What can it be?

Dear Doctor,

I am a 56 year old woman with a history of Hypothyroidism.  I  had back surgery (1974) - herniated disc, hysterectomy (1995) - ovarian cysts, Trigger thumb surgery (left hand- 2002) and carpal tunnel surgery (right hand - 2003.)

I take Synthroid, Toprol, Foltx, Fosomax, Calcium and a Multivitamin.

In January I saw my Doctor for stiffness in my hands and finger joints.  I wake up several times a night with my hands feeling "hot", stiff and swollen.  Sometimes they hurt all day, sometimes it goes away by afternoon.  In addition I had a trigger thumb on right hand and middle finger on left hand.

My Doc sent me to a Physiatrist who suggested it might be Rhuematoid Arthritis.  He ordered lab work and Occupational therapy, which I did for 2 weeks.  After 2 weeks, the therapist thought I no longer needed therapy and on the "QT" said she did not think I had RA because my hands did not have the typical appearance of the disease.

In the meantime, I saw a hand surgeon who injected cortisone into my thumb and finger.  He also mentioned that I have Dupuytren's Contracture.  The injections made a huge difference and I beleive the OT may have helped as well.

I had a follow up appointment with my Doctor this week and I recieved the results of the lab work.  Most of the labs are ok, but my Rheumatoid Factor is 15, Sed Rate is 21 and ANA is 1:80 with a  Nucleolar Pattern.

Doctor, when I look up the ANA information on the internet, most of the time, the Nucleolar pattern is associated with Scleroderma.  This scares me to death!  There are other diseases which fall into the autoimmune catagory, but the Nucleolar pattern seems to always be listed with Scleroderma.  I am wondering if the pattern sometimes occurs with other illnesses (hopefully not as serious as Scleroderma). I am hoping you have some encouraging information for me.

In your opinion, what would my next steps be?  And finally,what do you recommend I bring up in future discussions with my doctor?

Thank you for listening to me and reading my long letter.  I appreciated any insightyou can give me.

[Kevin Pho, MD]

Tough to say what it could be without examination.  An ANA of 1:80 is not considered markedly elevated.  It is true that a nucleolar pattern is associated with scleroderma.  However, this is not a specific test, since other diseases can be associated with this pattern as well.

If there is concern about scleroderma, you can consider testing for anti-centromere and anti-topoisomerase I (Scl-70).  Again, if all of these are negative, there is still a chance of disease since they are not 100% sensitive.

I would consider a rheumatology referral for further evaluation and consideration of these further tests.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[ToniL]

Thank you for your comments, Doctor.

Another question:  Does a Nucleolar pattern ALWAYS indicate some kind of disease? And if so,what other diseases fall into that category?

[Mother Margaret]

"Scleroderma affects the connective tissue. Scleroderma is a serious, progressive disease that affects the skin and connective tissue (including cartilage, bone, fat, and the tissue that supports the nerves and blood vessels throughout the body)."

It is said to be autoimmune.  There are a lot of things that are autoimmune.  It would surprise you. Even type 2 diabetes has an autoimmune aspect to it. http://home.gci.net/~blessing/pages/autoimmune.htm

And the fatigue doctors are looking for in CFS, CFIDS, 'gulf war syndrome' I believe to be autoimmune hemolytic anemia caused by 2-butoxyethanol.  I know several exposed to this chemical during 1989 Exxon Valdez oil spill cleanup and they have come down with serious rheumatoid arthritis, and lots of other things.  http://www.valdezlink.com/evos/summary.htm

However, this fatigue is foundational to what the cleanup chemical does (& it is in paint; in construction products; in mechanic's products; in products housewives use)

What to look for (an assortment of ailments):
http://www.valdezlink.com/pages/whattolookfor.htm

The USA doesn't realize that this chemical causes an autoimmune system however, http://home.gci.net/~blessing/pages/drUssery.htm

[beebug]

My rheumatologist first diagnosed me with osterarthritis.  I went in with my hands and feet hurting really bad.  My ANA was elevated and my white count is mildly low.  He has me on a lupus medicine.  I also get sores in my mouth about once a month.  I understand it is hard to diagnose Lupus.  I do not have any rashes though that accompanies lupus. All of my above symptoms are some symptoms of Lupus.

[ToniL]

Thank you for your comments and ideas.  It is difficult sometimes when you are having symptoms and the answer to why is so unclear.  All of the comments give me ideas of what to bring up when I see my doctor.  I will be seeing him next week and I assume he will take more blood work.  So far, the only real problem is my hands.  They are sore all day.  It makes it hard to do all the things I once enjoyed...like gardening and crafts.