-035

Research focusing on the nature of lupus (SLE) has accelerated sharply over the past twenty years. It is believed that the symptoms of lupus are the result of an abnormally functioning immune system. What causes the malfunction is not yet known. The normal immune system functions to protect the body against damage by viruses, bacteria and other foreign substances.

In lupus, this same immune system appears to react against the body's own healthy cells forming antibodies against them. This causes inflammation and the subsequent symptoms of the disease. Since the immune system functions throughout the body, the symptoms of lupus can vary widely in type and intensity, depending on the parts of the body being affected.

Why is it difficult?
Most people involved in lupus research and treatment would probably agree that lupus still remains a difficult disease to diagnose. Two reasons account for this difficulty:
There is no single set of symptoms that are uniformly specific to lupus.
There are no laboratory tests yet available that can prove conclusively that a person has or does not have lupus. Almost every symptom of lupus can also be easily attributed to other illnesses or disorders. In addition, the symptoms are sometimes vague or they may come and go spontaneously.

For instance, fever, weight loss, marked fatigue and weakness which are often experienced by someone with lupus, may also be symptoms of many others disorders, some more threatening, some less so.

Likewise if transient (temporary) joint or muscle pain is the initial problem, here again there are so many causes of such symptoms that it may be very difficult to link these to lupus. If pleurisy is a symptom and it spontaneously clears up rather quickly, the physician may assume that a virus was the cause and not necessarily lupus.

Approach to diagnosis
The diagnosis of lupus is usually made after a careful review of the patient's medical history, coupled with analysis of blood study results from both routine laboratory testing and some specialized tests related to immune system status. Since symptoms may present themselves slowly and may evolve over months or years, it is important that a physician follow the patient to see what happens.

Often it can take years for the diagnosis to be made. This can be a very difficult time for the person seeking relief from numerous symptoms. Only by a comprehensive examination can the probability of lupus be assessed and even then it is sometimes very difficult to be sure.

Evaluation of symptoms
The first principle in making a diagnosis of SLE is that the individual has clinical evidence of a multi-system disease (i.e. has shown abnormalities in several different organ systems). The following are typical manifestations (symptoms) which might lead to suspicion of SLE.

Skin: butterfly rash; ulcers in the roof of the mouth; hair loss.
Joints: pain; redness and swelling.
Kidney: abnormal urinalysis suggesting kidney disease.
Lining membranes: pleurisy; pericarditis and/or peritonitis (taken together this type of inflammation is known as polyserositis).
Blood: hemolytic anemia (the red cells are destroyed by autoantibodies); leukopenia (low white blood cell count);thrombocytopenia (low platelets).
Lungs: infiltrates that may be transient.
Nervous system: convulsions (seizures); psychosis; nerve abnormalities that cause strange sensations or alter muscular ability.

Evaluation of immune status
The second diagnostic principle is to examine the status of the immune system in individuals having a suspicious clinical history. In general, physicians now look for evidence of autoantibodies.

At this time some commonly used tests of immune status in the diagnosis of SLE are:
The anti-nuclear antibody test (ANA): a test to determine if autoantibodies to cell nuclei are present in the blood.

The anti-DNA antibody test: to determine if the patient has antibodies to the genetic material in the cell. The anti-Sm antibody test: to determine if there are antibodies to this substance, a nuclear protein. A variety of tests for the presence of immune complexes in the blood.
Tests to examine the total level of serum complement - a group of proteins involved in the inflammation which can occur in immune reactions - and tests to assess the specific level of C3 and C4, two proteins of this group.

LE cell prep: An examination of the blood looking for a certain kind of cell which has ingested the swollen antibody-coated nucleus of another cell. A positive ANA may occur sometime during the course of the illness in about 90 percent of patients with SLE, but it also occurs in a variety of other illnesses and in as much as 5 percent of the normal population. It is a very sensitive test and is now more frequently performed than the LE prep.

Tissue biopsy
Sometimes examination of a tissue sample can be helpful in making the diagnosis. A kidney biopsy, for example, can show certain changes characteristic of SLE if the kidney disease is severe. Even in early kidney involvement, examination of biopsy tissue can show deposits of antibodies and immune complexes in the kidney's filtration unit.

A skin biopsy can be helpful in identifying deposits of antibodies and complement proteins found at the junction of the outer skin layer, called the epidermis, and the underlying part of the skin, the dermis. A "positive band test" is significant only when the tissue sample is taken from an area which is not involved by the rash. The results, like those of a kidney biopsy, should be interpreted in combination with the clinical history, as well as all the other tests performed.

Criteria
In 1982, the American Rheumatism Association published a revised set of criteria to aid physicians in making the diagnosis of Lupus. The criteria (see note) are:

Malar Rash
Discoid Rash
Photosensitivity
Oral Ulcers
Arthritis
Serositis
Renal disorder
Neurologic disorder
Hematological disorder
Immunologic disorder

Positive fluorescent antinuclear antibody (FANA) or ANA test result A physician observing a person to have at least 4 out of the 11 criteria, either serially or collectively, should be suspicious to the possibility of lupus being the underlying disorder. However, physicians must also be careful in utilizing criteria for an individual case, as other diseases could also conform to the criteria.

Presently, the diagnosis of lupus is usually based on these findings:
evidence of a multi-system disease (more than one organ involved):
the presence of autoantibodies; the exclusion of other diseases and disorders which can mimic the features of lupus. Despite advances in medical education and technology it is still not uncommon for lupus to be incorrectly diagnosed or require a lengthy period of time to be diagnosed mainly because the symptoms vary so widely, come and go frequently, and because the disease mimics so many other disorders.

An important fact to remember concerning the treatment for lupus is that the diagnosis does not indicate the particular therapy to be used. In the absence of a cure, present-day treatment of lupus is still primarily tailored to symptomatic relief and not to the diagnosis.

Late Onset Lupus Fact Sheet

2006-12-20T09:17:00.000-05:00

Lupus can occur at any age, in either sex, in any race.
15% of people with Systemic Lupus Erythematosus (SLE) develop it later in life after age 55.
Late onset lupus affects women 8 times more often than men. Compared with younger SLE patients, late onset lupus affects a higher percentage of men.
Late onset lupus is found primarily in Caucasians, but occurs in all races.
Symptoms in most cases are relatively mild and commonly include: arthritis, pleurisy (chest pain with deep breathing), pericarditis (inflammation of the sac around the heart), muscle aches, dry eyes and dry mouth (Overlap syndrome).
Uncommon symptoms include: fever, swollen lymph glands, seizure, psychoses, and Raynaud's Phenomenon (fingers turn blue or white in the cold).
Because symptoms of lupus in older people mimic other diseases, eg., rheumatoid arthritis, Sjogren's syndrome, polymyalgia rheumatica, distinguishing among them is difficult and may result in a delayed or missed diagnosis.
Severe kidney involvement is less common in late onset lupus.
The average age of onset is 59 years; average age at diagnosis is 62 years.
As a rule, older people with lupus do better and their lupus can be managed with conservative therapy. When corticosteroids are required, symptoms are controlled with lower doses (i.e., less than 25 mg/day for one month).
Drug-induced lupus occurs more often in older people because they are more likely to have conditions (high blood pressure, heart disease) that require treatment that may cause the symptoms of lupus. Symptoms generally fade when the medication is discontinued.

Is Your Child at Risk?Atherosclerotic Heart Disease in Young People with Lupus

2006-10-19T09:37:00.000-04:00

Is Your Child at Risk?Atherosclerotic Heart Disease in Young People with Lupus
Susan Manzi, M.D., M.P.H., Janice M. Sabatine, Ph.D., and Laura E. Schanberg, M.D.
From Lupus News Fall 2002, Vol. 22, N. 3

It has been well established that accelerated atherosclerosis, or hardening of the arteries, occurs in adults with lupus, along with its eventual clinical outcomes-myocardial infarction (heart attack) and stroke.

However, atherosclerotic heart disease is emerging as one of the most serious concerns in children and adolescents with lupus. Young, premenopausal women with lupus are up to 50 times more likely to have a heart attack than women of the same age who do not have lupus (1). Our research and that of other investigators indicate that these clinical outcomes are generally related to accelerated atherosclerosis (2,3).

Evidence of heart problems in children with lupusChildren with lupus are known to experience myocardial infarction and stroke. Although the frequency of atherosclerosis in these young patients is not fully known, emerging evidence suggests the incidence may be similar to that in premenopausal women with lupus.

It is not unreasonable to suspect atherosclerotic development at young ages, as evidence of fatty streak formation-an early step in plaque formation-has been noted in healthy children as young as two to three years of age.

Atherosclerosis-promoting patterns of cholesterol, triglycerides, and other lipoproteins in children and adolescents with lupus have been documented (4). Coronary blood flow abnormalities were found in 16 percent of children and adolescents with lupus who had no cardiac symptoms. This suggests that there may be a significant percentage of young lupus patients with undiagnosed heart disease.

In addition, evidence of carotid atherosclerotic plaque and abnormal coronary blood flow have been detected two to five years after the onset of lupus, indicating that atherosclerosis may develop very early in the course of disease (5,6).

What causes heart disease in lupus?We do not completely understand the underlying biological cause for accelerated atherosclerosis in young patients with lupus, probably because we do not yet completely understand the underlying biological cause of lupus. One thing we do know is that two key factors are the disease of lupus, itself, and its treatment.

It was initially thought that the increased risk of heart disease in patients with lupus might be due to traditional risk factors, such as:
hypertension
diabetes
obesity
elevated cholesterol levels.

But recent evidence indicates that the presence of lupus itself, or the treatment for lupus, contribute more than those risk factors alone (2,7). The task now is to identify the biological processes occurring in lupus or resulting from its treatment that promote atherosclerosis.
It was once believed that excess cholesterol built up as plaque inside the blood vessels and obstructed blood flow. Investigators now know that fewer than 20 percent of heart attacks are due to restricted blood flow in progressively narrowed coronary vessels. More commonly, heart attacks occur when an atherosclerotic plaque ruptures and a blood clot forms around the plaque (8).

There are several potential parallels between lupus and the formation and rupture of atherosclerotic plaques (9).

A. For instance, damage to the lining of the blood vessels provokes an inflammatory response, which leads to deposits of immune cells containing fat droplets into the arterial wall. This in turn leads to plaque formation.

B. Inflammation is also responsible for thinning the fibrous cap that covers a plaque, making it more vulnerable to rupture. The inflammatory substances known as cytokines that drive the formation of atherosclerotic plaques and increase the vulnerability of the plaques to rupture are the same substances that play a major role in the inflammatory processes seen in lupus. This may explain why cardiovascular disease is accelerated in lupus.

C. Another factor related to lupus as a prime suspect as sources of damage to the lining of the arterial wall is high levels of circulating immune complexes. Although immune responses are important in the body's normal response to damage and microbial infections, in systemic lupus-and perhaps in atherosclerosis in general-these normally protective immune responses become dysregulated, leading to a high degree of inflammation and tissue damage.

D. A wide variety of autoantibodies may also hold responsibility. Elevated levels of antiphospholipid antibodies, which are often found in people with lupus, have traditionally been linked to an increased risk of blood clotting and may increase the risk of clot formation at the plaque site. More recent evidence suggests that these antibodies may also facilitate the uptake of oxidized low density lipoprotein, the "bad cholesterol," into inflammatory cells in the vessel wall. This is a key step in the formation of atherosclerotic plaque (10).

E. The amino acid homocysteine is another agent that is often elevated in lupus patients and is a likely source of arterial injury. Elevated levels of homocysteine have been linked to thrombosis in lupus patients (11) and to coronary heart disease and stroke in non-lupus patients. The reasons for elevated homocysteine in lupus are not entirely known, but may be related to kidney disease, diet, or treatment.

Is there a link between corticosteroids and atherosclerosis?With the advent of glucocorticoids (prednisone) in the 1950s, there has been a significant improvement in the lifespan of young people with lupus. Yet there is concern that these agents may actually contribute to the development of atherosclerosis, either directly by promoting plaque formation or indirectly by intensifying risk factors such as:

weight gain
hypertension
elevated serum glucose and lipid levels.

In contrast, some evidence indicates that the anti-inflammatory effects of glucocorticoids may actually provide protection against atherosclerosis, suggesting that poorly controlled lupus activity may contribute to cardiac disease, with corticosteroid treatment providing a degree of protection.

Perhaps with the use of newer biologic therapies with similar anti-inflammatory and immunomodulatory effects as corticosteroids, but fewer adverse side effects, we will begin to see a reduction in heart disease.

How can atherosclerosis be managed in young people? It is of critical importance that physicians and patients be aware of the increased risk of cardiovascular complications in lupus. Young people generally view their risk of heart disease as negligible, yet cardiovascular disease intervention and prevention has the potential to significantly lengthen and improve the quality of their lives over many years.

Chest pain. Any physician treating a young person with lupus, regardless of the patient's age or sex, should be suspicious of chest pain. Because the patients are young and because chest pain in lupus may be attributable to other causes, physicians may overlook conditions, such as angina (chest pain due to myocardial ischemia). Yet often there are no warning signs for an impending heart attack. For these reasons, a major focus on management strategies should rest on preventing the development of atherosclerosis.

Diet. There have been reports on the potential benefits of diet modification in controlling abnormal lipid levels in children with lupus, but diet alone is not always sufficient, and pharmacologic therapy may be necessary. However, the type, timing, and dosage of such therapy in children have not been well established by large studies.

Blood clots. Measures to reduce potential blood clots, such as anticoagulation or antiplatelet therapy, should be considered in patients at increased risk, such as those with kidney disease, antiphospholipid antibodies, and other coronary disorders.

