What causes rashes on abdomen, hematuria, diarrhea and radial nerve palsy?

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Posted on Mon, 3 Aug 2015 in Lupus
Question: I've had a year long bout with very strange symptoms. I'll go chronologically starting last May.

1. Severe skin rash on abdomen. Diagnosed as dermatitis. Resolved after 3 months.
2. Hematuria in December. I received a cystoscopy and CT scan. Normal results. Hematuria resolved in 1 week.
3. Radial nerve palsy of right hand, also in December. Resolved after 1 week.
4. From late March to early May I had horrible GI symptoms. Severe diarrhea and upper abdominal pain. I am obese, but lost 45 pounds in that time. Gastroenterologist performed abdominal US, abdominal/pelvic CT, colonoscopy with biopsy, upper endoscopy with biopsy, gastric emptying study, and various blood tests. All came back normal, EXCEPT a highly positive ANA titer of 1:1280 homogenous pattern. I was tested for anti ds-DNA antibodies, anti sm antibodies and a few others. All normal. Symptoms resolved in mid May. Have regained some weight. Currently being monitored by gastroenterologist. Cause is unknown.
5. Since early XXXXXXX I have had mild skin rash on abdomen and forearms.
6. Mid XXXXXXX until current time: Had pain in left ear/jaw. Dentist found palpable lymph node or other mass a few cm below left ear in parotid area. Subsequent visit to my doctor found palpable left supraclavicular, left axilary, left cervical, and left epitrochlear lymph nodes. Received CT with contrast of the neck and chest. Radiologist reported scan to be within normal limits. CBC found mildly elevated WBC (11.2) and mildly depleted hematocrit (39.8).

This whole last year I have been unusually fatigued and have occasional sweats.

My doctors cannot diagnose me with anything and I am worried. Are these swollen nodes and other symptoms possibly caused by an autoimmune illness? Or do I possibly have lymphoma?

Please. Any explanation will be most appreciated.

doctor
Answered by Dr. Naval Mendiratta 6 hours later
Brief Answer:
? Connective Tissue disease

Detailed Answer:
Good evening

Thank you for writing on health care magic

Well, I have gone through your history and would like to summarize the symptoms, so we can at least know where we are heading from here:

1. Rashes over the abdomen and forearms which have been intermittent but constant
2. Lymphadenopathy
3. Weight loss
4. Recurrent GI symptoms
5. Mononeuritis multiplex( Radial Nerve involvement)
5. Hematuria( ? Cause)
6. Constant fatigue

Well, with a constellation of these symptoms it looks like one disease causing multisystem problem rather than 5 different problems.

I would like to ask you a few more details before putting my diagnosis :

1. What treatment have you received so far?

2. Did they plan on doing a lymph node biopsy, cause if it is enlarged then that would give us a clue whether is it lymphoma or are the lymph nodes just reactive?
Reactive lymph nodes will go more in favor of Autoimmune etiology

3. What about your ESR and CRP. Has it been carried out yet? It will give us a clue on the sort of inflammation going on

4. IF you have any pictures of the rashes you could attach that? It would be helpful

5. What about XXXXXXX antibody??

From your history so far, I really feel it is an autoimmune process/ Vasculitic process going on. A lot of the vasculitic diseases needs clinical suspicion as there are no diagnostic markers for it. But never the less the 2 conditions can overlap. With lymphoma, it can mimic autoimmune disease again but then again we cant prove it without a lymph node biopsy

Do let me know these queries. Will try to guide you further from here

REgards
Dr Naval
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Naval Mendiratta 40 minutes later
1. I have recieved no treatment other than lorazepam for anxiety and naproxen sodium for pain.

2. I'm not entirely sure. I have my first appointment with a rheumatologist in 2 weeks, and I am supposed to follow up with my primary care doctor immediately after. I would assume he plans on a biopsy, but can't be sure.

3. ESR was very low. 3mm. CRP was at the upper limit of normal range 0.9 mm

4. I do not, but right now they are very mild. Just a collection of a few tiny red dots spaced a few mm apart.

No XXXXXXX test. Anti mitochondrial negative, IgA normal, ds-DNA normal. Ceruloplasmin normal.

IgG subclass:

Component     Standard Range     Your Value
IGG 1     382 - 929 mg/dL     426
IGG 2     241 - 700 mg/dL     263
IGG 3     22 - 178 mg/dL     23
IGG 4     4 - 86 mg/dL     24.1
IGG, SERUM     694 - 1618 mg/dL     774
TEST PERFORMED AT:
QUEST DIAGNOSTICS/NICHOLS SJC
33608 ORTEGA HWY SAN XXXXXXX CAPISTRANO, CA 92675-2042

igG
Component     Standard Range     Your Value
L-K M AB, IGG
Forgot to mention earlier that i also have 2 small thyroid nodules in left lone that are not indicated for biopsy and i have been diagnosed with Gilbert's syndrome. Total bilirubin 2.4 mg/dL direct bilirubin 0.4 mg/dL

This is all the information i have     
.
doctor
Answered by Dr. Naval Mendiratta 6 hours later
Brief Answer:
Is it connective tissue disease

Detailed Answer:
Good evening

Thanx for your reply

Well, we have a diagnostic dilemma here and we need to sort it out for you. The sort of symptoms you have described along with strong ANA positive does go in favor of connective tissue disease, more like lupus. It has been a very intermittent one but it is definitely affecting your life with fatigue and rashes.

The way to approach would be to get a Biopsy done of the lymph node. It will at least rule out lymphoma. If CT did not pick up, you can get an ultrasound of the neck done to determine the size and exact location of the node before getting it biopsied. If it comes out reactive, we know it is due to an autoimmune problem.

Secondly, You need to be on some treatment. AT least with low dose steroids and hydroxychloroquine. Considering that high ANA, this should be started to prevent the further conversion of ANA into a fully transformed disease. You can discuss it with your GP on starting hydroxychloroquine as it is a safe drug and can be continued by the rheumatologist.

Also get the whole ENA profile done including remaining antibodies . These have been a very few ones which may not indicate the disease completely.

I feel this should be our approach to your case.

DO let me know for more queries. Would be happy to help out

Regards
Dr Naval
Above answer was peer-reviewed by : Dr. Prasad
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Answered by
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Dr. Naval Mendiratta

Rheumatologist

Practicing since :2007

Answered : 748 Questions

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