Systemic diseases associated with uveitis

Many cases of uveitis are caused by diseases that affect different body systems. For many patients, uveitis is not an isolated pathology, but a symptom of a systemic disease. These patients may present with various symptoms throughout the body that could suggest the presence of a systemic disease, if they have not previously been diagnosed with one. Therefore, the medical evaluation of uveitis cases, in addition to ocular examination, includes an extensive patient history taking and evaluation of body systems.

Systemic diseases can be infectious or autoimmune. Infectious systemic diseases can be diagnosed by laboratory tests. However, systemic autoimmune diseases cannot always be diagnosed in the same way. The diagnosis of many of them is largely based on the presenting symptoms of the patients. Today, successfully diagnosing autoimmune diseases is a challenge for modern medicine because, among a myriad of complexities, symptoms do not always conform to a typical, easily deduced pattern. Some of the challenges that can make diagnosing systemic autoimmune diseases difficult include:

Episodic nature of symptoms

Many of the symptoms mediated by autoimmunity are episodic. Thus, they may not be present at the time of medical evaluation. Severe symptoms, which prevent the normal continuation of lifestyle, usually prompt patients to seek medical help. Less severe symptoms, especially those that can be relieved with simple remedies or over-the-counter medications, are not usually the reason patients seek medical help. The relatively benign nature of these symptoms and their easy management may cause patients to pay insufficient attention to them and even not report them during their medical evaluations. These symptoms may heal without sequelae or complications, thus relieving patients but delaying their diagnosis. On the other hand, it is common for symptoms associated with autoimmune inflammatory processes to appear during times of high stress or hormonal changes, so patients may associate the appearance of their symptoms as a product of their emotional states. For these reasons, it is very important to keep a record of your symptoms and take pictures of them.

Symptoms vary in severity

Symptoms associated with systemic autoimmune diseases often vary in severity. Sometimes they are very intense, but other times they seem to be milder. These diseases usually cause very severe main symptoms, which are the reason patients seek help, but they also cause other symptoms throughout the body that may be less severe. In addition, the same symptom may appear in different parts of the body. Some systemic autoimmune diseases have initially mild symptoms. However, their recurrences may progressively increase in intensity, especially if the disease is not adequately treated. Some of these diseases are difficult to diagnose during their initial stages, especially when their manifestations appear to be relatively benign. Their diagnosis is usually made once more characteristic but more severe symptoms have occurred.

Symptoms are generalized and very uncharacteristic

The symptoms associated with systemic autoimmune diseases can be diverse and affect different parts of the body. They do not all appear at the same time; i.e., the first episode of symptoms may only involve skin conditions, while a second episode of symptoms affects only the eyes and a third episode only affects the digestive system. At first glance, they do not appear to be related to each other or to suggest a possible relationship with uveitis. However, they all have one characteristic in common: they are caused by inflammatory processes. Systemic autoimmune diseases affecting connective tissue, also known as connective tissue diseases, produce symptoms in any part of the body composed of this tissue, including the eyes. So these symptoms can be confused with other diseases of an acute nature, which can be resolved with short-term treatment. For example, one of the most common symptoms associated with autoimmune diseases is fatigue or extreme tiredness. This symptom is commonly ignored, despite being one of the most indicative symptoms of autoimmunity. Autoimmune-associated fatigue is very unique and differs from normal fatigue in that it is usually severe, prevents patients from continuing their lifestyles and does not improve with rest. On the other hand, many autoimmune diseases produce very similar symptoms that overlap with each other. One autoimmune disease even predisposes to the development of another. For this reason, diagnosing them can be a complicated and lengthy process.

