Box 3.

Possible response to the potential referral letter to the rheumatology clinic in Box 1; Dr B

Dear Doctor,
re Patient A
Thank you for your helpful letter about Patient A. The referral was triaged through the regional referral management service to our EA (early arthritis) clinic and I reviewed her on my consultant's behalf today.
I took the opportunity to review her history in some detail. I note the previous history of gastrointestinal upset and headaches. She was also unwell with a short febrile illness while on holiday last year. As you note, she has widespread muscle pain and marked fatigue, and she also told me that she had had two aphthous mouth ulcers in the last year. Patient A also informed me that she was seen some years ago by Prof Y in London, who suggested the possibility of antinuclear antibody-negative lupus.
I think we need to exclude the possibility that she has inflammatory bowel disease and an associated seronegative arthritis. The headaches also raise the possibility of anti-phospholipid syndrome (a common cause of migrainous headaches in young women), or indeed systemic lupus erythematosus. The latter may, of course, cause myositis, which may be the explanation for her muscle pain.
The recent febrile illness is also a matter of concern, and Lyme disease, acute cytomegalovirus, Epstein–Barr virus or parvovirus are clearly possibilities. Parvovirus infection is, of course, not infrequently complicated by chronic arthritis.
I have therefore arranged for a repeat blood count, urea and electrolytes, and a full auto-antibody profile, including antinuclear antibodies, extractable nuclear antigen, anti-cardiolipin testing, anti-neutrophil cytoplasm antibodies, anti-tissue transglutaminase and Anti-C1q antibodies, as well a full panel of myositis-specific antibodies, including anti-Jo1 antibodies to exclude anti-synthetase syndrome. I am also checking her HLA-B27 status, and also for HLA-B51, to exclude Behçet's disease, in light of the mouth ulceration.
In addition, I have put in train magnetic resonance imaging of her brain and also spinal and sacro-iliac joint magnetic resonance imaging, and requested electromyography and nerve conduction studies.
I have arranged to review her to discuss the blood test results in around 3 weeks, and then again to review the imaging and electrophysiological testing in 3 months’ time (there is a considerable wait for these tests at present). If the diagnosis is still unclear at that point, I will consider a positron emission tomography – computed tomography, which is often useful in the setting of undiagnosed inflammatory conditions, such as Takayasu's arteritis.
Yours etc