1. Teenage 'growing pains'
Growing pains, at least in the UK, is a label widely used for joint pains in teenagers and seems to cover a spectrum of rheumatology from arthritis variants through to lupus.
2. Teenage migraine
Headache, cluster headache and migraine can be encountered and a strong history of teenage migraine may be of lupus significance, either at that time or subsequently.
3. Teenage 'glandular fever'
Prolonged teenage glandular fever is a label which crops up time and time again in lupus patients and prolonged periods off school in many lupus patients is a recurrent theme.
4. Severe reaction to insect bites
This is a feature of so many lupus patients. Not only are they susceptible to insect bites but often reactions are severe and prolonged - the skin is a major organ affected by lupus.
5. Recurrent miscarriages
Lupus itself seems not to be a cause of recurrent miscarriage but where the antiphospholipid syndrome (APS) is present, recurrent spontaneous fetal loss can be significant.
6. Pre-menstrual exacerbations
Although difficult to quantify, it is believed that significant pre-menstrual disease flare is sufficiently prominent in lupus to be included in this list. All rheumatic diseases are clinically influenced by the menstrual cycle.
7. Septrin (and sulphonamide) allergy
Adverse reactions to these drugs is quite common in lupus and the clinical onset of the disease may have coincided with the use of e.g. Septrin.
Agoraphobia/claustrophobia are often present at a time when lupus disease is active. A history of these conditions can be protracted, lasting for months or even years. In many cases the history is not volunteered or the episodes are in the interim considered unrelated to lupus.
9. Finger Flexor Tendonitis
Arthralgia and tenosynovitis are common features in lupus and although not specific, the finding of mild to moderate ten-finger flexor synovitis is a useful pointer in the presence of other lupus features. It is subtly yet significantly different in pattern from other arthritic diseases.
10. Family history of autoimmune disease
As the genetics and statistics of the various autoimmune diseases become better defined, the strength of a particular family history will become more precise. The family history is important, as lupus is genetically determined.
11. Dry Shirmer's test
A 'bone dry' Shirmer's test (levels of eye moisture) points towards one of the autoimmune diseases and in the patient with vague or nonspecific symptoms is worth its weight in gold.
12. Borderline C4
Genetic complement deficiencies have been known to be associated with lupus for over three decades and in the diagnostically difficult patient, especially where a family history is present, repeated borderline C4 levels can be significant indicators.
13. Normal CRP with raised ESR
An important diagnostic aid. A very low CRP in an otherwise inflammatory situation is strongly supportive of lupus or primary Sjögren's syndrome.
In the patient with non-specific complaints and unremarkable blood tests, a borderline or low lymph count can be overlooked. It can be common in lupus and is certainly worth inclusion among minor criteria.