Uveitis may be the first symptom of a systemic autoimmune disease

For many patients, uveitis is the first symptom indicative of autoimmunity. Many of them have not previously presented with symptoms suggestive of the development of a systemic autoimmune disease. Therefore, when evaluated by a physician, many do not report having experienced other systemic symptoms. Because most systemic autoimmune diseases related to uveitis are diagnosed clinically and not by laboratory testing, reaching a diagnosis requires an extensive process in which patients are re-evaluated periodically to check for the development of any other symptoms. In addition, it should be noted that the reverse is also true: people who have been previously diagnosed with systemic autoimmune diseases are unaware of their possible ocular involvement. They form a group of patients who begin to experience episodes of uveitis even while undergoing systemic treatment for the disease with which they were diagnosed. These cases may be poorly managed if they are not promptly seen by a specialist in ocular inflammation or uveitis.

Immunomodulatory treatment: svstemic corticosteroids or chemotherapeutic agents

Immunomodulatory treatment for non-infectious uveitis not only helps to improve the symptoms of ocular inflammation, but also controls the immune system mechanisms that could produce symptoms of a systemic autoimmune disease throughout the body. Therefore, these treatments can alleviate or even prevent the appearance of symptoms that could elucidate a clearer clinical picture in some cases, but especially those that are determined to be idiopathic. This may delay the identification of a possible systemic autoimmune disease responsible for uveitis.

Misdiagnosis

Some patients have received other diagnoses for symptoms they have previously experienced. They may even have received medical assistance to manage their episodic symptoms and this has been effective. These symptoms may be diagnosed and managed provisionally (acutely), but the autoimmune disease still remains untreated, causing the same symptoms and complications to recur. This can extend over a long period of time, with patients receiving different diagnoses and treatments. In addition, it is not unusual for patients not to keep the results of laboratory tests referred to them in the past, especially if they were negative, thus complicating the elucidation of the clinical picture. In the absence of a proper diagnosis, the disease cannot be managed effectively, thus causing a deterioration in the patients' quality of life. Many systemic autoimmune diseases produce symptoms that, in isolation, cannot be used to reach a diagnosis. Only when several symptoms occur together or have been identified in the patient's history can a clinical diagnosis be reached. That is, the pieces of the puzzle finally come together and produce a complete picture. Some patients seek medical help for their chronic symptoms but receive no diagnosis. Doctors may perform some tests and, if the results are normal, show no major concern. Patients receive and internalize the message that "everything is fine" or "it's nothing serious," and go back to their daily lives. Symptoms may improve but, if they have a chronic illness that has not yet been diagnosed, symptoms may also gradually worsen. Patients normalize the experience of these symptoms, believing that it is normal or not serious. They get used to them, stop complaining stop seeking medical help and stop reporting them. It is not until new symptoms begin to develop or become extremely severe, painful or disabling that they finally seek help and receive a diagnosis.

Delayed medical help

People who develop chronic illnesses usually delay seeking medical care for a variety of reasons. Among them is the stoic quality of tolerating symptoms in order to fulfill their obligations, responsibilities and duties; such as studies or work. Many people in this position often have no viable alternatives and are forced to fulfill their responsibilities or obligations at the expense of their health. In addition, they may also come from backgrounds characterized by chronic stress. Surprisingly, many people who have been diagnosed with chronic illnesses have symptoms for a long time before seeking medical help. It is important to recognize this phenomenon as a public health problem, without blaming the patients, in order to develop new alternatives that benefit the health of all.

Synchronicity of symptoms

Symptoms of systemic autoimmune disease are not always present when uveitis is active. This makes it difficult to elucidate a clearer clinical picture because they may be absent at the time of medical evaluation. Patients may not even report the symptoms they experience during inflammatory episodes, especially if they do not impede the continuation of their lifestyles and heal gradually. Certain systemic autoimmune diseases do produce bodily symptoms at the same time that uveitis is active, but others do not.

