Question

What is appropriate management of a 58-year-old postmenopausal woman with suspected systemic lupus erythematosus (SLE), with anorexia  (5- to 6-kg weight loss over 7-8 months), severe myalgia, antinuclear antibodies (ANA) strongly positive, ds-DNA negative, cardiac and renal profile normal, and cerebrospinal fluid (CSF) with 15% lymphocytes?

Response from Arthur Kavanaugh, MD

As is often the case with SLE in general, and with suspected central nervous system SLE in particular, the picture can be complicated. From the information presented in the case, it might be premature to offer advice regarding the most appropriate therapy; rather, I would focus on the underlying cause of the signs and symptoms. It is mentioned that the ANA is strongly positive; although higher titers of ANA are more closely associated with SLE than lower titers, the ANA by itself is never diagnostic of SLE. With the information presented, such as the negative DNA but, more importantly, the lack of other systemic manifestations of SLE, I would question whether the patient did indeed have SLE. This is all the more important given the patient's age; although SLE can certainly develop in a 58-year-old postmenopausal woman, the prevalence is substantially lower than it is in women of reproductive age.

Also, in this case, myalgia is mentioned; however, with the normal cardiac profile it might be inferred that the creatine kinase level was normal, thereby decreasing the chances of inflammatory myositis, which might also explain some of the symptoms. Paraphrasing the bank robber Willie Sutton, in this case I would "go where the money is" and pursue the etiology of the CSF lymphoctyosis. What was the CSF protein? Were imaging studies performed? Was there anything else in the history that might explain this finding?

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