[2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus]

Systemic lupus erythematosus (SLE), a complex and heterogeneous autoimmune disease, represents a significant challenge for both diagnosis and treatment. In 2019, under the leadership of the Chinese Rheumatology Association, a multidisciplinary guideline development group was established. The objective was to develop an evidence-based diagnosis and treatment guideline for SLE in China based on emerging new evidence. The guideline was registered at International Practice Guidelines Registry Platform (IPGRP-2019CN022). The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations, and the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was followed to report the guideline. The guideline provides recommendations for the SLE classification criteria, disease activity monitoring and assessing, medication principles and considerations organ and system involvement and management of patients during pregnancy. This guideline is intended to serve as a tool for Chinese clinicians for the best decisions-making on diagnosis and treatment of SLE.

[The 476th case: skin rash, edema, thrombocytopenia and anemia]

The 21-year-old male patient was admitted to the Department of Rheumatology and Immunology at Peking Union Medical College Hospital with chief complaints of "skin rash for 1 year and edema for 2 months". He was diagnosed with systemic lupus erythematosus (SLE) with renal, cardiac and hematological involvement. Remission was not achieved after glucocorticoid pulse treatment. The patient experienced oliguria, malignant hypertension, accompanied by thrombocytopenia and low serum complements, and elevated lactate dehydrogenase and serum creatinine. Schistocytes were seen in the peripheral blood smear. Thrombotic microangiopathy (TMA) secondary to SLE was diagnosed. Though plasma exchange was partially effective, TMA could not be controlled yet. The activity of serum von Willebrand factor -cleaving protease (ADAMTS 13) was 100%, and ADAMTS 13 inhibitor was negative. Finally, remission of the disease was achieved after second glucocorticoid pulse therapy and rituximab treatment. At the 3-month follow-up, the patient's condition was stable with mild anemia and normal platelet count. Patients with TMA secondary to SLE are heterogenous, while normal ADAMT 13 activity indicates poor prognosis. Early and aggressive treatment is important for disease control, and plasma exchange is helpful as a supportive care.

[Matrix metalloproteinase-3 in patients with systemic lupus erythematosus and its significance in differentiating disease activity from pulmonary infections]

The purpose of this study is to investigate the matrix metalloproteinase-3 (MMP-3) levels in patients with systemic lupus erythematosus (SLE) and its significance in identifying disease activity and pulmonary infections. A total of 122 SLE patients were enrolled, including 21 with pulmonary infections, 16 with arthritis, 26 with nephritis, 10 with vasculitis, and 23 healthy controls. Serum MMP-3, C-reactive protein (CRP), serum amyloid A (SAA), and haptoglobin (HPT) levels were measured in all subjects. The results showed that the levels of MMP-3 in SLE combined with pulmonary infections [(230.10±44.92) μg/L], arthritis [(140.20±20.76) μg/L], nephritis [(155.40±23.36) μg/L] were higher than those in SLE only [(91.74±10.47) μg/L]. The levels of MMP-3 [(210.30±45.71) μg/L], CRP [(12.11±5.21) mg/L], HPT [(1.57±0.23) g/L] in active SLE combined with pulmonary infections were higher than those inactive SLE without pulmonary infections including MMP-3 [(124.00±15.22) μg/L], CRP [(7.76±2.96) mg/L], HPT [(0.89±0.09) g/L]. The levels of CRP [(10.03±2.70) mg/L], SAA [(89.22±36.77) mg/L] in active SLE with pulmonary infections and CRP[(7.76±2.96) mg/L], SAA [(60.22±19.7) mg/L] in active SLE without pulmonary infections were higher than CRP [(1.90±0.39) mg/L], SAA [(17.60±3.89) mg/L] in stable SLE with pulmonary infections. It suggests that the levels of CRP and SAA are elevated in active SLE with pulmonary infections. Serum MMP-3 in combination with CRP may assist in differentiating from SLE pulmonary infections.

[Rectal Ulcer Developed in Systemic Lupus Erythematosus without Ischemic Colitis]

Rectal involvement by systemic lupus erythematosus (SLE) is quite rare. Approximately 14 cases have been reported worldwide, but only one with ischemic colitis has been reported in Korea. A 17-year-old female patient was hospitalized with abdominal pain and hematochezia. Sigmoidoscopy revealed only a simple rectal ulcer without ischemic colitis. cytomegalovirus and bacterial infections were excluded. A sigmoidoscopic rectal biopsy indicated a rectal invasion by SLE, but the patient showed an acute worsening conditions that did not respond to treatment. This paper reports a case of rectal ulcer that developed in SLE without ischemic colitis with a review of the relevant literature.

