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This case could be mistaken for arthritis or fibromyalgia. But if the patient had presented with the characteristic malar (butterfly) rash, you would have likely guessed the diagnosis: systemic lupus erythematosus.
Keep in mind, however, that only about 30% of patients present with malar rash, and it doesn’t always appear on the bridge of the nose and cheeks.
To make things even more complicated, there is no gold-standard diagnostic test for lupus. Instead, physicians consider it a diagnosis of exclusion and rely on medical history, family history, and physical exam for help. A biopsy of the kidney or skin are helpful in picking out autoimmune disease, but antinuclear antibodies picked up in blood and urine have low specificity.
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