There are few clinical data on the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on atherosclerosis. However, some evidence suggests that the selective inhibitors of the prostaglandin-producing enzyme COX-2 might actually enhance blood clot formation in some non-lupus populations. Further investigation in this area is currently underway.

Aspirin. There is strong evidence from clinical trials to support the use of low-dose aspirin therapy in preventing heart attacks in the general population. At low doses, aspirin is probably
reducing the clotting risk but not reducing inflammation.

Dietary supplements. There is some evidence that the antioxidant vitamins E and C may improve arterial dilatation in children with familial hypercholesterolemia or combined hyperlipoproteinemia. However, the long-term benefit of antioxidant therapies in reducing cardiovascular risks in lupus is unknown. Measures to reduce homocysteine levels with folate supplementation may be beneficial; again, however, the effects on prevention of coronary events are unproven.

Steroids. Based on the possible opposing effects of corticosteroids-increasing traditional risk factors and controlling inflammation-there are no established recommendations about the use of corticosteroids concerning cardiovascular risk in lupus. In general, judicious use of these agents to control the underlying disease and to minimize the proven long-term side effects is recommended.

Table 1 (below) illustrates suggested strategies to manage and/or prevent atherosclerosis in young patients with lupus. These strategies are targeted at both traditional cardiovascular risk factors and at potential lupus-specific factors. Physicians should communicate these potential risks to patients and their parents, and provide relevant information and resources for patient education.

Table 1. Strategies For Managing Cardiovascular Disease Risk In Children With Lupus

Step 1: Physician awareness
Recognize increased risk in young population.
Conduct a thorough cardiac evaluation if there is any suspicion of heart disease.

Step 2: Patient education
Make patients and parents aware of increased risk.

Step 3: Minimize traditional cardiovascular risk factors
Encourage a regular aerobic exercise program.
Establish guidelines for a heart-healthy diet.
Assist with weight loss program, if necessary.
Start a smoking cessation program.
Control hypertension and diabetes, if present.
Treat hyperlipidemia.

Step 4: Address potential lupus-specific risk factors
Use corticosteroids judiciously.
Reduce homocysteine levels (folate supplementation).
Consider aspirin or anticoagulant therapy for patients at high risk for blood clotting.

Physicians also should work together with the patients and parents to encourage a heart-healthy diet, a regular exercise program that involves aerobic activity, and weight loss, if necessary. Patients should be advised not to start smoking and to quit if they have already started. Hypertension and diabetes should be managed aggressively.

Bottom line
It is clear that premature atherosclerosis in children, adolescents, and young, premenopausal women with lupus is a substantial medical concern. The reasons that atherosclerosis is accelerated in lupus patients likely involve the inflammatory and immune-mediated mechanisms shared by these two disease processes.

Until new biologic therapies are available that can halt the immune dysregulation and resulting inflammation and vascular damage in lupus, we must promote aggressive approaches to reducing traditional cardiovascular risk factors.

Noninvasive methods for specifically identifying vulnerable plaques might also pinpoint those lupus patients at greatest risk for heart attack and those most likely to benefit from intervention. Investigations into the pathways that lead to premature heart disease in lupus may provide an ideal model for examining the role of inflammation in all populations with cardiovascular disease.

About the AuthorsSusan Manzi, MD, M.P.H., is an Associate Professor of Medicine and Epidemiology at the University of Pittsburgh School of Medicine in Pennsylvania.
Janice M. Sabatine, Ph.D. is a medical writer and editor.
Laura E. Schanberg, MD is an Assistant Professor of Pediatric Rheumatology at Duke University Medical Center in Durham, NC.

References
1. Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger TA, Jr., Jansen-McWilliams L et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Am J Epidemiol 1997;145:408-415.2. Manzi S, Selzer F, Sutton-Tyrrell K, Fitzgerald SG, Rairie JE, Tracy RP et al. Prevalence and risk factors of carotid plaque in women with systemic lupus erythematosus. Arthritis Rheum 1999;42:51-60.3. Selzer F, Sutton-Tyrrell K, Fitzgerald S, Tracy R, Kuller L, Manzi S. Vascular stiffness in women with systemic lupus erythematosus. Hypertension 2001;37:1075-1082.4. Ilowite NT. Premature atherosclerosis in systemic lupus erythematosus. J Rheumatol 2000;27 Suppl 58:15-19.5. Gazarian M, Feldman BM, Benson LN, Gilday DL, Laxer RM, Silverman ED. Assessment of myocardial perfusion and function in childhood systemic lupus erythematosus. J Pediatr 1998;132:109-116.6. Falaschi F, Ravelli A, Martignoni A, Migliavacca D, Sartori M, Pistorio A et al. Nephrotic-range proteinuria, the major risk factor for early atherosclerosis in juvenile-onset systemic lupus erythematosus. Arthritis Rheum 2000;43:1405-1409.7. Esdaile JM, Abrahamowicz M, Grodzicky T, Li Y, Panaritis C, du BR et al. Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus. Arthritis Rheum 2001;44:2331-2337.8. Libby P. What have we learned about the biology of atherosclerosis? The role of inflammation. Am J Cardiol 2001;88:3J-6J.9. Manzi S. Systemic lupus erythematosus: a model for atherogenesis? Rheumatology (Oxford) 2000;39:353-359.10. Vaarala O. Autoantibodies to modified LDLs and other phospholipid-protein complexes as markers of cardiovascular diseases. J Intern Med 2000;247:381-384.11. Petri M, Roubenoff R, Dallal GE, Nadeau MR, Selhub J, Rosenberg IH. Plasma homocysteine as a risk factor for atherothrombotic events in systemic lupus erythematosus. Lancet 1996;348:1120-1124.

July 30, 2003

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Lupus and Pregnancy

2006-08-29T18:11:00.000-04:00

Lupus and Pregnancy
Philip Samuels, MDSteven G. Gabbe, MD

While lupus can have profound effects on both mother and child during pregnancy, most women with lupus can conceive, have a successful pregnancy and a healthy baby. Pregnancy does not seem to affect the long-term course of their lupus. It is very important to remember that later pregnancies may affect lupus differently in the same patient.

There appears to be an increased risk of lupus flares during pregnancy, especially during the days surrounding childbirth. There is also an increased risk of miscarriage in patients with lupus. The miscarriages associated with lupus often occur in the third and fourth months of pregnancy and may not necessarily have any relationship to how mild or severe the mother's other symptoms are at that time. Currently research into possible causes for recurrent miscarriages is focusing on the lupus anticoagulant and the anti-cardiolipin antibody. Such antibodies are found in the blood of approximately fifteen percent of patients with lupus.

It appears that therapy with prednisone, aspirin, heparin, or gamma globulin either alone or used together may help reduce the number of miscarriages in these patients. Pregnant patients with lupus may have an increased chance for a premature delivery. This is due both to spontaneous premature labor and to emergency Caesarean section.

The Caesarean section is done if the mother's condition is deteriorating or the baby is in jeopardy. Patients with lupus may also have an increase in the possibility of having a stillborn child. This is especially true in patients who have severe kidney involvement. Infants bom to mothers with lupus may have rashes on their face, scalp, and chest. These rashes usually disappear by one year of age.

Once in a great while, these babies may develop a congenital heart block. In these cases, the baby's heart beats at a slower rate than normal before birth, and continues to do so after delivery. This disorder is associated with the presence of the anti-Ro (SS-A) antibody in mothers with lupus. If this problem is recognized early, however, most of these babies will do well after birth. Most patients with lupus can have a successful pregnancy. There are certain factors that must be watched and there are certain measures the pregnant patient herself can take to help assure that she has a healthy baby. Most importantly, a patient's lupus should be in clinical remission before conception.

If possible she should try to wait six months after her last flare of lupus before conceiving. If her condition is stable, the patient greatly increases her chances for a normal pregnancy. Before conception, the patient should have blood tests performed for the presence of the anti-Ro antibody, the lupus anticoagulant, and the anti-cardiolipin antibody. If the anti-Ro antibody is present, the patient should be watched closely for the possible development of fetal heart block. If the lupus anticoagulant or anti-cardiolipin antibody is present, the patient should probably receive steroid therapy throughout her pregnancy.

The obstetrician and rheumatologist must work together as a team to help the patient throughout her pregnancy. The patient's blood pressure should be checked frequently. Her kidney function should be checked monthly. Ultrasound exams should be used frequently during pregnancy in a patient with lupus to make certain that the fetus (unborn baby) is growing properly. Ultrasound is a technique which uses high frequency sound waves to photograph the fetus. This test is painless and safe. Another safe test involves use of a fetal heart rate monitor to observe the patterns of the fetal heart rate for 20-40 minutes.

In the last months of pregnancy, this test may be done frequently to assess the condition of the unborn baby. Finally, frequent blood tests will be performed to make certain that there are no flares of the lupus. Although having blood tests performed is a nuisance and is somewhat uncomfortable, it is very important that the doctor watch the level of certain antibodies in the blood during late pregnancy to be assured that the mother's condition is stable.

Upon leaming that they are pregnant, many women react by immediately stopping all medications. This should not be done without consulting both the obstetrician and rheumatologist. Steroids are the mainstay of treating lupus, and they and most medications used to treat lupus cause no serious problems for the fetus. Patients should choose an obstetrician who is familiar with lupus and who feels comfortable treating pregnant patients with this illness.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Sex and Lupus

2006-08-29T18:08:00.000-04:00

Sex and Lupus
Mary P. Brassell, MA, CRRN

Many couples experience some type of sexual difficulty when one partner has a chronic disease such as lupus. Sexuality may be affected by disease symptoms, medications and/or psychological concerns. Disease symptoms of lupus which may influence sexual activity include: oral ulcers, vaginal ulcers, arthritis, Sjogren's syndrome, and Raynaud's phenomenon. Each of these problems will be discussed in detail. Oral ulcers occur in about 10-15% of people with lupus.

They can interfere with pleasant oral sensations. A prescription mouthwash with antibiotics and/or steroids may be necessary and can help heal the ulcers. Remember, they do not last forever! Vaginal ulcers are present in less than 5% of patients with lupus. They are rarely painful but when they are they can interfere with intercourse. A prescribed steroid cream or other medication can be used to treat them. Alternate forms of sexual expression can also be used until healing has taken place. Joint pains or arthritis that often accompany lupus may respond to warm baths, a few warming up exercises, and taking anti-inflammatory medication an hour before sexual activity. The vaginal dryness associated with Sjogren's syndrome responds well to the use of a water soluble lubricant which is absorbed and does not have to be removed. (Vaseline-like ointments should be avoided since they can encourage infection.) Water soluble lubricants (e.g. K-Y jelly) are available over the counter at drugstores or supermarkets.

People who have Raynaud's phenomenon have a condition in which blood vessels constrict (become narrower) when they are exposed to cold. It can be very painful. Raynaud's can cause fingers and toes to change color (first white, then blue, then red). Here are some solutions: Avoid having sex in an air conditioned room. Wear socks if your feet are sensitive to cold. Try a warm bath (not hot) prior to sexual activity as it will help open the blood vessels. During sex, blood pools in the genital area and less blood goes to the fingers and toes. Take the bottom position - it helps avoid the pressure on hands and feet that can further reduce blood flow. Medications can certainly influence sex life. Tranquilizers (antianxiety agents), anti-hypertensives (drugs that lower high blood pressure), and corticosteroids (prednisone) can affect both sexual desire (libido) and performance.

Some anti-hypertensives decrease libido in men and women as well as produce temporary impotence. It is best to discuss these drugs with your doctor, who may be able to prescribe a different blood pressure drug that won't interfere with sexual performance. A small percentage of men and women have experienced libido changes while on steroids. If you experience any of these changes, talk with your doctor. Psychological factors can also have a powerful influence on a satisfying sex life. If the person with lupus has developed low self esteem, unhappiness about the way their body looks, feelings of worthlessness, depression, fatigue, and feelings of inadequacy, the sexual relationship will certainly be affected. The patient may withdraw from his/her partner.

The healthy partner may feel that this withdrawal means rejection and the loss of affection and love. If communication does not occur, the relationship may be in serious jeopardy. Sexual pleasure is an important aspect of any relationship. Some studies have reported that arthritis patients are free from joint pain for up to six hours after intercourse. Sex, therefore, seems to be therapeutic. Even if intercourse is not possible, other forms of sexual expression such as cuddling, holding, stroking, kissing, and closeness are all manifestations of sexual affection that can help reinforce your sense of self-worth and desirability.

Many publications contain various suggestions for different methods of sexual expression. The Arthritis Foundation has a publication titled "Living and Loving with Arthritis". It costs less than a dollar and can be obtained from the local branch of the Arthritis Foundation. This booklet contains information about sexual expression, illustrations of comfortable positions to assume during sexual activity, and some sound advice about coping with sexual challenges. Suggestions for improving a sexual relationship are offered. Sexuality is a part of life. It is a normal and usual activity of daily living. Whether sexual problems are physical or emotional or both, willingness by botb partners to discuss and search for solutions to sexual problems is essential.

Help in reaching solutions can be sought from a physician, from nurses in the field of arthritis and lupus, from psychologists, and/or from sex therapists. infon-nation is readily available at low cost. All that is required is that the patient and partner find the necessary person or publication. Sexuality is best thought of as another form of communication that helps couples enjoy each other and deepen their intimacy in a loving relationship. Sometimes if this communication does not happen, other parts of the relationship will suffer. Solutions can be achieved with a little effort by both patient and partner, but there must be an effort!

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Rehabilitation in Lupus

2006-08-01T20:08:00.000-04:00

Rehabilitation in Lupus
Bertram Greenspun, DO

Rehabilitation medicine is the field of medicine that concerns itself not only with how the disease process has affected the individual but also with how the disease has changed the person's ability to maintain the lifestyle and roles in life which they had before the disease started.

