Adelowo: Lupus can be effectively treated if presented early
Ahead of World Lupus Day coming up on Wednesday May 10, 2017, Femi Adelowo, a professor of medicine and consultant rheumatologist at Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos, and President, African League of Associations of Rheumatology (AFLAR) and Chairman, executive committee of World Body of Rheumatology (ILAR), spoke to PAUL ADUNWOKE on preventions, treatments and management of the disease.
What is lupus?
Systemic Lupus Erythematosus (SLE) often shortened and called Lupus is a condition belonging to the group of diseases called auto-immune diseases “body at war with itself.” There are many other conditions classified under this particular group, such as scleroderma, polymyositis, dermatomyositis and antiphospholipid syndrome. Lupus is a rheumatological condition characterised by episodes of acute and chronic inflammation in the body.
The World Health Organisation has designated May 10 every year as World Lupus Day, to draw the community’s attention to this otherwise serious and poorly understood illness. Previously said to be rare among black Africans, we now know that to be contrary. Many of the studies showing the fallacy of this assumption of rarity have been done in Nigeria. We know that SLE is quite common and many sufferers often times come to harm because of this poor knowledge.
How does this ‘body at war with itself’ originate?
Our blood is mainly fluid, but embedded in it are distinct cells, not obvious to the human eyes, but can be seen when viewed under the microscope. There are three basic types of cells. Firstly, the red blood cell, which transports oxygen hormones and nutrients from one part of the body to another. The haemoglobin in them is what ‘gives life.’ Secondly, we have the platelets. These are cells that plug our skin and any damaged organ, when there is injury and thus prevent us from bleeding to death. The third are the white blood cells, which are called the ‘soldiers’ of the body.
And like all soldiers, they are arranged into various ‘divisions’ ‘companies’ or ‘battalions.’ Each grouping has specific ammunition to fight enemy germs, which abound in the food we eat, the water we drink and the air we breathe. These white cell ‘soldiers’ are forever patrolling in our blood vessels, rounding up germs and killing them. Our body does not normally fight itself because our ‘soldiers’ white blood cells recognise what is self because of the ‘uniform’ protein the cells have.
For many reasons, medical science does not quite understand why, some of these ‘soldiers’ gang up together and become ‘rogue cells’ or ‘area boys’ attacking the body and not the germs. They carry out what some of our soldiers were notorious for in past, coups. Of course, loyal white blood cells often resist, resulting in a lot of ‘roforofo’ fight with resultant destruction and formation of immune complexes. It is these that cause inflammation and damage. Auto-immune disease can occur in any structure, including the eyes, mouth, brain, kidneys, lungs, liver and even the womb, causing recurrent pregnancy losses. The net effect is inflammation in any of these organs and damage. It could affect any organ at a time or sequentially or all together!
What age and sex does Lupus affect?
While it can affect any age group, children inclusive, it, however, has a particular predilection for women of childbearing age, twenties and thirties. It rarely affects male. Female to male ratio is about 9.1 percent.
Is it a killing disease?
Thirty years ago, that may have been true. But previous researches and ongoing researches have shown that we now have very effective medications in managing this condition. We are also able to recognise this condition early enough, apart from availability of potent antibiotics to treat infections that they are particularly prone to.
How does Lupus present among Nigerians?
The commonest presentations among Nigerian patients are recurrent fever, which is mistakenly managed as malaria, fever or typhoid over and over again without a sustained improvement. Our patients also present with joint pains and extreme fatigue. Many of them are short of blood— anaemia, and are often transfused with blood over and over again without a sustained improvement. They also present with mouth sores, sore throat, chest pain and cough. Skin rashes are common, as well as significant loss of hair, especially while combing.
A few patients will present with seizures and sometimes, psychotic behaviour and depression. Kidney involvement is particularly common among our patients and may predate other manifestation of lupus. Recurrent pregnancy losses are common, as this ‘body at war’ battle is even waged in the womb.
How is it diagnosed?
The specialist who is trained in the management of this often diverse manifestation is known as a rheumatologist. Rheumatologists in Europe and USA have solely drawn up the guidelines in the management and diagnosis. We have developed our own guidelines in Nigeria, too.
The history is important and knowledge of the disease is critical in sieving through the diverse manifestations. The affected person will be examined system by system looking out for weight loss, anaemia, skin rashes, loss of hair, fever, mouth ulcers, fluid covering the lungs and heart.
Are blood tests necessary?
Yes, blood must be taken to examine for anaemia and low white blood cells leucopoenia lymphopenia; low platelets thrombocytopenia kidney functions urea, creatinine; urine analysis and microscopy, elevated ESR.
The definitive diagnosis is from estimate of the chemicals these ‘rogue cells’ are releasing to fight the body, called auto antibodies, which include anti-nuclear antibody, extractable nuclear antigen, double stranded DNA, anti Sm, Smith, antibody, anti Ro/SSA, anti La/SSB, anti cardiolipin antibody especially useful in patients with recurrent pregnancy losses. Of course, each of the organs affected will also have specific investigations, such as the kidneys, brain, lungs and heart.
What are the misconceptions about lupus?
Probably the most dangerous misconception is that this condition is a ‘spiritual attack’ or some ‘arrow’ sent by enemies. So many lives have been lost because of these erroneous beliefs. So much delay before medical treatment is sought. So many herbal medicines have been given to patients. So many families have been destabilised because of these false beliefs. This condition occurs in the Western world and they do not spiritualise illness the way we do; and they get better!
How is Lupus treated?
The rheumatologist is trained in the management of this condition and early referral to him makes a lot of difference. If the general practitioner sees a patient with above symptoms, an early ESR will point towards the diagnosis. The ESR will be very high in the neighbourhood of 80 percent and above. He should refer immediately.
Drugs that have been used are called immunosuppressive to suppress the ‘rogue’ ‘area boy ‘coup plotter cells’. They include steroids, hydroxychloroquine, azathioprine, mycophenolate mofetil, tacrolimus, cyclophosphamide, and cyclosporin. Many of these drugs are also used in the management of cancer. But then, drugs can have multiple functions, for instance, aspirin. Of recent, a new group of drugs called biologics have been developed. These are rituximab, belimumab, and abatacept. Other modalities of treatment are intravenous immunoglobulin and plasma phareses.
Lupus patients must also use sunscreen, as excessive sunlight predisposes to attacks. They should avoid stress physically and emotionally. They should eat well and rest. Overall, we have in our custody very effective medications and we can switch from one to another, as the case may be.
Is there any hope?
Yes, life expectancy is as in normal persons. If the patient takes his/her drugs and goes for follow up, chances of survival are there.