Arthur Kavanaugh, MD

Disclosures

April 03, 2001

Question

What options do I have in treating a 30-year-old woman with a 6-year history of Raynaud's disease, onychodystrophy, arthritis of the hands and knees, myopathy, hair loss, and malar rash? All antibody tests have been negative and skin biopsy is inconclusive. She has been treated as having systemic lupus erythematosus (SLE).

Response from Arthur Kavanaugh, MD

The question relates to treatment in a patient for whom the diagnosis still seems to be somewhat unclear. From the description, the patient has definite arthritis of the hands and knees. However, the duration of the arthritis is not clear, nor whether the arthritis is inflammatory or noninflammatory.

Likewise, hair loss and malar rash are mentioned, but the duration of these symptoms is not. Could the malar rash represent rosacea or seborrheic dermatitis? Was the inconclusive skin biopsy from the facial rash? Is the myopathy inflammatory?

I assume that the negative antibody tests include ANA and rheumatoid factor. This is relevant, because the lack of ANA virtually excludes a diagnosis of SLE. Potential confounding factors include the possibility of lab or specimen error.

If this patient indeed has an inflammatory, chronic, polyarticular arthritis, I would favor considering a diagnosis of seronegative rheumatoid arthritis or undifferentiated connective tissue disease. With either diagnosis, treatment would be driven by the most prominent symptom, which seems to be the arthritis.

You say that the patient was treated for SLE: Were NSAIDs given? Corticosteroids? If so, what was the therapeutic response? Of course, important adjunctive therapies for the treatment of arthritis, such as physiotherapy, joint rest, and simple analgesics, should be considered.

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