The rehabilitation team concentrates on how to improve the person's functioning and independence to the highest possible level. Systemic Lupus Erythematosus (SLE) at times presents problems that can be helped by an individualized rehabilitation program. Among the body systems that can be affected by lupus (and may be helped by rehabilitation) are the central nervous system (CNS), the musculoskeletal system (muscles, bones and joints), and the vascular system (blood vessels).

The CNS can be involved in a variety of ways. Patients who develop stroke-like syndromes or problems of the spinal cord usually require an in-patient program in a comprehensive rehabilitation center. These problems often result in weakness of one or both arms or legs. Weakness can be so profound that it may result in paralysis. Under such circumstances, passive range of motion (ROM) exercises should be started by the physical therapist (PT). Family and friends may also be instructed by the physical therapist to perform ROM exercises for the patient. These exercises are done without the patient having to do any of the work. Since some degree of strength almost always returns when the stroke or the spinal cord damage resolves, it is vital not to allow contractures to develop.

Contractures happen when the joints are allowed to stiffen to the point where they will be unable to bend. Should this occur, even if muscle power returns it will do no good unless the stiffness is reduced or eliminated. This can take a very long time and even require surgery. It is much wiser and easier to prevent contractures in the first place than it is to correct them after the fact. As the patient improves, he/she can move the joint along with the physical therapist. Then the exercise is known as active-assistive ROM. When the patient can move the joint through the entire ROM, he/she no longer needs the assistance of another person and is instructed on how to do regular, active ROM exercises independently.

In addition to ROM exercises, strengthening exercises can be started under proper supervision as soon as is medically possible. The strengthening program should begin at a low intensity that is well within the capability of the patient. It is increased only gradually and slowly. The patient must learn to "listen" to his/her body. This means that if muscle pain or fatigue lasts for more than an hour to an hour and a half after a session, the level of exercise intensity should be temporarily reduced. if the discomfort or fatigue continues after each session the physician who prescribed the program should be notified.

Too much exercise, done too quickly, can easily make the situation worse. If the weakness is associated with acute inflammatory joint pain, isometric exercises can be helpful. Isometric exercises involve contracting the muscles without moving the involved joint. In this way strength can be maintained without triggering the intense pain associated with moving an acutely inflamed joint. Since isometric exercises can cause the blood pressure to rise they should be performed cautiously and without holding the breath, especially in the individual with hypertension. Almost all patients with lupus will, at some point in the disease process, have joint pain. There is often associated morning stiffness and joint swelling. Tenderness and painful movement are common. Deformities may result. Most of these problems can be dealt with on an out-patient basis.

An early morning shower will frequently shorten the duration of morning stiffness. Moist heat is quite helpful for most joint problems and is used prior to ROM exercises. This can be provided by using an inexpensive hydrocollator pack (a wan-n, moistened, sand-filled canvas bag). The moist heat helps to prevent or reduce joint pain caused by motion. For chronic pain, deep heat, such as is provided by ultrasound, can be applied by a PT.

For acute, severe joint pain, ice is most helpful. Bed rest is occasionally prescribed for widespread severe pain. In such cases, it is especially important to properly position the patient in bed to avoid the development of contractures of the joints. One of the most common mistakes is to put pillows under the knees. This forces the knees into a bent position and, along with them, the hips. To imagine the difficulties this can cause, try walking with your hips and knees bent. Both musculoskeletal and CNS manifestations can lead to problems in performing the activities of daily living (ADL) such as dressing, bathing, toileting, etc. An occupational therapist (OT) can be most helpful in suggesting ways to solve these problems.

The OT can provide tools such as button hooks and long-handled sponges to make these activities easier, and can fit splints to allow painful hands and arms to rest while keeping them positioned properly. The OT can educate the patient in joint conservation techniques (ways to protect the joints yet still get the task done). The OT can also aid in the selection of devices to make living at home less difficult (tub benches, raised toilet seats, stair glides, etc.) and can help evaluate the home environment from the point of view of the patient's safety. If mobility has become a problem as a result of joint or CNS involvement, the PT teaches transfer techniques (bed to chair, sit to stand,etc.) and ambulation training, including going up and down stairs. The physical therapist also teaches patients to make proper use of assistive devices such as canes and crutches and helps the patient to adapt to leg braces and splints.

As a result of lupus vasculitis (inflammation of the blood vessels), patients may develop ulcerations of the skin. Special exercises can then be used to help improve circulation and whirlpool treatments can be given to clean the ulcers by removing dead tissue. Rarely, as a result of ulcerations of the feet or ankles, or as a result of blood clots in the major leg arteries, amputation of part of a leg may become necessary.

There has been dramatic improvement in prosthetic (artificial) feet in the last three to four years, allowing many more normal activities such as running and jumping, and materials are now available that result in a much lighter limb. In each state, there is a government office concerned with helping individuals with disabilities obtain training or education so that they can return to gainful employment if their disability prevents them from resuming their previous vocation. This office is usually known as the Office of Vocational Rehabilitation. Social workers can be most helpful in directing people with lupus-related disabilities to the appropriate office or case worker.

The social worker is familiar with the many resources that can help the person with lupus obtain a wide variety of services. Social workers are available in medical clinics, hospitals and social agencies and are members of all rehabilitation teams. If lupus patients have to be hospitalized in a rehabilitation center they will encounter physicians responsible for directing their rehabilitative care. Such physicians are specialists in Physical Medicine and Rehabilitation and are called "physiatrists". In addition to the PT, the OT and the social worker, the rehabilitation team usually includes a number of other professionals. These are a rehabilitation nurse (who has had special training in working with patients disabled by different diseases) a psychiatrist and/or psychologist (to help with the emotional problems that may be present), a recreational therapist (to get patients involved in activities that they may have enjoyed previously or to introduce new interesting activities that make them aware that life can still be enjoyed) and a speech therapist (to help in problems with language or with swallowing difficulties). As well as working with the patient, all members of the rehabilitation team work with the patient's family and friends so that they know what to do and what not to do, when the patient goes home. In summary, the primary purpose of any rehabilitation program is to improve the functional independence of the individual.

Most of the patients requiring a rehabilitation program can be treated in an out-patient setting or at home. Only a small minority will require an intensive in-patient program. While no patients are cured, almost all can be helped.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Lupus in Childhood

2006-08-01T20:07:00.000-04:00

Lupus in Childhood
Phyllis Slutsky, MEd, RNBarbara E. Ostrov, MD

About 20-25% of all lupus occurs in children. While the exact number of cases is not known, it is not a rare disorder. Girls have lupus about three to seven times more often than boys. Research is being done to study many possible causes of lupus.

Several studies have shown that there is a tendency for lupus to run in families. It is known that there are certain inherited factors called HLA types which make a person more likely to develop lupus. (See Chapter 4.) There is also an inherited lack of immune system proteins (serum complements or immunoglobulins) which increase the risk for developing lupus in some people.

When a susceptible person is exposed to a "trigger" such as a virus or other environmental factor, lupus can develop. A particular kind of lupus may develop in infants of mothers who have SLE. This is called "neonatal lupus" and is associated with an anti-Ro antibody in the mother. An infant with neonatal lupus may have a rash on the face, scalp, or chest. Very rarely, these infants may also be born with an abnormally slow heart rhythm (congenital heart block).

During the first six months to one year, the rash disappears but the slow heart rhythm can be serious and may require the placement of a pacemaker. Systemic lupus erythematosus in childhood can range from mild to severe and affects each individual differently. The usual course of lupus includes periods of "flare-ups" (when symptoms are active) and remissions (when symptoms go away).

Stressors such as infections (which may be more frequent in childhood) and hormonal changes may lead to a flare of symptoms. This may explain why lupus is more common in girls after puberty and may flare up during menstruation and pregnancy. In children, as in adults, sun exposure can bring on symptoms of lupus. Serious complications of lupus are most common when organs such as kidneys, heart or the central nervous system are involved.

The most common time to find out what body systems are involved is at the time that lupus is first diagnosed. As time goes on, the likelihood decreases that new body systems will become involved. Diagnosing lupus involves a thorough physical examination and often many laboratory tests.

There are guidelines which have been developed by the American College of Rheumatology which are used to diagnose lupus. (See Table 1) Four of their eleven selected symptoms and/or laboratory tests (criteria) must be present to make a definite diagnosis. Symptoms of lupus may start in a variety of ways.

A child may be very ill or have only mild symptoms. The most common symptoms in children are rash, fever, fatigue, and joint pain and swelling. Decreased appetite and weight loss are particularly common in children during the active phase of the disease. Inflammation of the kidneys (nephritis), inflammation of the heart covering (pericarditis), enlargement of the liver and spleen, and a low blood count (cytopenia) may be more frequent in children than in adults. Many children have rashes that can appear on the face or anywhere on the body. Ulcers of the mouth and nose are common in children with lupus. Hair loss (alopecia) may range from gradual thinning and change in texture, to loss of large amounts of hair when combing.

Central nervous system symptoms (affecting the brain and spinal column) can occur and may cause headaches, seizures, or a change in memory or thinking ability. Visual changes can also occur, making it important to have frequent checks by an eye doctor. Changes in mood or behavior can occur in children with lupus. These can be an understandable reaction to having an illness. Feelings of sadness or irritability do not necessarily mean there is central nervous system involvement. However, it is important to keep a careful watch on a child's behavior to decide if these things are caused by the lupus or are due to the child's reaction to the illness.

Diagnostic tests such as spinal taps, EEGS, and brain x-rays and scans can be helpful in deciding what is caused by lupus and what is due to psychosocial causes. The kidneys can be affected by lupus. A urinalysis may reveal problems which can then be further investigated with other tests. It is common to collect urine for 24 hours to do further studies. A kidney biopsy is sometimes necessary to determine how seriously the kidney is affected.

This test is used as a guideline for treatment and for monitoring changes over time. The treatment of lupus depends on what part of the body is affected. Being careful about sun exposure is important for all children. Planning the child's schedule to avoid exposure during the peak time of 12:00-3:00 P.M. each day is recommended. Children should be included in working out the schedule so that they understand the importance of any restrictions and will be more willing to cooperate. Another important aspect of treatment is to be alert for any signs of a developing infection.

Families should be aware that fever and increased tiredness or shortness of breath could be a sign of either a "flare-up" of lupus or possibly an infection. The doctor may need to evaluate the child when fever develops. There are a variety of medications used to treat lupus. Many children are treated with a non-steroidal anti-inflammatory drug (NSAID) which helps reduce inflammation and joint pain. Antimalarial drugs such as Plaquenil are sometimes used to treat the skin rashes of lupus. Steroids are sometimes necessary to treat lupus. The goal when using steroids is to use the lowest possible amount needed.

As symptoms improve, smaller and smaller doses are gradually given until the medication can be stopped altogether. When high doses of steroids are used over a long period of time, side effects can occur such as eye problems, and a decrease in the growth of the child. Giving steroids every other day helps to lower the chances of harmful side effects. Some other drugs used mainly when kidneys are affected by lupus are Cytoxan and Imuran. These work to control the reaction of a child's immune system so that it causes less harmful effects on the body. Recent studies have shown that these drugs can be used safely in children and can control the more serious effects of lupus on internal organs. A chronic illness like lupus will of course have a large effect on a child's life.

Often a child misses school during "flares". It is important to make contact with the school as soon as possible and stay in contact during the absent period. A school counselor or nurse can make arrangements to help the child. Some children may need home or hospital tutoring while others may be able to do make-up work on their own. This depends on how sick they are and how long they will be out of school. Because lupus symptoms come and go, arrangements may need to be made before a child is sick so that tutoring can start right away if needed. Many rheumatology centers that treat lupus have a health care team that includes a social worker and a nurse who can help the family with getting services needed for their child. Often children with lupus (like those with other chronic conditions) should have an Individualized Education Plan (IEP) .

This is an evaluation of all of the child's educational, psychosocial and physical needs which is done by a "study team" in each school district. The IEP identifies what each child needs in order to function well at school. Every child in the USA is entitled to this plan due to a government law (PL#94 -142). Children with lupus are also entitled to vocational planning services in order to prepare for school or job training for their future employment.

Each state has an Office of Vocational Rehabilitation (OVR) which offers career counseling that takes into account a child's physical abilities. Any illness in a family member is likely to cause reactions in other members of the family. These can help or hurt successful coping. There is often an increased burden on the family when caring for a sick child. This can also mean lost work time for parents and added financial problems due to medical expenses. Studies have been done to measure the effects on a family of a child with chronic illness. The families that coped best were those that did not place their child in a sick role, and so did not limit the child's activities in daily life.

Families based around a good quality marriage, and with good support from family, friends and/or religious groups cope better with a chronic illness. Support groups for parents of children with lupus exist through the AJAO (American juvenile Arthritis Organization) which is a part of the Arthritis Foundation. The large number of teenage and young adult women with lupus raises some special concerns. A major problem for teenagers is the change in appearance, often on the face, caused by lupus.

The characteristic rash and puffiness of lupus, or the acne caused by steroids cause the child to wonder, "How do I look to the world?" It is important to discuss this as openly as possible with the teenager, as these issues are a major source of stress and worry. Concerns about sexuality and pregnancy are also often uppermost in teenagers' minds when they become ill. Standard oral contraceptives which contain the hormone estrogen may cause an increase in symptoms of lupus and therefore are not recommended.