Multiple physicians

In some instances, when symptoms are effectively treated as isolated cases but not considered suggestive of a systemic autoimmune disease, patients go about their daily lives without giving much thought to their health. They may have been seen by a primary care physician, in the emergency room or by a specialist who is not revisited, as there is usually an asymptomatic period in their lives. The episodic nature of the symptoms means that there are periods of time when patients do not experience discomfort. In turn, this may lead to their being seen by other physicians when they begin to present symptoms again. Moreover, because the symptoms affect different parts of the body, patients may be seen by physicians from different specialties each time they have symptomatic episodes. For example, they might see a dermatologist for their skin conditions, a gastroenterologist for their digestive problems, or an ophthalmologist for their eye complaints, treating their symptoms as isolated, unrelated episodes. The disease is usually diagnosed correctly once it has produced serious symptoms and complications. It is also not uncommon for this to happen after an extremely stressful or life-changing event for patients.

Personality

Interestingly, many people who are diagnosed with chronic diseases have similar personality traits. They tend to be responsible, compliant, helpful, cooperative, etc. In their personal lives, many of these people are hard workers, lead active lives, try to be perfectionists and independent. They have a stoic quality to their character. They find it difficult to say "no" and they care about others. These are good qualities that can become self-destructive in situations that require the opposite. Because they tend to put the needs of others above their own and their duty to their health, they tolerate their symptoms more than they should. They even continue to work while they are sick. They get used to their symptoms, try not to give medical personnel too much work to do, and demonstrate willingness. The downside of all these characteristics is that they sacrifice their health and well-being. They tend to repress their negative emotions, especially anger. They are not very assertive. They do not express their opinions if they know it would upset others, even when their well-being depends on it. All of these qualities, good and bad, may cause physicians to be unaware of their patients' symptoms or their severity. The unconscious tendency to minimize the severity of their symptoms when reporting them to physicians may cause a delay in diagnosing the disease, especially when the disease is clinically diagnosed.

What can we do about it?

The aforementioned factors are just some of the aspects that hinder the diagnosis of autoimmune diseases. Despite being a problem that progressively affects more and more people, the general population is still unaware of the development of these diseases and the symptoms they produce. Therefore, it is very important to raise awareness about these diseases, to recognize the problem they present for public health and the impact they have on the quality of life of the people who suffer from them. In addition, it is also important to mobilize information to populations that are more predisposed to the development of these diseases.

Learn to identify symptoms suggestive of autoimmunity and their particular development

Symptoms caused by immune-mediated diseases are not as easy to identify and associate as those of other diseases. For this reason, learning to recognize the basic symptomatology associated with autoimmune diseases can expedite diagnosis and mobilization of appropriate medical care. There are three main ideas that distinguish the development of these diseases:

a) Symptoms are episodic, affect different parts of the body and vary in severity. They do not follow a typical pattern of development and usually begin with symptoms that progressively increase in severity. They can become uncomfortable, painful and disabling. They impede the normal performance of patients.

b) Many of the systemic autoimmune diseases associated with uveitis are those that affect connective tissue. So they will produce symptoms in many of the areas of the body that are made up of this tissue: eyes, skin, joints, blood vessels, etc.

c) The symptoms associated with diseases affecting the connective tissue, or connective tissue diseases are characterized by inflammation. In turn, inflammation is a process characterized by: redness, heat, swelling, pain, irritation.

d) They appear at times of great stress. They are almost always inopportune moments because the person could be going through a situation that requires responsibility, diligence or obligation. There are no symptoms during more relaxed times, such as vacations, but they appear during stressful situations.

Keeping a record of symptoms and taking pictures

Individuals who present with symptoms associated with autoimmune inflammatory processes and who have not received a diagnosis could benefit from keeping a record of all the symptoms they have presented along with photographs. The importance of this lies in being able to reach a proper diagnosis as soon as possible and, consequently, to find the most effective therapeutic alternative. Maintain a record of medical appointments, diagnoses, laboratory results and procedures. Saving lab results and keeping a history of medical appointments, along with the respective diagnoses received, may help expedite the process of diagnosing a systemic autoimmune disease. This should include even past illnesses that have been successfully cured, such as a common cold or infection. It should also include any negative laboratory tests. Diagnosing autoimmune diseases is a complex process because many of them cannot be diagnosed by lab tests, but instead by the clinical picture presented by patients. Tests and labs are used primarily as tools to support patients' symptomatology, not as definitive diagnostic labs. Nevertheless, they are still useful. Negative test and lab results, or in other words "nothing bad", still provide valuable information to physicians.

