Family physician Misses Lupus Diagnosis

This case involved a thirty-five-year-old female who developed renal failure as a result of a delayed lupus diagnosis. The patient began to frequently visit her family physician with complaints of excessive fatigue. She indicated that she could not carry out daily activities, despite sleeping nine hours a night. Her fatigue became so severe that she was let go of her job due to low productivity. The physician reassured her that fatigue was part of the normal aging process. Six months later, she began to experience diffuse joint pain impairing her ability to use her hands in knitting, cooking, and other daily activities. She also became very depressed accompanied by reduced interest in doing things she used to enjoy. Her physician told her there was nothing to be done and referred her to a psychiatrist. She was initiated on an anti-depressant, which failed to improve any of her symptoms. Over the next several months, she began to develop low-grade fever and severe joint pain. Every time she went outside in the sun, she also developed a painful rash on her cheeks which distributed in a butterfly-like pattern. Of most concern, she started noticing blood in the toilet bowl after urinating. She researched her symptoms on the internet, which suggested she may have developed an autoimmune disease, known as systemic lupus erythematosus (SLE), and Antiphospholipid Syndrome. She visited a rheumatologist for a second opinion. After collecting her blood, he told her that several antibodies were elevated, which confirmed her suspicion of lupus. Her labs also showed that her kidney function was affected. The rheumatologist recommended a kidney biopsy, which later revealed glomerulonephritis. She was immediately started on immunosuppressants.

Question(s) For Expert Witness

1. Did this family physician exhibit proper standard of care for this patient, and if not, what could have been done to prevent organ damage in this patient?

Expert Witness Response

This physician did not follow proper standard of care for this patient. Fatigue is a very non-specific finding in medical practice. However, fatigue to this extent should have been worked up for serious disease including infection, autoimmunity, and cancer. Autoimmune disease commonly affects African American women during their reproductive years. Autoimmune disease is characterized by elevated levels of antibodies which are responsible for organ damage. This physician should have, at the very least, ordered antinuclear antibody (ANA) levels, which are elevated in numerous autoimmune diseases. The additional findings of joint pain and depression should have also clued the physician into the diagnosis. Systemic lupus erythematosus is an autoimmune condition that involves the immune system attacking multiple organ systems. Of most concern is damage to the kidneys and heart. Patients should be initiated on immunosuppressants to prevent inflammatory tissue damage.