Sometimes the mini-pill, which contains only the hormone progesterone, is safe in lupus patients. Diaphragms and condoms are fine, and all of these options should be reviewed and discussed. It is recommended that a woman not become pregnant during an active period of lupus. Lupus has not been found to affect the ability to get pregnant, but miscarriages are more common when the disease is active. It is very possible to become pregnant and have a healthy baby, but careful planning with the doctor for the best time to get pregnant is advised. There are many obstetricians available who specialize in "high risk" pregnancies. Because of the many issues and adjustments necessary for a teenager with lupus, individual counseling may be necessary and can be helpful to some adolescents.

Support groups are an ideal way for teens to get the peer support and acceptance they need. Teens who attend these groups report a decrease in feelings of isolation and are better able to accept their illness. There has been a remarkable improvement in the prognosis of children with lupus during the past thirty years. This has happened due to improvements in diagnosis and treatment. Most importantly, children and their families need to seek careful and competent medical treatment and to cultivate the support of their health care team, their school and their community.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.

Dental Problems and the Lupus Patient

2006-06-09T21:45:00.000-04:00

Dental Problems and the Lupus Patient
Jay A. Denbo, DDS

COMMUNICATION, SELF-EXAMINATION, and PREVENTION are the keys to controlling dental problems for the lupus patient. Lupus patients have specific dental problems because of the disease process and the medications needed to control lupus symptoms.

Communication

Communication between patient, physician, and dentist is essential. Lupus patients should visit the dentist at regular intervals, usually every two to six months. The patients must tell the dentist about their current and past medical history. The dentist should also be supplied with a complete list of medications the patient is taking. The dentist also needs to know the dosage and any side-effects of all the medications. The patient's physician should in turn be made aware of any dental problems and the proposed treatment.

If the lupus patient needs dental surgery, open communication between physician and dentist is especially important. The surgical procedure may well require a change in the dosage of any steroid medications and may require prophylactic (preventive) antibiotics if the patient has certain kinds of lupus heart disease (the kind that affects the valves of the heart). In such cases it may be necessary for the dentist to consult the patient's physician to decide on the best management. Post-operative examinations for the lupus patient must be more frequent and extend over a longer period of time than would be the case for the non-lupus dental patient.

Self-examination

Self-examination of the mouth should regularly be performed by lupus patients. Periodontal disease, which causes the greatest amount of tooth loss in adults and affects almost everyone, usually does not cause pain and may not give warning until significant tissue breakdown has occurred. However, there are signs and symptoms of periodontal disease which the patient can detect with self-examination. There are also certain procedures the patient can perform to prevent and help control periodontal disease. Periodontal disease is a group of inflammatory conditions which affect the gums (gingiva) and supporting bone around each tooth. The most common periodontal disorders are gingivitis (inflammation of the gingiva or gums) and periodontitis (inflammation affecting the bone under the gingiva). The presence of any of the following signs and symptoms may indicate the presence of gingivitis.

Bleeding gums: Gingiva which bleeds on eating or brushing teeth, or bleeds without any obvious cause.
Swollen gums: Enlarged gingiva which is not bound tightly around each tooth.
Red Gums: Gingiva which is red in color. Dark colored gingiva due to naturally occurring melanin (the substance which colors the gums) is not an indication of inflammation.
Sensitive gums: Gingiva which is painful to brushing. Untreated gingivitis can progress into the tissues under the gingiva and cause the bone which supports the teeth to become weakened and resorb.

Periodontitis is a form of dental disease which is marked by bone loss and will eventually lead to loosening or loss of teeth. It is usually painless and may have the same signs and symptoms as gingivitis. If any signs or symptoms of gingivitis or periodontitis are noted, the tupus patient should tell his/her dentist. A dentist can accurately diagnose and treat periodontat disease.

Prevention

Prevention is the best treatment for dental disease. The only way to prevent periodontal disease is by effective tooth brushing techniques. Putting toothpaste on a toothbrush and swishing the brush around your mouth for 15 to 30 seconds once or twice a day is not effective tooth brushing. Tooth brushing must clean all five surfaces of each tooth. The most critical area of the tooth to clean is immediately adjacent or next to the gingiva or gums. Therefore, the junction between the gum and the tooth should be very carefully brushed. The area between the teeth cannot be cleaned by a toothbrush. Dental floss, dental tape, rubber tips, special (interproximal) brushes and Stimulators are used to remove the dental plaque which is deposited between adjacent teeth. It should take approximately three minutes to brush your teeth thoroughly. Plaque which causes dental caries (cavities) and periodontal disease accumulates on all tooth surfaces and must be removed daily. Any areas of gingival sensitivity, tooth sensitivity, or gingival bleeding require effective brushing or the sensitivity and bleeding will get worse. If it hurts or if it bleeds, it should be brushed harder.

Lupus patients should check the inside of their mouths regularly for any red or irritated areas. If such areas are noticed, these should be brought to the attention of the physician and dentist. Approximately 25% of lupus patients have these kinds of oral problems, which are usually accompanied by a skin irritation or facial rash. Oral problems in lupus are also found on the lips and on the tissue inside the cheeks. Patients with active oral problems should not use denture powder or denture paste to hold in removable dentures. if toothpaste irritates the mouth, baking soda and water should be substituted for it.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.
With COMMUNICATION, SELF-EXAMINATION, and PREVENTION, the lupus patient can keep dental problems under control.

Avascular Necrosis of Bone and Lupus

2006-06-09T21:35:00.000-04:00

Avascular Necrosis of Bone and Lupus
Marvin E. Steinberg, MD

Avascular necrosis of bone (AVN) is a disorder in which an avascular (lacking in blood supply) area of bone undergoes necrosis (dies). AVN is not common, but it is encountered in a certain number of patients with lupus. The area most often affected is the hip and in particular the upper part of the thigh bone (the femoral head) which makes up the ball of this ball-and-socket joint. This problem primarily affects younger adults. In 50 to 60 percent of cases it occurs in both hips. The goal for treatment of AVN is to save the natural hip joint if possible and not to have to replace the affected femoral head with an artificial joint. In order to accomplish this, early diagnosis is very important. Other bones may also be affected by AVN, but much less often than the hip. (These include the knee, the shoulder, and rarely the small bones of the wrist and the foot or ankle.) The following discussion will, therefore, focus on the hip.

Causes

Many things can cause AVN. One of the most common causes is a fracture through the thigh bone which results in tearing of the blood vessels that nourish the femoral head. AVN can also occur without a fracture or other major injury. These same blood vessels can be blocked by blood clots (thrombi or emboli). They can also be blocked by fat droplets which form in the circulating blood, by clumps of abnormal red blood cells (as in sickle cell disease), and occasionally by nitrogen bubbles (which form in individuals such as deep sea divers who work under different atmospheric pressures). AVN can also result from inflammation or narrowing of the arteries, and from increased pressure outside the blood vessels. it is frequently seen with excess use of alcohol. A very small percentage of people who use corticosteroids for prolonged periods of time will also develop it. Why this is so is unclear. It may be that certain individuals are especially sensitive to steroids and form circulating fat droplets as a result. Although some authorities are of the opinion that the blood vessel changes in lupus itself can result in AVN, there are almost no cases of AVN reported in patients with lupus who have not been treated with steroids.

Within a few hours after the blood circulation to the bone is blocked, the cells in the bone marrow and the bone begin to die. The body then makes an attempt to repair the damage. During this repair process the pressure within the bone begins to build. In approximately 80 percent of cases, a steady progression of damage takes place. The dead area of bone becomes weakened and begins to collapse. This starts in the soft bone underneath the surface of the joint. Eventually, however, the joint surface itself becomes involved, and actual flattening of the normally round femoral head results. The cartilage of the joint is subjected to abnormal stresses and undergoes gradual degeneration (breakdown). Since this cartilage gets its nourishment from the fluid within the joint and not from the blood supply of the underlying bone, it remains alive for quite some time after the initial degeneration begins. In the later stages, cartilage damage ultimately leads to advanced degenerative arthritis involving the entire hip joint.

Clinical Course

At first the patient with AVN has no symptoms. Later the buildup of pressure within the femoral head may cause a mild and vague type of pain. Once collapse of the joint surface occurs, the pain usually increases dramatically and may become severe. Some patients however have only mild discomfort in spite of significant involvement of the joint. As the process continues, most patients develop a limp and note some decrease in motion of the hip joint.

Early on, routine x-rays in AVN are entirely normal. As the softer bone below the joint surface begins to collapse, a fluid filled space is left which shows up as a dark semi-circle or "crescent sign" on the x-ray. Later actual flattening of the normally round femoral head may be seen. Thinning of the cartilage of the joint results in narrowing of the joint space. This will show on an x-ray. Still later the characteristic picture of advanced degenerative joint disease is seen on the x-ray and may be accompanied by complete loss of the joint space, the formation of spurs (or osteophytes), large cysts, and areas of dense bone.

There are other special imaging techniques which are frequently used to diagnose AVN in addition to plain x-rays. Often these techniques show clear changes in the bone before such changes can be detected on the routine x-ray. These include bone scans, computerized tomography (CAT) scans, and magnetic resonance imaging (MRI). During the last few years, MRI has proven to be the single best method for the early diagnosis of AVN. The MRI does not use x-rays but uses magnetic waves to show very early changes in the marrow of the bone, bone itself, and other tissues in and around the hip joint. It is a very safe technique and is both very sensitive and very specific for AVN.

Treatment

In 80 or 90 percent of cases of AVN, the condition will progress even if we restrict activities and limit weight bearing on the joint by having the patient use canes or crutches. For this reason, it is usually best not to try to treat the hip "conservatively" if it is important to save the joint. (The shoulder and knee do better with "conservative management" than the hip does, and this is usually the treatment of choice for these joints.)

Although there is no completely effective method for preventing early AVN of the hip from progressing, there are a number of surgical procedures which give better results than conservative medical management. These should be very seriously considered during the early stages of AVN, before there has been any collapse of the joint. They include drilling small or large holes to relieve the pressure, bone grafting, osteotomy (cutting across the bone to change its position), and electrical stimulation. There have been some encouraging reports about the use of electrical stimulation, but this technique is still in a somewhat experimental stage. Another new procedure which seems quite promising is the use of a bone graft containing its own blood vessels which can be attached to the arteries and veins in the region of the hip. Although none of these surgical treatments gives consistent or completely satisfactory results, progress is being made, and the use of one of these techniques will usually give better results than non-operative management, as mentioned earlier.

Once there has been definite flattening of the femoral head, these early surgical interventions are seldom of much value. At this stage, patients should be treated conservatively with measures designed to decrease their pain and preserve function of the hip. Such measures include restricted activities, use of a cane, and non-steroidal anti-inflammatory drugs or mild pain relievers.

When pain and disability have progressed to the point that conservative methods of treatment are no longer effective in relieving symptoms, reconstructive surgery should be considered. There are two commonly used procedures: The replacement of only the upper end of the femur (the "ball") with an "endoprosthesis" and the replacement of both the ball and the socket with a "total hip replacement". Of these two operations, the use of a total hip replacement seems to give the most consistent and durable results. It leads to complete or nearly complete relief of pain and relatively normal function in 90 to 95 percent of patients. With modern techniques and devices these artificial hips should continue to function for at least ten to fifteen years in the majority of patients. In the younger individual they will rarely last a lifetime, but when they do wear out, they can be replaced.

Summary

AVN is a rather uncommon complication in patients with lupus and is probably related to the need to use corticosteroids rather than to the underlying disease itself. The area most frequently involved is the hip and specifically the femoral head. Although the condition may heal spontaneously (without any treatment) in 10 to 20 percent of diagnosed cases, most of the time it will get worse without specific treatment. The goal is therefore to diagnose this condition as early as possible and to use any one of a number of surgical procedures which may prevent or slow down its progression. Although the results with the present surgical methods of treatment are not as good as we would like, they are generally better than simply relying on symptomatic treatment. We remain optimistic that some of the newer methods will give better results. When the condition has become fairly advanced, such preventative measures are of little value and patients are treated symptomatically for as long as possible. When sufficient pain and disability have developed, reconstructive surgery is usually needed. Of the available measures, total hip replacement gives the best results. This procedure can allow patients to resume a relatively normal lifestyle with little pain or disability.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Lupus and the Eye

2006-04-24T21:42:00.000-04:00

Lupus and the Eye
Stephen H. Sinclair, MDErnesto L. Collazo, MD
Systemic lupus erythematosus is a disease which can involve every organ in the human body. It is no surprise, therefore, that it can involve not only the eyes but also the orbit (eye socket) around the eyes and the eyelids that house them. It may even involve the nerve connections from the eye to the brain. Before we can discuss eye problems in lupus, it is first necessary to understand the structure of the human eye. The eye can be compared to a photographic camera.

The camera contains a lens which focuses an image onto the film, located against the back wall of the camera. The eye is arranged in a similar fashion. It is protected by the eyelids which act as windshield wipers, spreading tears over the surface of the eye (the cornea) to keep the cornea moist and clear. The lids have a smooth inner lining known as the conjunctiva. The conjunctiva is essentially a membrane which also covers the front portion of the eyeball preventing objects such as dirt and contact lenses from getting behind the eye. The front surface of the eye is covered by the cornea, a transparent window similar to the crystal of a watch. Behind the cornea is the iris which may be of various colors (brown, blue, green, etc.) and acts similarly to the diaphragm of the camera by controlling the amount of light that enters the eye.

Behind the iris is the lens which, like the lens of the camera, focuses the image on the retina at the back of the eye. It is not composed of glass but rather is a bag of clear protein. The eye's outer wall or sclera, the white of the eye, provides structural strength. The inside layer of the eye, known as the retina, is the light sensitive layer that is similar to the film of the camera. It lies flat against the back inside wall of the eye. The nerve impulses which it produces are transmitted to the visual part of the brain through the optic nerve in the back of the eye.

