By Martin Farber, M.D., Ph.D.
In the September / October 1999 issue, we published the article “Diving & The Body Systems: Diving with conditions of the endocrine, pulmonary and cardiac systems,” By Dr. Guy de Lisle Dear, DAN Associate Medical Director, With Additional Reports From DAN Vice President of Medical Services Joel Dovenbarger.
In this article, we did not fully explain concerns over diving with lupus. Some editing mistakes resulted in confusion by some of our members, especially those who have lupus.
We are revisiting this issue with the help of DAN member Martin Farber, M.D., Ph.D., an active diver who is in private practice as a rheumatologist.
Lupus erythematosus (/bE) is a generalized inflammatory disease induced by abnormally functioning T lymphocytes, part of the white blood cell family. LE is an autoimmune disease that can affect many body organs and tissues. Onset is usually between 20-45 years of age. There are three forms of LE: systemic, discoid and drug-induced. Systemic lupus, or SLE, causes the most serious outcome.
Approximately 90 percent of individuals with systemic lupus erythematosus (SLE) are female. The cause is unknown. Inflammatory joint disease, the most common manifestation of SLE, occurs in 90 percent of cases. Aseptic necrosis, or bone cell death, has been identified in 3 to 30 percent of SLE cases in different studies. The relative contribution of drug therapy in the disease activity is hard to know (a known side effect of long-term prednisone use is aseptic necrosis). Fevers, malaise and a typical “butterfly rash” or other skin problems are common with LE.
Lupus can affect the lungs and kidneys. Lung damage occurs in 50 percent of these cases and can vary from being asymptomatic (having no symptoms) to life-threatening. It can affect the nervous system, causing stroke, neuropathy (nervous system disorder), seizures, weakness or other ills.
The disease can be drug-induced, but it is usually short-lived, if recognized, and the offending drug removed. Drugs that may cause an LE-type illness include isoniazid (for tuberculosis), procainamide (for irregular heartbeat) and hydralazine (for hypertension). While individuals with SLE may have skin lesions with discoid lupus, patients diagnosed with discoid lupus do not have systemic involvement. These lesions are found commonly on the face, causing hyperkeratosis (thickening of the skin), follicular plugging and inflamed red patches.
Fitness & Diving Issues:
The severity of symptoms in LE can vary, ranging from mild to life-threatening. Clearly, consideration for diving must be made on the basis of symptoms and their effects on the individual’s ability to respond to the exercise requirements of diving. Many cases are mild and should pose no problem for diving once the individual has been evaluated and cleared for unrestricted activity by their personal physician. Consult DAN if needed.
Individuals with impaired pulmonary or cardiac function, and perhaps chronic joint inflammation with tissue changes, may carry a higher risk of compromising these body systems during a scuba dive. Individuals with CNS damage may be at greater risk of seizures, and hence drowning. As a result, they may be not be medically certified to dive. Whether diving is synergistic with the disease or its treatment (corticosteroids), and can increase the probability of aseptic bone necrosis, is unknown.
In such a wide-ranging disease where many body systems can be affected subclinically, it is not uncommon for physicians to require some exercise tolerance or pulmonary function testing to help determine if there may be an undue risk for individuals with LE. Also, there is a concern regarding exposure to sunlight, which can induce or exacerbate LE activity, though this varies among individuals.
Treatment of LE may include sunscreens for photosensitive rashes, steroid creams for skin lesions and oral steroids for more severe cases. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs — like ibuprofen) may help decrease pain. Antimalarials such as chloroquine or low-dose steroids are used for severe skin problems. Because they inhibit or destroy cell function, cytotoxics like methotrexate, cyclophosphamide and azathioprine have also been used to help control the disease.
WEBSITES ABOUT LUPUS
www.arthritis.org American College of Rheumatology
www.rheumatology.org Lupus Foundation of America