An Army Sergeant With Mysterious Pain: Crack the Case

Christopher L. Tracy, MD

Disclosures

November 10, 2014

Testing for Antinuclear Antibodies

On the basis of the previously discussed principles of appropriate use of diagnostic screening—and in the absence of specific symptoms related to systemic lupus erythematosus or other connective tissue disease—it is highly likely that this result is false positive. Screening for ANA in patients with nonspecific musculoskeletal symptoms is not recommended and is considered not reflective of high-value care. In addition, current evidence does not support serial testing to follow immunologic disease activity.[10]

Nonspecific symptoms found in connective tissue diseases that are reported in many patients with fibromyalgia can pose a challenge in diagnosing FMS, even though it is a well-known clinical entity. Many studies have investigated the significance of ANA frequency and its clinical importance in patients with FMS. For example, one study of 160 female patients found that 11.5% of them tested positive for ANA but did not develop a connective tissue disease by a mean follow-up of 3.3 years.[11]

In another study of 232 individuals with fibromyalgia, ANA positivity was found in 11.8%—similar to the frequency in the healthy control population.[12] However, nonspecific symptoms associated with connective tissue diseases (Raynaud phenomenon and photosensitivity) were more common in the FMS patients than in controls. Overall, patients with fibromyalgia reported more frequent xerostomia, xerophthalmia, and oral ulcers than did healthy controls.

In a cohort of 450 fibromyalgia patients, the probability of developing a connective tissue disease within 1 year of diagnosis is 0.0027%, which is comparable to the incidence of systemic lupus erythematosus in the general population (0.005%).[13] The risk of developing autoimmune diseases was independent of ANA status in this group of fibromyalgia patients.

The presence of low-titer ANA in the case patient is not considered significant in the absence of specific symptoms that are related to a connective tissue disease, such as arthritis; serositis; blood count abnormalities; distinctive rashes; specific renal abnormalities; or neurologic findings.

The patient would like to avoid taking additional medications for treatment and asks whether she should look into acupuncture as a treatment for her chronic pain syndrome.

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