Skin and Eyelids

Lupus can produce inflammatory lesions (or sores) of the eyelids. The lesions may be small and individual ("discoid") or they may b more widespread causing swelling, irritation and redness of the eyelids, and sometimes loss of the eyelashes. Over time these lesion, if untreated, may cause scarring which can distort the eyelids and prevent them from performing their function of blinking and wiping the front of the eye. Treatment usually consists of systemic (taken internally) or topical (applied locally) corticosteroids to decrease inflammation.

Conjunctiva

The conjunctiva may also become inflamed causing redness and tearing, although this does not occur often. The tear glands are located in the conjunctiva. When lupus affects the conjunctiva, causing inflammation and scarring, it may reduce tear production resulting in dryness of the eye (which is often associated with mouth and vaginal dryness and is known as sicca or Sjogren's Syndrome). With reduced wetting, the cornea can lose its clarity and become roughened and irritable as well as prone to infection (ulcers). Rarely inflammation of the sclera or iris may also occur. Again systemic or topical (eye drops in this case) corticosteroids are used to reduce the inflammation. In addition artificial tear preparations and ointments can be used to reduce the dryness and subsequent irritation. Infection or ulcers of the cornea require prompt and careful treatment with antibiotics.

Retina

By far the most common effect of systemic lupus erythematostis on the eye is injury to the blood vessels that supply the retina. Small retinal hemorrhages can result, as well as occlusions or blockages of the smaller retinal blood vessels. This causes damage to the retinal tissue due to lack of an adequate blood supply. Infrequently, larger arteries may also be occluded leading to loss of function in large areas of the retina. When this involves the center of the retina, known as the macula, a large area of central vision is lost. The optic nerve may also suffer from blockages of the blood vessels which supply it, resulting in loss of vision in the entire eye. In rare cases the blockages of blood vessels in the retina may be so severe and widespread that the retina may, in response to the blockages, attempt to develop new vessels. This process is termed "neovascularization." Such new vessels grow abnormally out from the surface of the retina into the central vitreous gel (the substance that fills the inside of the eye). They are prone to bleeding when stretched or pulled by the gel, resulting in severe vision loss. Although these abnormal blood vessels are rare in patients who are on adequate treatment for lupus, all lupus patients should be followed with periodic eye examinations because the blockages and abnormal vessel growth may occur without the patient noticing symptoms. If blockages or neovascularization are detected early, they may be treated with a laser. This procedure is usually done as an outpatient.

Central Nervous System

Involvement of the central nervous system is uncommon but, when it occurs, may be due to blood vessel inflammation and blockage within the brain. The resulting damage may affect the visual system in a variety of ways. These include defects or gray areas of the visual field in one or both eyes, eye movement abnormalities which can lead to double vision, disturbances in the function of the pupils, and damage to the optic nerve leading to loss of vision in one eye.

Complications of Systemic Drugs

Treatments for reducing the systemic inflammation of lupus (inflammation which can affect any area of the body) are vitally important to the well-being of the patient and also lessen the effect of inflammation on the eye, eyelids, or orbit. Some of the drugs which are used in the treatment of systemic lupus, however, can have side effects on the eyes. The long-term use of steroids, either systemic or topical, may cause the formation of cataracts. A cataract is a change in the lens of the eye which can affect the ability of the lens to focus. It can produce opacities or defects that create glare and haziness of vision. Most mild cataracts are treated with corrective eyeglasses or special lens filters. When the glare or haziness become such a problem that patients can no longer see well enough to go about their daily lives, then the lens with the cataract can be removed surgically and replaced with an artificial lens which restores the vision.

In addition, corticosteroids can lead to the development of' glaucoma, a condition in which an increase in the pressure within the eye causes damage to the optic nerve and an irreversible loss of' vision. This condition can be treated with medications to lower the pressure within the eye, therefore preventing further damage to the optic nerve. Periodic eye examinations are vital to the early detection and treatment of glaucoma. The use of antimalarials has become widespread in the treatment of lupus patients. One of the first of these, chloroquine, was found to have a significant toxic effect on the eye. Over the years the drug has a tendency to accumulate in the layer between the retina and the sclera, and in some cases this leads to severe destruction of the central retina with central vision loss.

A drug similar to chloroquine is more commonly used today. It is called hydroxychloroquine (Plaquenil). This drug is apparently not as toxic and vision loss is extremely rare, even with relatively high doses taken over several years. Lupus patients who are on Plaquenil are still checked carefully with periodic vision and field testing and evaluation of the retina. If toxic side effects to the retina do occur, they are detected early, and the drug can be stopped without any further retinal damage and no injury to vision.

Lupus and Anemia

2006-04-24T21:41:00.000-04:00

Lupus and Anemia
Douglas B. Cines, MD

Anemia is the condition in which an individual has less than the normal number of red cells in the blood. Anemia occurs frequently in patients with lupus and some of these patients may require special attention. How do you know if you are anemic? Patients with anemia may have no symptoms or may feel fatigued because not enough red blood cells are available to carry oxygen to muscles and other tissues. However, similar feelings of fatigue may be caused by lupus itself. Occasionally, patients who are anemic may feel dizzy, experience a rapid heart beat or chest discomfort. These symptoms are more likely to develop following exercise when the body's demand for oxygen is increased.

If you experience increasing fatigue or related symptoms, your physician may check to see if you are anemic. Your doctor may use the term "hematocrit" to describe the number of red cells in your blood. The hematocrit refers to the proportion of whole blood occupied by the red cells themselves. Usually about 40% of the blood is composed of red cells, but in patients with anemia, this proportion may be reduced to 20-30%.If you are found to be anemic, your physician may order other tests to find out the cause. There are four common causes of anemia that patients with lupus experience.

Anemia of Chronic Illness. Normally, as red blood cells age, approximately 1% of them are removed from the blood each day. The bone marrow, where all blood cells are made, replaces these cells with new ones. When lupus is active, many patients develop anemia because the bone marrow produces fewer red blood cells than are needed. The exact reason why fewer cells are produced is unknown, but in some way this is related to the tissue inflammation caused by lupus. In most patients, this form of anemia is mild and produces no symptoms. This form of anemia does not respond to changes in diet, vitamins, etc., but improves when the lupus has been controlled.

Iron Deficiency Anemia. Sometimes anemia is caused by iron deficiency. Iron deficiency is also a common cause of anemia in healthy women who do not have lupus. It usually results from loss of iron over many years due to normal menstrual bleeding. Medications used to treat lupus, such as aspirin, may cause irritation of the stomach lining leading to bleeding and iron deficiency. If you are anemic, you should get a blood test to determine if you are iron deficient before taking iron pills, because iron has no beneficial effect if the anemia is caused bv another problem.
Anemia of Kidney Disease. Some patients with lupus develop kidney damage. The kidney makes a hormone called erythropoietin that is needed by the bone marrow to produce red blood cells.

If the kidney is damaged and does not produce this hormone, the bone marrow will produce fewer red blood cells. Your doctor will be able to tell by urine and blood tests if kidney damage is responsible for the anemia. If kidney function improves with treatment, the production of erythropoietin increases and the anemia improves.

Autoimmune Hemolytic Anemia. Anemia may also result from the production of an antibody that binds to an individual's own red blood cells. 'I'his form of anemia, called autoimmune hemolytic anemia (AHA), occurs in approximately 5% of patients with lupus. An antibody is a type of protein made by the body, usually in response to infection. Patients with lupus commonly produce antibodies that bind to their own cells. In some cases, these antibodies bind to the red cells. These red cells coated with antibodies are quickly removed from the blood and destroyed by white blood cells, called macrophages, that normally destroy antibody coated viruses or bacteria as part of the body's defenses against infection. If the production of new red cells cannot keep up with this destruction, the patient becomes anemic.

Your physician can tell if you have autoimmune hemolytic anemia by looking at your blood under the microscope. If you do, the physician will see both red cells whose shape has been altered by these macrophages and a large number of newly produced, young red blood cells. The diagnosis of AHA is confirmed using the direct antiglobulin test, or Coombs' test, which measures both the presence and type of antibody bound to the red cell. The treatment of AHA depends upon its severity. If the anemia is mild, there may be no need for treatment. In one variety of uncommon AHA, called "cold-agglutinin disease", simple measures such as preventing exposure to cold may be sufficient. Periodic transfusions of warmed blood are often useful for patients with cold-agglutinin disease who have mild symptoms.

Patients with the more common, "warm-antibody" type AHA often require additional measures to correct the anemia. In most cases, the doctor will recommend the drug, prednisone, which both decreases the rate of red cell destruction and the amount of antibody produced. Sometimes prednisone must be taken for several weeks before its effect becomes apparent. Patients who do not respond to prednisone, or who require high doses of prednisone to control the anemia, may be advised to have an operation to remove their spleen. The reason why this procedure is so often recommended is that in many patients, most of the red cells to which antibodies have become attached are trapped and destroyed by macrophages within the spleen. In some patients the hormone, Danazol, or other drugs such as cyclophosphamide (Cytoxan) may also be recommended.

Transfusions are used only as a temporary measure since the transfused red cells will also quickly become coated with antibodies and will be destroyed. AHA can be managed Successfully in practically all patients with systemic lupus, but the specific recommendations for treatment vary among different patients for several reasons. First, the doctor must be sure of the diagnosis. Other causes of anemia may also be present and may contribute to the anemia. Second, the doctor must determine if the anemia is actually contributing to the patient's symptoms, since one of the major reasons to treat a patient is to improve how she/he feels. Third, the amount of medicine needed to treat AHA may vary from time to time. Patients vary widely in their ability to tolerate anemia and their ability to tolerate each form of treatment. Therefore, treatments must be custom tailored to fit each individual.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

2006-03-05T14:46:00.000-05:00

Neurological Complications of Lupus
Terry D. Heiman-Patterson, MD

LEARNING ABOUT LUPUS: A USER FRIENDLY GUIDEFrom the Lupus Foundation of Delaware Valley, Inc.Edited by: Mary E. Moore, Ph.D., M.D., Carolyn H. McGrory, MS, RN, Robert S. Rosenthal, M.D.

Systemic lupus etythematosus (SLE) is a multisystem disorder that frequently affects the nervous system. In fact, of all the connective tissue disorders, lupus has the highest incidence of nervous system complications. These neurologic complications may occur in 30-75 percent of patients. In order to understand the variety of complications, one must have some notion of what makes up the nervous system.

The nervous system contains the brain, brain stem, spinal cord, nerves outside the brain and spinal column (peripheral nerves), and muscle. The brain has centers for speech, movement, sensation, and also more complex functions such as thinking, memory, and personality. The brain relays commands and messages to other areas of the nervous system and receives information from these areas, as well. The brain blends together all this information so that persons can interact with their environment. Between the brain and the spinal cord is the brain stem. The brain stem contains nerve cells that control the muscles of eye movement, facial expression, speaking, swallowing, hearing and balance. The spinal cord contains nerve cells that supply impulses to and from the muscles (i.e., innervate the muscles), and that receive sensory information from the skin and joints.

Muscles attach to bones and when they contract they enable a person to move. Information travels from the brain to the brain stem and spinal cord where contact is made with the nerve cells, (i.e. the cranial and peripheral nerves) innervating muscles of the head and arms and legs. Sensory information is also relayed from these areas through contacts in the spinal cord and brain stem to the sensory centers of the brain. There are several possible ways that lupus can damage the nervous system. First, the blood vessels of the brain may themselves be damaged, leading to poor blood flow, to death of brain tissue (strokes), or to bleeding (hemorrhage). There may be an immune system attack on the nervous system because of antibodies that are produced. These can cause problems directly by attacking nerve cells (antineuronal antibodies) or indirectly by causing blood clots in the brain (lupus anticoagulants or anticardiolipin antibodies).

When lupus affects the nervous system, the type of symptom and the distribution of complaints will depend on what area of the nervous system is involved and on what sensory and motor pathways are damaged. When there is more general involvement of the brain, a patient may demonstrate personality changes and psychiatric disorders. Actual psychosis (severe mental illness) can occur, or mood changes such as depression, or even an unnatural feeling of well-being (euphoria) can occur. Other patients may experience anxiety that is out of proportion to the problems they are experiencing. in all these psychiatric disorders, thinking and memory are normal. However, some patients may actually have loss of intellectual skills (i.e., dementia), or experience confusion and altered consciousness, (sleepiness and even coma). Although confusion and altered consciousness may occur because of direct involvement of the brain by lupus, it can also occur because of drugs used in the treatment of lupus (i.e. steroids) or because of other complications from lupus (i.e. infection, kidney failure).

In these instances, withdrawal of the drug, treatment of the infection, or management of the other systemic complications will help to clear the confusion and improve alertness. Another complication due to brain involvement is having seizures or convulsions. These can occur in up to 20% of patients. In patients with kidney failure due to lupus, the rate of seizures rises to almost 50 percent. Lupus can also cause strokes in which there is a sudden onset of neurologic symptoms. Strokes can be due to bleeding into the brain or to death of brain tissue because of lack of blood flow. These problems occur if there is inflammation of blood vessels, clotting of blood within vessels, or not enough clotting of blood causing patients to hemorrage more readily. Patients with strokes may have a variety of symptoms, including loss of sensation on one side of the body, loss of movement (paralysis) on one side of the body, problems with verbal expression, or problems with vision.

The exact symptoms will depend on what area of the brain is damaged. Headaches can occur in 20-25 percent of lupus patients. These are most like migraine headaches that are pounding, associated with nausea and vomiting, and cause photophobia (light hurting the eyes). Other much rarer complications due to brain damage relate to problems with coordinated movements. Brain stem involvement with lupus also causes a variety of symptoms. These are primarily due to involvement of the nerves to the muscles of the head and of the sensory pathways from the face. Problems with movement of the eyes can cause double vision. Inflammation of the nerve for vision can cause blurring of vision.

