Question

Jamie is a 26-year-old graduate student at the University of Arkansas—Monticello. She is working on her PhD in biology. As a biologist, she enjoys spending time outdoors when she can. The campus is on the edge of the woods and it is a nice place for Jamie to walk and relax to relieve the stress of graduate school. Jamie has not been able to enjoy her walks lately due to the fatigue she has been experiencing. Others have noticed that she does not have the stamina she had in the past to complete her research.

Her major professor convinces her that it would be a good idea to make an appointment to see her family physician to determine the source of her fatigue. He suggests that maybe she has a viral infection, and she just needs to get some rest. She is able to get an appointment with her family practitioner. When she arrives at the clinic, the nurse takes her blood pressure and temperature. Her blood pressure is 128/74 and her temperature is a slightly elevated 101.2°F.

She is asked to provide her family medical history and to describe any symptoms she has noticed. Jamie tells her doctor that her maternal grandmother had rheumatism and was not able to get around. Her father had prostate cancer. She cannot think of any other family illnesses. She tells her doctor that in addition to feeling run down, her knees and elbows have been aching, and she has been having trouble pipetting because of pain in her hands. She has been experiencing frequent cold sores that she has been treating with over-the-counter medication. She attributes her recent weight loss to poor eating habits as a student. On general examination, the doctor finds a rash on her upper back where she is typically exposed to the sun and swollen lymph nodes on her neck.

The doctor decides that further tests are required to rule out some obvious possibilities. He suspects an autoimmune disease such as lupus (systemic lupus erythematous, SLE) or rheumatoid arthritis (RA), a tick born disease like Lyme disease, anemia, or chronic Epstein Barr virus syndrome. Jamie is sent to the lab where blood is drawn. She is asked to return the following week to review the lab test results.

Questions:

1. What information provided by Jamie would lead the physician to suspect a systemic disease? Include any environmental or lifestyle clues.
2. Define autoimmune disease and autoantibody.
3. What environmental triggers are associated with autoimmune diseases?
4. What are some of the autoimmune diseases?
5. What are the typical signs and symptoms of autoimmune diseases using lupus as an example?
6. Using WebMD or MedlinePlus, find the criteria for the diagnosis of systemic lupus erythematous, rheumatoid arthritis, Lyme disease, and chronic Epstein Barr syndrome.
7. Why does the doctor suspect that Jamie may be anemic?

Answer 1

* cause for suspecting a systemic disease- General fatigue, rise in temperature( normalis 98.5° F, but her temperature is 101.2°F, which indicates fever), difficulty in doing routine work.

* The fact that the woods are near her campus and she is used to visit there for a relaxing walk gives clue about an insect bite born systemic infection.

* Autoimmune disease- It is a disease condition in which body's immune system mistakenly act against body itself.  

* Autoantibody- It is the antibodies produced during an autoimmune disorder, which mistakenly act against normal , healthy body tissues or proteins. Example for an autoantibody - anti nuclear antibody.

* Environmental triggers broadly include all the factors surrounding a person and it contributes to 70% of the disease precipitating causes. 30% predisposition comes from genetics.

Atmospheric pollutants, dietary protein- allergens like milk protein and wheat protein, poor digestion due to stress, certain bacteria and virus infection are the main environmental triggers for autoimmune diseases.

* some autoimmune diseases are- coeliac disease, rheumatoid arthritis, type 1 diabetes, systemic lupus erythematosus, graves disease, multiple sclerosis etc

* Typical signs and symptoms of autoimmune diseases with reference to SLE - low grade fever, malaise ( general weakness and fatigue) , muscle and joint pain, anaemia, mouth ulcers, swollen lymph nodes, skin rashes, affections of cardiovascular system, kidney and nervous system.  

* Diagnosis -

1. SLE - Anti nuclear antigen (ANA,) testing and anti- extractable nuclear antigen ( AENA) testing.

2. Rheumatoid arthritis- X ray, MRI, ultrasonography, blood test for rheumatoid factor (RF), anti citrullinated protein antibodies (ACPAs) , testing of synovial fluid.

3. Lyme disease- From history of exposure to tick infested area, presence of erythema migrans( the red rash), joint pain, fever and malaise, laboratory test like ELISA and western bloating for detecting antibodies against Borrelia bacteria, PCR test to detect bacterial DNA, rarely neuro imaging techniques.

* Epstein barr virus disease - clinical signs like fatigue, enlarged lymph nodes of neck region, skin rashes, enlarged spleen, blood smear examination for mononucleosis, blood test for detecting antibodies, viral nuclear antigen etc

* In this case , the history of maternal grandmother having rheumatoid arthritis is significant with the symptoms shown by Jamie, but the prostate cancer has no relevance in this situation. She shows early symptoms which is suggestive of an autoimmune disorder like rheumatoid arthritis or SLE, so differential diagnosis is required.

* Her age group ( 10to 30 years) is predisposive to Epstein barr virus infection, and she shows all the initial symptoms, so differential diagnosis is required.

* History of she going into the woods or even proximity of woods indicates a chance of tick born lyme disease. She shows all the typical initial symptoms of lyme disease, so a differential diagnosis of lyme disease is required.

* Jamie may be suffering from anaemia also, since loss of stamina, fatigue and muscle aches can result from anaemia, and there is history that her eating patterns are not healthy due to the stress from extensive study pattern of Jamie. So chances of anaemia should also be ruled out.