This is not an uncommon question that I frequently get asked.
Unfortunately some fibromyalgia patients are erroneously diagnosed as having
lupus, a potentially dangerous condition that affects about 2 in every 1000
people. Through your doctor and educational literature and support groups, you
have learned lupus patients can have involvement of almost any system of the
body including severe involvement of the kidneys, heart and brain. This is scary
information; even though you know that only a minority of lupus patients have
such a severe course.
problems encountered by most lupus patients are joint pains, muscles pains,
fatigue and skin rashes. It is not unreasonable to assume an increased level of
fatigue and increasing joint pain heralds a severe flare of your lupus that may
even progress to life-threatening internal organ involvement. Such thoughts are
anxiety-provoking and depressing; they can cause sleepless nights. Both you and
your doctor may be convinced that your accelerating symptoms represent a lupus
flare. You may be put on prednisone or the dose of your steroids may be
increased. But before you and your doctor jump to conclusions, consider the
possibility that you could also have fibromyalgia.
Fibromyalgia is a common condition of
musculoskeletal pain, sleep disturbance and fatigue, that affects about 20 out
of every 1000 persons. Recent studies have shown that approximately one-third of
patients with lupus also have fibromyalgia. It is important to understand that
the fibromyalgia in these patients develops after the lupus has become
well established. It is extremely rare for a fibromyalgia patient to later
develop lupus - I have only seen this in 2 patients in 30 years of practice as a
Rheumatologist. Although fibromyalgia patients have widespread body pain which
arises from their muscles, they often feel that the pain is originating in their
joints. In addition to widespread pain, other common fibromyalgia symptoms
include a decreased sense of energy, poor sleep and varying degrees of anxiety
and depression (related to a changed physical status). To complicate matters
further, other medical conditions are commonly associated with fibromyalgia.
These include irritable bowel syndrome, tension headaches, migraine, irritable
bladder syndrome, premenstrual tension syndrome, cold intolerance (including
Raynaud’s phenomenon) and restless leg syndrome. This combination of pain and
multiple symptoms may lead physicians to pursue an extensive course of
investigations, which are often frustratingly normal. In fact, there are no
blood tests or x-rays which reliably diagnose fibromyalgia. In order to diagnose
fibromyalgia, a physician must take a careful history and perform an examination
which focuses on specific local areas of tenderness. These locations are called
tender points. As many of the symptoms of fibromyalgia are similar to those
experienced by lupus patients, there is a natural concern that the symptoms of a
fibromyalgia flare could be the underlying lupus picking up steam. Ultimately,
the treating physician has to make a call on these increased symptoms. In
general, lupus patients who are undergoing a flare have other findings; such as
evidence of true arthritis (usually with joint swelling), skin rashes, sores in
their mouth, fever, hair fall or evidence of specific organ disease such as
pleurisy or microscopic amounts of blood and protein in the urine. Furthermore,
in active lupus, blood tests such as the sedimentation rate often become
elevated, the white count (particularly the lymphocyte subset) becomes depressed
and there is often an increase in the level of anti-DNA antibodies. None of
these findings are a feature of fibromyalgia -- thus the distinction between a
flare of fibromyalgia and a flare of lupus should not be too difficult if the
problem is approached systematically. The American College of Rheumatology have
developed criteria for diagnosing lupus - just as they have for diagnosing
fibromyalgia. To have a definite
diagnosis of lupus you must have 4 or more of the following features:
|1. Malar Rash
||Rash over the cheeks,
typically spares naso-labial folds (not
2. Discoid Rash
to sunlight, resulting in the development of or increase in skin rash.
4. Oral Ulcers
the nose or mouth, usually painless.
arthritis involving two or more peripheral joints (arthritis in which
the bones around the joints do not become destroyed) - observed by a
or pericarditis (inflammation of the lining of the lung or heart).
7. Renal Disorder
protein in the urine (greater than 0.5 gm/day or 3+ on test sticks)
and/or cellular casts (abnormal elements the urine, derived from red
and/or white cells and/or kidney tubule cells.)
(convulsions) and/or psychosis in the absence of drugs or metabolic
disturbances which are known to cause such effects.
anemia or leukopenia (white blood count below 4,000 cells per cubic
millimeter) or lymphopenia (less than 1,500 lymphocytes per cubic
millimeter) or thrombocytopenia (less than 100,000 platelets per cubic
millimeter). The leukopenia and lymphopenia must be detected on two or
more occasions. The thrombocytopenia must be detected in the absence of
drugs known to induce this abnormality.
test for antinuclear antibodies (ANA) in the
absence of drugs known to induce a positive test/
stranded anti-DNA test, positive anti-Sm test, positive antiphospholipid
antibody such as anticardiolipin, or false positive syphilis test (VDRL).
It is important to realize
that the symptoms of fibromyalgia do not respond to corticosteroids such as
prednisone or even immunosuppressive agents, such as azathioprine,
methotrexate or cyclophosphamide. These are powerful and important drugs in
the treatment of lupus but are often associated with undesirable side
effects. Thus, making a distinction between fibromyalgia symptomatology and
lupus symptomatology is of great practical relevance in deciding what
medications to use.
In my experience, most lupus patients are
often shocked to hear that they also have fibromyalgia, and in many cases
dont like being given that diagnosis. They somehow think that
fibromyalgia is not a
real disease and detracts attention away from the realities of having lupus.
I can understand these thoughts. However, knowing that some of your
musculoskeletal pain is fibromyalgia-related and not lupus should also be
good news -- as who wants to have lupus flare? Lastly, there are some
"lupus" patients who have only fibromyalgia, but on testing were
found to have a weakly positive ANA. They were incorrectly diagnosed as
having lupus on the basis of the blood test. There is an increasing
recognition among lupus specialists that this false diagnosis scenario is
not at all uncommon.
Also see: What
is an ANA ?
Concurrence of Lupus and FM Laboratory
tests in the diagnosis of lupus