Sensation or movement of the face can be altered, causing numbness or tingling or weakness of the face. In addition, other symptoms of brain stem involvement include hearing problems, slurred speech, and trouble swallowing. Since the longer nerve pathways that carry motor and sensory information between the brain and spinal cord may also be damaged in the brain stem, there may be sensory and motor symptoms, not only of the head and face, but also in the arms and legs. Spinal cord involvement is very rare. When it does occur, it is called "myelopathy" and patients may not be able to move their arms and legs depending on what section of the spinal cord is involved. In addition, sensation is also changed below the area of the spinal cord that is involved. The patient may not feel pain or temperature properly. Other sensations may also be affected such as the ability to feel a vibration or to sense the body's position.

Lupus can imitate inflammation of the spinal cord that is usually due to other diseases such as multiple sclerosis. These symptoms require careful examination to determine their cause. The peripheral nervous system includes the rest of the motor and sensory nerves and the muscles. It includes the nerves that come from the spinal cord to all parts of the body. The peripheral motor nerves carry motor information (originating in the brain) from the spinal cord to the muscle. The muscle will then contract so movement can occur. The sensory fibers carry sensory information from the skin, joints, and muscle to the spinal cord, where it can then be relayed back to the brain. Damage to the peripheral nerves occurs in 10-15 percent of patients with lupus and can result in numbness (pins and needles sensation) of the feet and hands, an inability to feel a pin prick, temperature change, vibration, or change in position, and weakness. If this peripheral nerve damage is severe, patients may inadvertently hurt themselves without knowing it.

If this becomes a frequent occurrence, it can lead to infections, ulcerations, and joint problems. Sometimes individual peripheral nerves to the arm or leg can be damaged. This results in more local sensation and movement problems. Finally, some types of sensation may be more affected than others. If position sense is altered, difficulties with walking may result. This is due to an inability to sense where the feet are being placed. In addition to peripheral nerve involvement, the muscle can also be involved with inflammation or other nonspecific damage. This occurs in 5-30 percent of patients. Patients with muscle problems will experience weakness of the thighs and shoulders. They may have trouble arising from chairs or going up stairs. There will be complaints related to combing the hair and putting things up on a shelf. There may also be some muscle tenderness.

When patients with lupus are clearly weak, other factors should also be considered, i.e. steroid-induced weakness and weakness due to other problems from lupus. Kidney disease, poor nutrition, or immobility can all lead to muscle weakness. When neurologic complications begin, the first step is to identify lupus as the causative factor and make sure all other possible causes are considered (i.e., infection, anemia, kidney failure, drug toxicities). If they are present, these other causes should then be treated appropriately. On the other hand, if the complication is primarily due to lupus, then treatment of the lupus itself is necessary.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Lupus and the Kidney

2006-03-05T14:42:00.000-05:00

Lupus and the Kidney
Alan G. Wasserstein, M.D.

LEARNING ABOUT LUPUS: A USER FRIENDLY GUIDEFrom the Lupus Foundation of Delaware Valley, Inc.Edited by: Mary E. Moore, Ph.D., M.D., Carolyn H. McGrory, MS, RN, Robert S. Rosenthal, M.D.

Lupus does not always cause kidney disease, but when it does, kidney involvement can be one of its most significant problems. In all of these cases, the kidney problems are due to the production of abnormal autoantibodies. These antibodies are directed against the patient's own tissue, for example, against DNA, the material of which the genes are made. The formation of immune complexes (combinations of these antibodies joining with normal body substances) appears to set up an inflammatory reaction in the kidney.

Several serious clinical disorders can result. The kidney may leak large amounts of protein, a condition called the nepbrotic syndrome. In the nephrotic syndrome, the ability of the kidneys to remove salt and water from the body is impaired. Excess fluid accumulates in the legs and abdomen and around the eyes, causing discomfort and inconvenience. Patients can not fit into their clothes or shoes. Diuretics are usually prescribed to help eliminate the excess fluid by increasing urination. The most feared complication is kidney failure. Kidney failure may or may not be preceded by nephrotic syndrome. Minor abnormalities in the results of urine or blood tests often provide the clue that damage to the kidney exists. Such abnormalities include excessive amounts of protein in the urine, red blood cells in the urine, or a slight loss of kidney function indicated by a rise in the serum creatinine (a blood study).

Sometimes kidney damage is more severe than the clinical symptoms reveal. A kidney biopsy should be done early if such problems are suspected. If kidney damage caused by lupus is diagnosed and treated early, the treatment is usually more effective. There is no doubt that the biopsy is the best way to determine the extent of disease and the need for treatment. After the kidney has been located with ultrasound or a CAT scan, a biopsy is done with the patient lying on his or her abdomen. Only a local anesthetic is required. A tiny cylinder of kidney tissue is withdrawn with a special needle. This tissue is examined under a microscope. Since there is a risk of bleeding from the kidney, the patient must stay in the hospital for observation for 12 hours or overnight following the biopsy.

A treatment plan is developed on the basis of the biopsy. Mild abnormalities are present in practically all lupus patients, even those with no other clinical or laboratory evidence of kidney involvement. These do not require treatment. Corticosteroids, such as prednisone, have been the basis of treatment for a long time. Their use may result in some improvement in lupus kidney disease, but the improvement is not as long lasting as we would like. (They are very effective, however, for other lupus problems such as arthritis, rash, fever, etc.) A significant advance in the treatment of lupus-related kidney disease has been the use of immunosuppressive drugs, specifically Cytoxan (cyclophosphamide).

Immunosuppressive drugs reduce the production of antibodies which cause inflammation. Cytoxan is usually given in combination with prednisone. In many cases it has led to clear improvement in lupus kidney disease. This has been demonstrated by observing improvement in biopsy specimens, reduction in the amount of protein in the urine, and increase in kidney function. Cytoxan is a toxic drug, however, which has many side effects. These include a decrease in the white blood cell count which makes a patient more susceptible to bacterial and other infections. It can also cause bleeding from the bladder (hemorrhagic cystitis), hair loss, sterility, and, years later, some patients may even develop cancer from its use. Sometimes kidney failure occurs very rapidly in patients with lupus (acute renal failure). in these cases, extremely large doses of corticosteroids and/or Cytoxan given intravenously (pulse therapy) may be helpful.

Patients who do not respond to treatment may progress to kidney failure, requiring dialysis or a kidney transplant. Although these are unfortunate outcomes, both dialysis and kidney transplants may have favorable results. Patients who have kidney failure which is advanced enough to require dialysis develop a natural immunosuppression and their lupus improves. As a result, dialysis patients with lupus do as well as other dialysis patients without systemic disease. Similarly, there has been success with kidney transplants in lupus patients. For the best outcome, a patient's lupus should be in remission at the time of the transplant. Kidneys for transplantation may come from either relatives or organ donors. In order to minimize the chance of rejection, the tissue type of the donated kidney should match the tissue type of the patient as closely as possible.

Cyclosporine, a new immunosuppressive drug given to kidney transplant patients, has significantly improved the success rate of transplants. Once the new kidney has been accepted by the body, recurrence of lupus in the kidney is rare.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

The Skin, Sunlight and Lupus

2006-01-22T09:30:00.000-05:00

LEARNING ABOUT LUPUS: A USER FRIENDLY GUIDEFrom the Lupus Foundation of Delaware Valley, Inc.Edited by: Mary E. Moore, Ph.D., M.D., Carolyn H. McGrory, MS, RN, Robert S. Rosenthal, M.D.

The Skin, Sunlight and Lupus
Warren R. Heymann, MD

Sensitivity to the sun from exposure to ultraviolet light (either sunlight or artificial sources) is one of the symptoms the American College of Rheumatology uses to diagnose systemic lupus erythematosus. This chapter will review the effects of lupus on the skin and will explore what is known about the relationship between ultraviolet light and lupus. it will also discuss what the lupus patient should do to avoid the damaging effects of the sun.

The cause of lupus is unknown. Many factors may be involved in the clinical picture of lupus in a particular individual. Exposure to sunlight may play an important role either in the start of lupus in some patients or in causing flares of existing disease in others. It is important to realize that many lupus patients are not negatively affected by the sun. For this reason lupus has been called a "photoaggravated" disorder or one which may be, but is not always, made worse by the sun. Lupus represents a wide range of disease. At the less severe end of the range is discoid (chronic cutaneous) lupus.

Generally, patients with discoid lupus have few problems which affect the whole body. Most patients with discoid lupus have skin problems on the head, scalp, and neck. First these appear as red, swollen plaques (a raised circular patch of skin) while later the patients experience thinning of the skin, scarring, changes in skin color and "plugging" of the hair follicles.

Aggravation of discoid lupus by the sun is quite variable but may occur in up to 50% of patients. The more severe form of lupus is systemic lupus erythematosus. Symptoms affecting the skin are the "butterfly" rash on the nose and cheeks, hives, a net-like pattern of redness on the arms and legs ("livedo reticularis"), dilated blood vessels of the finger and toe nail folds ("periungual telangiectasias"), hair loss and ulcers of the lining (mucous membrane) of the mouth, nose, or the vagina. Sun sensitivity may occur in lupus after even mild sun exposure.

It is also possible to find sun sensitivity in a less severe form of lupus called subacute cutaneous lupus. The skin findings in this condition may resemble psoriasis or have a ring-like (annular) shape. These lesions are found in areas exposed to sunlight (i.e.. face. upper chest, upper back, and sides of the arms). Systemic findings are mild and are usually limited to joint and muscle pains. it should be emphasized that because lupus involves a range of symptoms, an individual may have any of the skin or systemic features.

Although it is evident that lupus may be negatively affected by ultraviolet radiation, little is known about how this actually occurs, Most experts agree that ultraviolet B radiation, the "sunburn" rays, (290-320 nm) are most important. There is some evidence, however, that ultraviolet A radiation, the "tanning" rays, (320-400 nm) may also result in sun sensitivity reactions. The theory behind this is that ultraviolet light may alter the DNA (deoxyribonucleic acid) of the uppermost layer of the skin (epidermal cells) so that DNA causes an immune response. DNA is the material of which genes are made. DNA which is not exposed to the sun's rays does not cause this immune response, while sun-exposed DNA does.

It is also possible that sunburn may act as a non-specific trauma or injury. Other environmental agents such as cold, heat, and wind may also aggravate lupus or cause it to begin in a previously well person. Individuals affected by lupus should learn to protect their skin from the sun. By practicing common sense measures, the sun need not be strictly avoided and the out-of-doors may be enjoyed. The midday sun should be avoided (between 11 A.M. and 2 P.M.). Use of a broad-rimmed hat or staying in the shade is encouraged, and the use of sunscreens should become a daily habit. A sunscreen with a sun protection factor (SPF) of at least 15 is recommended for the summer months.

Remember that snow reflects sunlight and if the individual likes to be outside throughout the year, use of sunscreens should be continued in all seasons. Tanning parlors are absolutely taboo for the lupus patient. It is apparent that ultraviolet rays may affect all forms of lupus, especially systemic lupus erythematosus. Although it is not understood exactly how this occurs, it is clear that by fairly simple precautions the damaging effects of sunlight on patients with lupus may be diminished or avoided altogether.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Genetics and Lupus

2006-01-22T09:27:00.000-05:00

Genetics and Lupus
Raphael J. DeHoratius, MD

The most frequently asked question about lupus is, "Is lupus inherited?" The answer to this question is both "yes" and "no"! Genes, those parts of our individual make-up that we inherit from our parents, are important in the development of lupus, but the answer is much more complicated than a simple "yes". Estimates are that from four to six or more genes must be combined for a person to inherit a susceptibility to acquire lupus.

It is nearly impossible to inherit all the genes necessary to develop lupus from a single parent, since an individual's genes come from both parents. This is one very important reason why it is unusual for lupus to occur in multiple generations of a family. If only some of the lupus genes are inherited, a person may not have lupus but may test positive for some of the immunologic tests, such as the antinuclear antibody (ANA).

A positive ANA occurs in up to one third of healthy family members of lupus patients.Genetic information is coded in chromosomes which are located in humans in a tiny part of the center (nucleus) of each cell. Humans have 46 chromosomes, each of which is made up of thousands of genes. Each chromosome is divided into a long and short arm. Most of the important genes in systemic lupus erythematosus are located on the short arm of chromosome #6. The genes on chromosome #6 have many complex functions.

Some regulate complement components (proteins important in acute and chronic inflammation and in the formation of immune complexes). When these complement components are missing, a milder form of lupus, which usually lacks kidney involvement, may develop. Complement genes are important but they are not the whole story in the development of this form of lupus.

For example, many susceptible individuals who lack these genes for complement never develop lupus at all.Another important area on the short arm of chromosome #6 is the HLA (human leukocyte antigen) region. It is located next to the area for complement genes. The HLA area has been very thoroughly studied since it is used to match donors genetically to recipients for organ transplants. it is further divided into smaller regions called HLA-A, HLA-B, HLA-C, HLA-DR, HLA-DQ. In lupus patients there is an increased frequency of the HLA genes called Al, B8, Dr2, or Dr-3 and DQ1.Associations between genes and diseases such as lupus are established by comparing lupus patients to a normal or "control" population.

Particular HLA markers found in white lupus patients (on whom the majority of studies have focused) have not been shown to be present in black patients or Japanese patients with lupus. The reasons for these differences are not clear. There may be other as yet unknown genes or there may also be important genes on other chromosomes which play a part in making a person susceptible to developing lupus.