Establish a differential diagnosis

There are more than eighty autoimmune diseases, which is why reaching a proper diagnosis can be a lengthy process. One strategy to diagnose these diseases is to employ a process of elimination. First, the main diseases that are suggested by the symptoms are ruled out and then the less common ones are eliminated

Report it to the doctors

Patients with uveitis sometimes do not report symptoms that have occurred throughout their body because they are not informed about their possible systemic association. It is important that both physicians and patients adopt a collaborative approach to the management of these cases especially those that are idiopathic. Patients should be well informed about the systemic associations of uveitis and the impact it has on their lifestyles in order to establish new measures that fit their needs. Writing a list of all symptoms, including a description and date of onset, is a viable alternative for solving undiagnosed cases.

Symptoms suggestive of autoimmunity

General symptoms

• General malaise

• Dropping objects unintentionally

• Any of the following sensations in some parts of the body, especially in the extremities and/or face: numbness, paralysis, tingling, "pins and needles", hot/cold, pressure, etc.

• Fainting

• Seizures

• Fatigue or excessive tiredness

• Dizziness or vertigo

• Loss of appetite

• Unintentional weight gain or loss

• Recurrent or persistent fever

• Cold or night sweats

• Inflammation of lymph nodes

• Loss of balance and/or coordination

• Sensitivity to sunlight or artificial light

Head symptoms

• Thinning or hair loss

• Loss of pigment in the hair (white patches)

• Severe or frequent headache

• Scalp irritation

• Neck pain or stiffness

Auditory symptoms

• Tinnitus or "ringing in the ears"

• Hearing impairment or loss

• Severe or recurrent ear infection

• Inflammation of the earlobes

Nasal and oral symptoms

• Dry eyes and dry mouth

• Recurrent or severe nose bleeds

• Sinusitis, nasal congestion and/or nosebleed

• Infection in teeth or gums

• Inflammation of the gums

Cardiovascular symptoms

• Chest pain

• Inflammation or swelling of the legs

• Easy or frequent bruising

• Easy or frequent bleeding

Respiratory symptoms

• Frequent or severe colds

• Recurrent or chronic cough

• Coughing up blood

• Recent viral infection

• Asthma

• Breathing difficulties or shortness of breath

• Bone and joint symptoms

• Pain, stiffness or swelling in the joints

• Back pain

• Low back pain

• Back pain when sleeping or waking up

• Muscle pain

Skin symptoms

• Ulcers in mucocutaneous areas of the body: mouth (aphthous ulcers), nose, genital and/or perianal areas

• Decreased or loss of pigment in the skin or hair: vitiligo or poliosis

• Skin rashes, irritation or rashes

• Skin ulcers

• Itchy skin

• Acneiform lesions on the face or body

• Easy sunstroke on exposure to sunlight (photosensitivity)

• Inflammation of the skin of the legs: superficial thrombophlebitis or erythema nodosum

• Pain in the fingers or toes when exposed to the cold

• Change in color of fingers or toes when exposed to the cold

• Yellowish skin

Gastrointestinal symptoms

• Indigestion or gastrointestinal problems

• Difficulty swallowing

• Constipation

• Recurrent or severe diarrhea

• Blood in the stool

• Ulcers in the digestive tract: mouth, stomach, intestines, anus

• Indigestion or gastrointestinal problems

• Incontinence

Genitourinary symptoms

• Renal problems

• Urinary incontinence

• Blood in urine

• Urethral discharge

• Genital ulcers

• Prostatitis

• Testicular pain (epididymitis)

Other

• Risk of exposure to sexually transmitted infections

• Risk of exposure to tuberculosis

• Risk of exposure to human immunodeficiency virus (HIV).

• Ingestion of raw meats or undrinkable water

• Contact with animals: dogs, cats, horses, or livestock.

• Insect bites or tick bites

• Recent trips