The newest research methods now being used to study genetics come from the field of molecular biology. They are redefining the way in which we look at the genetics of disease. When methods of molecular biology are used to study the HLA system in various diseases, we are finding that what looked like a specific HLA type, by our current standard tests, in reality is slightly different and Much more complex. This methodology should lead to new important findings, both in genetics and in lupus.

Another way of studying the genetics of lupus is by looking at families in which lupus occurs in more than one member. Familial cases are reported in approximately 10% of the lupus population. The most thoroughly studied family association is between twins. If one of a pair of identical twins (twins with exactly the same genes) has lupus, the other will develop it more than two thirds (69%) of the time. If a fraternal or non-identical twin (a twin with genes no more similar to his twin than to any other brother or sister) has lupus, the other twin has only a 5% chance of developing it. It is obvious that genetics are important, since the frequency of developing lupus is so much higher in identical twins than in fraternal twins when one of the twins already has lupus.

Genetic factors cannot be the only answers, however, or susceptible identical twins would both develop lupus 100% of the time. Environmental factors, therefore, must also be important. It appears that some people are genetically predisposed to develop lupus but then must be exposed to the proper environmental triggers in order to have the disease.In summary, heredity is involved in the development of lupus but it is rare to have more than one family member who has lupus.

Much is known about the genetics of lupus, yet even more needs to be discovered. It is only through careful family studies using molecular biological techniques that the answer to the genetic riddle of systemic lupus erythematosus and the relationship between heredity and environment will be solved.

=========================================================== This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

LEARNING ABOUT LUPUS: Laboratory Tests in Lupus

2006-01-07T10:44:00.000-05:00

LEARNING ABOUT LUPUS: A USER FRIENDLY GUIDE
From the Lupus Foundation of Delaware Valley, Inc.
Edited by: Mary E. Moore, Ph.D., M.D., Carolyn H. McGrory, MS, RN, Robert S. Rosenthal, M.D.
Laboratory Tests in Lupus
Burton Zweiman, MD

Most physicians with a lot of experience in the care of lupus patients can make the diagnosis of systemic lupus erythematosus based upon certain symptoms and findings when they take a medical history and do a physical examination. Sometimes, however, these physical symptoms or clinical clues are not well defined early in the course of lupus and, therefore, certain laboratory tests are useful in making the diagnosis.

Many people ask, "is there a laboratory test that can diagnose lupus in all patients?" Despite much research in this area, the answer must still be "No". There is no one test which can do this. The laboratory test performed most often is the immunofluorescence test for antinuclear antibodies (ANA). This is often simply called the ANA test. It has almost entirely replaced the older LE cell test which is more time consuming to perform and is less accurate. The ANA test is a very sensitive one. Over ninety-five percent of untreated lupus patients have high ANA levels in their blood.

A small number of individuals have an unusual lupus disorder with a negative ANA test, a rash and a high sensitivity to sunlight. For most people, however, an ANA test with negative results in several repeated tests performed in a good laboratory is strong evidence against the diagnosis of systemic lupus. The ANA test is not specific for lupus. This means that people with other diseases can also have a high ANA. Elevated blood ANA levels are found in a number of other disorders including some with symptoms similar to lupus. Sometimes this leads to confusion and a diagnosis of lupus is made in someone with another disorder just because the ANA test is abnormal. Much research has been done to expand and refine the ANA test in order to help find a test more specific for lupus. Although the ANA levels in the blood are generally higher in untreated lupus patients than in patients with other diseases, this is not always so.

A diagnosis of lupus, therefore, cannot be made only on the basis of a high ANA. It is helpful to know in diagnosing lupus that the ANA is actually a group of antibodies directed against different parts of cells within our bodies. in laboratories with special equipment, these antibodies can now be detected individually. Some of these individual antibodies are very specific for the diagnosis of lupus. Some of these are listed below:

Anti-ds (double-stranded) DNA antibodies. These are substances which react to the material which makes up the genes found in cells. Double stranded DNA also plays a key role in the growth and multiplication of these cells. increased blood levels of antidsDNA antibodies are found in about 70% of lupus patients, and found very infrequently in other disorders. However, the dsDNA used in the test must be prepared very carefully so that it does not contain single stranded DNA. Antibodies against this single stranded DNA are commonly found in disorders other than lupus, and can confuse the results of the test. Anti-dsDNA antibodies are more commonly found in lupus patients whose disease is active, particularly when the disease involves the kidneys or the central nervous system.

Anti-Sm (Smith) antibodies. These antibodies are named after the patient, a person named Smith, in whom they were first found. They react with another part of the cell nucleus, the central part of the cell, and are found in about 30% of lupus patients. Anti-Sm antibodies are found very rarely in disorders other than lupus.

Anti-Ro (or SS-A) antibodies. These are found in some lupus patients, particularly those with a certain type of sun-sensitivity rash. If a pregnant lupus patient has anti-Ro antibodies, it is more likely that her baby will have a certain type of congenital heart disorder.

Anti-Ro antibodies are also found in a disorder called Sjogren's syndrome. Sometimes lupus can occur together with Sjogren's syndrome. Antihistone antibodies. These antibodies are found in the blood of many lupus patients and are directed against a protein which is frequently attached to the DNA (the material of which genes are made) within the cell nucleus. These antibodies are of particular interest because they are also found in the blood of some people who have high ANA tests caused by taking certain medications. Recent evidence suggests that the antibodies in lupus patients react with different histones than do the antibodies in these individuals with high ANA tests related to medications.

Anti-RNP (ribonucleoprotein) antibodies. These antibodies occur commonly in lupus and some other disorders. Certain individuals (mainly women) develop a group of symptoms that do not point strongly to lupus or to one of the other connective tissue inflammatory diseases, but rather to a combination of several of these diseases. This has been called "mixed connective tissue disease" or "overlap syndrome". Anti-RNP antibody levels are often very high in this disorder.
Several other antibody tests are often performed when trying to make a diagnosis of lupus because they help tell the difference between lupus and certain other diseases. Antiscleroderma 70 (Scl70) antibody is found in one form of scleroderma. Anticentromere antibodies are found in another form of scleroderma. Anti-PM-1 and anti-Jo-1 antibodies are found in poliomyelitis. Rheumatoid factor (RF) is often found in the blood of patients with rheumatoid arthritis, a condition which can sometimes be confused with lupus.

Rheumatoid factor may also be found in the blood of about 20% of lupus patients, and in a number of other disorders. The levels of certain non-antibody proteins in the blood, called complement components, may be low in lupus patients, particularly when the disease is active. Low complement levels are not very helpful in diagnosing lupus, however, because they can be found in other diseases as well. Complement levels are more useful both in following the disease activity and the response to treatment of individual lupus patients. There are many laboratory tests which measure and identify whether or not specific organ systems are affected by luptis. These can be very valuable in the care of the individual lupus patient.

These will be discussed in other chapters dealing with involvement of individual organ systems in lupus but several examples are described briefly here.Kidney involvement in lupus can be determined by measuring the amount of protein found in the urine during a 24 hour period. The 24 hour urine collection can also be used to find out if there is any decrease in the filtering function of the kidneys and to check for growth of bacteria if an infection of the urinary tract is suspected. If enough bacteria grow when the urine is cultured, these bacteria can also be tested to help determine the best way to treat the infection.

In certain situations it may be necessary to perform a kidney biopsy to find out what type of involvement of the kidney is present. This involves inserting a needle into the kidney under local anesthesia (somewhat like having your jaw numbed to have dental work performed). One or more small pieces of kidney tissue are removed and looked at under the microscope.

Involvement of the central nervous system occurs commonly in lupus, but is often difficult to diagnose. The cerebrospinal fluid, (fluid which is present around the spinal cord and the brain), is abnormal in about 50% of those patients with central nervous system involvement in lupus. X-rays and magnetic resonance imaging (MRI) signals are now also being used to help diagnose involvement of the nervous system in lupus. Other blood tests can also be helpful for lupus patients. Anemia or a low blood count is frequently the result of disease activity. Levels in the blood of leukocytes (white blood cells), and platelets (small blood cells which are part of the clotting mechanism) may also be lower in active lupus. This happens so often that these particular abnormal findings are considered one of the criteria on which the diagnosis of lupus is based. Occasionally the platelet count is so low that a bleeding and bruising tendency may be present. In some individuals with lupus, there are abnormal blood proteins that appear to be antibodies against something in the platelets.

Platelets are involved in normal blood clotting. When these abnormal proteins are present certain blood clotting tests are abnormal (a lupus anticoagulant is detected) or the test for an antibody (anticardiolipin) is positive. What is surprising is that individuals with these antibodies do not have a bleeding tendency.

If anything, there is a tendency to develop blood clots. Women with these antibodies may have spontaneous abortions (miscarriages) if they become pregnant. This is discussed in more detail in Chapter 18 on Lupus and Pregnancy. These antibodies can also result in a false positive test for syphilis. An individual with such antibodies who is tested for syphilis when applying for a marriage license or job, or during routine admission to the hospital, may be told that the test is positive even though they do not in fact have syphilis. The reason for this is that these antibodies against platelets closely resemble the antibody that produces the positive test for syphilis.

Even though these patients do not have syphilis, their blood reacts to the test. Fortunately, this false-positive test can now be distinguished from a true-positive test for syphilis by another, more specific test for syphilis. If a person has repeated normal results using current very sensitive ANA blood tests, this is very strong evidence against a diagnosis of lupus. There is no test which is as specific for lupus as we would like. Results obtained from a group of tests can help the experienced physician distinguish lupus from other conditions with similar symptoms. In some ways they can also help to measure the response to treatment and whether or not disease activity is increasing.

Repeated measurements of certain blood tests may also help determine whether problems with the lupus patient or the fetus are developing during pregnancy. Intensive research is leading to new tests of the immune system. Hopefully, these will lead to easier diagnoses and improved treatment.

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This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Systemic Lupus Erythematosus LEARNING ABOUT LUPUS: A USER FRIENDLY GUIDE

2006-01-07T10:38:00.000-05:00

Systemic Lupus Erythematosus LEARNING ABOUT LUPUS: A USER FRIENDLY GUIDE From the Lupus Foundation of Delaware Valley, Inc.
Edited by: Mary E. Moore, Ph.D., M.D., Carolyn H. McGrory, MS, RN, Robert S. Rosenthal, M.D.

Systemic lupus erythematosus (SLE or lupus) is a disease which can affect many parts of the body, can be both acute and chronic, and can cause many different symptoms. The disease can range from very mild to very severe. Among adults, nine females will have lupus for every one male. Lupus most commonly affects people between the ages of twenty and forty and occurs, therefore, most frequently in women during their child-bearing years. Three times as many black as white women are affected. Children and teens can also get lupus.

During the first ten years of life girls will have lupus three to seven times more often than boys. (Childhood lupus is the subject of Chapter 15.)The cause of lupus is not known. The immune system, which is nature's way of protecting us from infection and cancer, works improperly in patients with lupus. Certain white blood cells, the T lymphocytes, aid in control of the immune system. In lupus, these cells fail to fulfill their regulatory function and the immune system becomes active when it is not supposed to. What starts this has not been discovered.

It appears that some foreign invader, some trigger or triggers from the outside must enter the body and set this process in motion. For years the search has gone on in vain to find a virus which could act as such a trigger. We do know that sunlight and some chemicals appear to trigger lupus in some patients, though not in all. We also know that some people have an inherited tendency to develop lupus. Something in their genetic makeup makes them especially sensitive to an environmental trigger. (Chapter 4 discusses recent advances in the genetics of lupus.)To aid in the diagnosis of lupus, the American College of Rheumatology has listed various criteria (guidelines based on symptoms and laboratory tests) to be used in identifying the disease (Table 1). The list contains the problems that are most typical of lupus as compared to other similar diseases.

It is not meant to include all, or even the most common problems a patient with lupus may experience. Persons with lupus most frequently suffer from fatigue, fevers, muscle and joint aching and stiffness, swollen glands, and generalized feelings of being unwell. None of these are listed as criteria for diagnosing SLE, however, because they occur in many other diseases as well. The first of the criteria involve the skin. The best known of the skin problems in lupus is the "butterfly" rash. This is a red rash over the cheeks and the bridge of the nose (the malar area). Several other skin-related problems which commonly occur are sun sensitivity, loss of hair, red plaques (slightly raised patches of skin that have a definite border) associated with scaling and plugging of the hair follicles ("discoid" rash), hives, dryness and ulceration of the mucous membrane (mouth, nose, and vagina), and dilated and broken blood vessels. (These are discussed in more detail in Chapter 5 and referred to in Chapters 12 and Chapter 14.) The circulation of blood to the skin and the underlying tissues is sometimes temporarily decreased in lupus, this is known as Raynaud's phenomenon.

The decrease is most commonly caused by cold temperatures but can also result from psychological stress. The tips of the fingers, the tips of the toes, and occasionally the nose and the ears are affected. These areas first turn white, then blue, and finally, as the circulation returns, red. If the circulation is reduced over a long period of time, the skin may break down and ulcerations (sores) appear.Almost all lupus patients have joint pains at some time during their illness, and many have joint inflammation (swelling, warmth, redness, pain) or arthritis. The type of arthritis associated with lupus is similar to that seen in rheumatoid arthritis but is usually not as severe and does not cause a wearing away of the bone with resulting deformity. It most commonly affects the small joints of the hands, the wrists, the knees, and the feet. Sometimes patients with lupus, especially those on corticosteroids, have involvement of the bone due to a loss of blood supply.

When this occurs in the bone near a joint, degenerative arthritis may result. (See Chapter 13.)Serositis is the inflammation of the delicate tissues which cover certain internal organs and line body compartments. It is quite common in lupus, most often occurring as inflammation of the covering of the lung and the lining of its compartment in the chest (pleuritis), and as inflammation of the covering of the heart (pericarditis). Movement of the involved tissues may cause chest pain, and the doctor can often hear a characteristic "rub" when listening over the inflamed areas with a stethoscope. Abdominal pain in lupus is sometimes caused by inflammation of the covering of the intestines and the lining of the abdominal cavity (peritonitis), and can imitate pancreatitis, diverticulitis, appendicitis, etc. Fluid sometimes accumulates as a result of serositis and may have to be withdrawn by a needle. In the case of pericarditis, an operation to make an opening in the covering of the heart (a "Pericardial window") may be necessary to relieve pressure on the heart from this fluid.One of the most feared complications of lupus is involvement of the kidney.

It is present to some degree in about 50% of cases. It can vary from very mild involvement which causes the patient no symptoms, to severe disease leading to kidney failure and the need for dialysis or kidney transplantation. Doctors detect early kidney problems by discovering protein or blood cells in the urine. They frequently ask the patient to collect 24 hour urine samples so as to be able to make better estimates of the degree to which the kidney is functioning. At times it is necessary to obtain a biopsy of the kidney to look for the presence of antibodies and kidney cell damage. (Lupus and the kidney is further discussed in Chapter 6.)The central nervous system (CNS) may become involved by systemic lupus erythematosus. Such involvement may cause a variety of disorders including seizures, psychosis, paralysis and personality disorders.

Since very similar problems might be the result of infection, hardening of the arteries, or mental illness, etc., and since there is no one test for central nervous system lupus, these disorders may be difficult for the physician to diagnose. (Neurologic problems seen in lupus are discussed in detail in Chapter 7, neuropsychological testing is discussed is Chapter 8 and depression in lupus is discussed in Chapter 10.)One of the frequent disorders in lupus is a decrease in the number of white blood cells, especially the lymphocytes. Since some of the drugs used to treat lupus can also cause a decrease in the white blood cell count, monitoring the safe use of these drugs can, at times, be difficult.

The platelet is another blood cell frequently decreased in lupus. Platelets play a key role in blood clotting and having too few platelets can lead to serious bleeding disorders. Anemia, a decrease in the number of red blood cells, is almost always present in cases of active lupus. It may result from bleeding, from a bone marrow which is depressed by illness and therefore does not produce enough red blood cells, or from the destruction of red blood cells by antibodies. (More about the anemia of lupus in Chapter 11.) When the number of certain T lymphocytes is decreased, the B lymphocytes of the lupus patient are stimulated to manufacture many different antibodies. Among these are antibodies called "autoantibodies" which target the lupus patient's own tissues. The body, in essence, attacks itself. In addition to the widely known antinuclear antibody (ANA), there are many other antibodies, the presence of which aid in the diagnosis of lupus. (See Chapter 2 for a discussion of ANA, anti-DNA, anti-Sm, anti-Ro, anticardiolipin, etc.)Certain drugs in common use may cause antinuclear antibodies to develop and, therefore, cause a mild form of lupus known as drug-induced lupus.

Drug-induced lupus is characterized by muscle pain and arthritis, fever, and pleuritis. Kidney and central nervous system involvement typically do not occur. Drugs which have been associated with drug-induced lupus include antibiotics, certain thyroid medication, and drugs used to control blood pressure, seizures, and heart rhythm. Two of the most common offenders are hydralazine (Apresoline) and procainamide (Pronestyl). Because of these drug effects, it is important to know what medications a patient diagnosed as having lupus has been taking.Pregnancy is the occasion for special concern in the patient with systemic lupus erythematosus.

While pregnancy does not appear to affect the overall life expectancy of the lupus patient, lupus may flare during pregnancy and there is an increase in premature delivery and in stillbirth among lupus patients. Therefore, it is very important for the woman with lupus to seek medical help early in her pregnancy from an obstetrician who is experienced in dealing with high-risk pregnancies. (This topic is covered in Chapter 18.) Lupus may be difficult at times to diagnose and to distinguish from other connective tissues diseases and the symptoms may actually overlap with some of them. Rheumatoid arthritis involves a similar, though usually more severe, arthritis with morning stiffness.

Patients with rheumatoid arthritis may have a positive ANA in addition to a positive test for an antibody known as the rheumatoid factor. Scleroderma (systemic sclerosis) typically is associated with Raynaud's phenomenon, arthritis and a positive ANA but is characterized by the development of remarkably tight skin. Dermatomyositis involves a facial rash and may be associated with arthritis and lung disease, but profound muscle weakness also occurs. Overlapping symptoms of lupus, derrnatomyositis, and scleroderma is not uncommon. Some of these overlap cases (including those referred to as mixed connective tissue disease) respond well to treatment and do not develop significant kidney or neurologic disease.Some patients with lupus require very little treatment.

They may need only steroid skin creams or ointments and sunscreens. Other patients may require the use of simple pain medications and mild anti-inflammatory medicines such as aspirin and NSAIDS (nonsteroidal anti-inflammatory drugs) for muscle pain or arthritis. Drugs such as hydroxychloroquine (an anti-malarial medication) are used for patients with arthritis and skin disease. Adrenal corticosteroids (steroids) given by mouth are usually reserved for the more serious cases such as those with kidney or central nervous system disorders, certain blood cell problems, or serositis. To supplement steroids or to replace them when they don't work, immunosuppressive drugs, which were originally developed for use in cancer chemotherapy but have also been found to be helpful in treating lupus, are used. (These and other treatments are dealt with further in Chapter 3.)

In addition to medical treatment, there are other important considerations in the treatment of lupus. Clubs and support groups are available to offer education and psychological help. (See Chapter 19.) Physical and occupational therapy and other methods used by rehabilitation medicine can provide pain relief and can help to maintain functioning (discussed in Chapter 16). Psychotherapy and counselling can be an important addition to other forms of treatment and are available from different sources including psychiatrists, psychologists, and social workers. (These are mentioned in connection with depression in Chapter 10 and with sexual dysfunction in Chapter 17.)

Finally, one of the most helpful aspects of the treatment program is a good doctor-patient relationship. This will be the subject of an entire chapter later on (Chapter 20).Over the years, we have had more and more success in the treatment of lupus. Studies done at Johns Hopkins University in 1954 showed a survival rate less than 50% after four years. Several large studies done in the 1980's, however, revealed an approximate 87% five year survival and an approximate 78% ten year survival. A smaller study from Holland published in 1989 found an even better ten year survival of 87%! There is good reason to believe that this upward trend will continue in the future as we learn more about the disease and how to control it.
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This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

What is Lupus?

2005-09-17T14:30:00.000-04:00

What is lupus?
Systemic Lupus Erythematosus (SLE) is an autoimmune disease. Normally, the immune system protects the body, but in lupus, the immune system attacks its own body. The disease manifests itself in so many different ways, and it may invade various systems of the body.

The death rate among African American women ages 45-64 years has increased seventy five percent (75%), and more than one-third of all deaths from SLE occurred among persons less than forty five (45) years of age.

To find out more about lupus, please visit the Lupus Alliance of Michigan/Indiana

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This information is for "informational purposes" and is not meant to be used for medical diagnosis. Always consult your physician on matters such as this.

Who is Latreese Fagan?

2005-09-17T14:23:00.000-04:00

Biography of Latreese Fagan

We are thankful to God for giving us the dearest of His blessings and that was a wonderful daughter, the late Latreese Nicole Fagan. She was a strong young lady who faced many challenges, but overcame many obstacles that stood between her and her goals. Latreese was respected and admired by her family and friends.

She was determined to put her difficulties behind and her lifelong dreams ahead. She never lost her strong faith in God.

Sometimes we need reminders of special people who continue to bless our lives. Latreese had a unique personality that was a treasure to the world. She was sensitive and caring, but very independent and powerful. Latreese never put limits on herself. She just persevered to the end of her spectacular life. Latreese would want everyone to know that there is an enduring worth to every positive step you take, and that the good decisions that you make will come back to bless you one day. We, her family, pray that Latreese’s life story will inspire you to reach for the stars and to achieve the things that are so important to you.

At the tender age of twelve, our beloved daughter was experiencing many of the symptoms of the disease Systemic Lupus Erythematosus (SLE). We were unaware at the time that Latreese was showing signs of a lupus flare. This meant that her disease was no longer in remission, but it had become very active. She was experiencing chronic headaches, joint pains, rashes, low-grade fevers, fatigue and chronic infections. We took her to a pediatrician who was very perplexed with her multiple symptoms. The physician decided to have her admitted to a hospital to find a derivative diagnosis. After many questions and tests, the infectious disease doctors at the hospital gave us a diagnosis of “Systemic Lupus Erythematosus.” Our normal reaction was “what is lupus?”

Lupus is a very serious autoimmune disease. Our daughter’s immune system was producing antibodies that were attacking her healthy tissues. In other words, some parts of the immune system were no longer protecting her body, but it was harming her vital organs. We were then referred to a rheumatologist who started Latreese on a regimen of different medications and treatments. The doctors stabilized her condition on I. V. steroids and oral steroids. Latreese was never able to be drug free and she was always dependent on some types of medications. She had to endure many flare-ups that necessitated her going into the hospital numerous times, missing school, and one time she missed a whole year of school. She never had self-pity, and she always had her school assignments completed in a timely manner. Her teachers marveled at her fortitude to get her homework done knowing that many times she was not feeling well.

Latreese was eventually transferred to Mott’s Children Hospital in Ann Arbor, Michigan, due to the complexity of finding a workable treatment program. We thank God that she was able to graduate from Mercy High School in Farmington Hills, Michigan, at the top of her class. She was a Phi Beta Kappa graduate and an honor graduate! She did not graduate with her graduating class due to her missing a whole year of school, but she did not let that bother her. She was too focused on getting into a reputable college and getting her college degree. Latreese eventually was transferred to the adult rheumatology department at the University of Michigan Hospital. Many great physicians in the rheumatology and hemodialysis departments as well as other departments saw her on a regular basis. We commend the doctors, social workers, nurses, caretakers, and others for the excellent care she received.

Latreese was accepted at the University of Michigan in Ann Arbor, Michigan. She eventually declared her major in Industrial and Operations Engineering. She successfully completed each year of her schooling. She worked as a summer intern for Ford Motor Company her freshmen and sophomore years. She loved the internship program at Ford Motor Company and was seriously giving thought to becoming a permanent employee after graduation. But she wanted to diversify and accepted a summer internship position at General Motors.

It was during this internship that her lupus flared again. Her doctors were able to get her lupus under control enabling Latreese to get back in school. She was so very happy to start her senior year. But her disease eventually returned to an active stage. She fought hard to complete her senior year, but she suffered renal failure that was very life threatening. The start of hemodialysis hindered her plans to return to college, but not her strong desire to get her college degree. She maintained this desire until shortly before her death. Latreese succumbed on May 18, 2001. She remained very positive and still was in an upbeat mood about the future until her untimely death.

Latreese never knew the meaning of giving up. All of her doctors, nurses, and caretakers marveled at her strength. They witnessed and saw first hand her life and death struggles to live. She survived numerous intensive care admissions, intrusive operations, and experiments. She told us that her doctors called her a “miracle” and an “enigma.” They could not understand how she survived so long with them knowing the severity of her conditions. We saw her weakening, but she made the most of her remaining strengths. We referred to her as our “little tiger” because we could see that she was trying to conquer all of her limitations. She just refused to stay down, but fought hard to soar like an eagle.

In the long run, the lupus had harmed every internal organ in her body. It had attacked her skin, vascular system, lungs, heart, joints, central nervous system, brain, among others. Due to the damage to her lungs, she became oxygen dependent. The doctors maintained a treatment of mainly corticosteroids and immunosuppressants. The side effects of these drugs caused her additional complications such as glaucoma, hypertension, osteoporosis, cataracts, loss of hair, stomach ulcers, and more infections. She never knew what organs were going to be attacked next, but she fought each attack with a vengeance. Latreese was a strong warrior in every sense of the word.

Latreese knew that her strong faith in God sustained her during those difficult periods. She turned her anxious moments into a positive by staying in a great frame of mind. She was blessed with many talents. She jumped into her craft making with a determination to succeed. Latreese has made calligraphy cards, picture frames, padded albums, seasonal bears, designed t-shirts, socks, tennis shoes, tote bags, and handmade jewelry, among others. She also has an impressive Beanie Babies Collection. Latreese believed in looking your best at all times no matter how bad you felt. She set her goals and methodically accomplished each one.

The University of Michigan College of Engineering in Ann Arbor, Michigan, granted a posthumous Bachelor’s Degree in Industrial and Operations Engineering to our daughter. The graduation ceremony was held on April 27, 2002 at the Crisler Arena in Ann Arbor. We (her parents) adorned the traditional graduation cap and gown and walked on stage and accepted her college degree. We are very proud of our daughter’s accomplishments.

In memory of our daughter, we started the Latreese Nicole Fagan Memorial Scholarship Fund, Inc.. Latreese was the epitome of hard work, strong determination, strong faith and a strong desire to succeed. This scholarship fund is designed to assist other lupus patients who exemplify the same traits as Latreese in their desire to get their college education. Latreese realized what it meant to work hard for something and to reach the goals that she had set. We can stand up and feel so proud of our daughter’s legacy. She earned her success!

The longer-range goal of the Latreese Fagan Scholarship Memorial Scholarship Fund, Inc. is to help lupus patients not only with their academic pursuits, but some of their personal problems. This is a very complex disease to fight and it can consume every emotional and physical fiber. We have asked the Lord to bless this organization so that it can help many more lupus patients. We need your financial help to enable us to reach our goals. Your contributions are tax deductible. We need contributors who are willing to donate on a one-time basis as well as regularly.

God bless all of you,

Edgar & Bettye Fagan