[A multicenter study of the condition of children's rheumatic disease associated medical resources in Fujian province]

Objective: To investigate general condition of children's rheumatic disease associated medical resources in Fujian Province. Methods: This questionnaire-based survey was conducted in 19 hospitals in Fujian province from December 2, 2018 to May 1, 2019. The questionnaire was designed to survey the general condition of the medical resources and the hospitalization of patients with rheumatic diseases from January 1, 2014 to December 1, 2018. Results: In the 19 hospitals, there were 15 general hospitals and 4 children's hospitals, and only 5 hospitals had children's rheumatic specialist clinic. There were only 53-62 beds for rheumatic disease patients in the 19 hospitals, accounting for 1.7%-2.0% of the total inpatient beds (3 137). There are 29 pediatric rheumatologists in total, accounting for 2.6% (29/1 120) of the total pediatricians. In the past five years, 613 patients with rheumatic diseases, accounting for 0.1% (613/625 214) of total hospitalized patients, were treated in these hospitals. Among them, 201 had juvenile idiopathic arthritis, 295 had systemic lupus erythematosus, 39 had dermatomyositis, 7 had scleroderma, and 57 had inflammatory bowel disease, 9 had Sjogren's syndrome, 5 had Behcet's disease, and none had overlap syndrome or mixed connective tissue disease. Conclusion: The medical resources of children rheumatic diseases in Fujian province are insufficient which need to be developed.

[Lupus nephritis]

Lupus nephritis (LN) is the most frequent and one of the most severe organ manifestations of systemic lupus erythematosus. The central pathogenetic mechanism is characterized by the loss of immune tolerance against autoantigens of the cell nucleus, which can lead to renal inflammation via the formation of nuclear autoantibodies. The clinical manifestations of LN encompass nephritic syndrome with the special form of rapidly progressive glomerulonephritis, nephrotic syndrome and thrombotic microangiopathy. The diagnostic procedures consist of renal function and urine analysis as well as the determination of serum autoantibody profiles and complement components. An early renal biopsy enables a differentiation between the prognostically different forms of LN. In addition to supportive measures, a differentiated immunosuppressive treatment is the main approach for prognostically unfavorable forms. Important components are corticosteroids, cyclophosphamide and mycophenolate mofetil for induction treatment. Currently investigated treatment principles include next generation calcineurin inhibitors and anti-B cell treatment.

[Neuroimmunology and rheumatology: overlap and differential diagnoses]

Multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) are chronic inflammatory diseases of the central nervous system (CNS). They may cause inflammation in the brain, spinal cord and optic nerve. Both conditions must be differentiated from CNS manifestations of other systemic autoimmune diseases such as systemic lupus erythematosus (SLE), Sjögren's syndrome, autoinflammtory diseases and sarcoidosis, since amongst others myelitis and optic nerve inflammation may also occur in these conditions. Nevertheless, coexistence of MS or NMOSD with rheumatic disorders such as SLE or Sjögren's syndrome has also been reported especially in NMOSD. Since the therapeutic approach is different it is important to determine a clear diagnosis. In addition some drugs used in rheumatic disease such as anti-tumor necrosis factor biologics may induce inflammatory disease of the CNS and should be avoided in MS. An interdisciplinary approach between neuroimmunology and rheumatology is important for optimal care and treatment in such patients.

Acute pancreatitis and macrophage activation syndrome in pediatric systemic lupus erythematosus: case-based review

Pancreatitis is uncommon in systemic lupus erythematosus (SLE) and is rarely reported in children, possibly being related to macrophage activation syndrome (MAS). The incidence of MAS in children with lupus pancreatitis is unknown, as is their prognosis. In this case-based review, we report a pediatric patient with SLE complicated with pancreatitis and MAS, and performed a literature review. We report an 11-year-old girl with SLE and MAS who developed pancreatitis on the second day of methylprednisolone pulse therapy (500 mg/day). We continued methylprednisolone pulse therapy, and performed three rounds of DNA-immunoadsorption and three rounds of hemoperfusion. A second course of methylprednisolone pulse therapy was initiated 9 days later. The patient received a monthly cyclophosphamide pulse therapy (10 mg/kg/day, 2 consecutive days every month) for 6 months, after which she was treated with mycophenolate mofetil 20 mg/kg/day. The condition of the patient gradually improved, her blood amylase and lipase decreased. She was in a stable condition during 13-month follow-up period. Review of the literature of pediatric patients with SLE and pancreatitis showed that there are 127 cases that have been reported in the past 30 years, 40 cases were excluded in our study because of inadequate information. Of the 87 patients included in our literature review, the mortality rate was 33.33%, and 52.86% of the patients with pancreatitis had MAS at the same time. Pancreatitis is uncommon in SLE, but must be suspected if a patient with SLE develops digestive symptoms. Patients with SLE with pancreatitis have a high incidence of MAS and high mortality rate; however, early recognition and effective treatment can relieve the disease symptoms.

Preventing ovarian failure associated with chemotherapy

Alkylating chemotherapy is often used to treat pre-menopausal women for various malignancies and autoimmune diseases. Chemotherapy-associated ovarian failure is a potential consequence of this treatment which can cause infertility, and increases the risk of other long term adverse health sequelae. Randomised trials, predominantly of women undergoing alkylating chemotherapy for breast cancer, have shown evidence for the efficacy of gonadotropin-releasing hormone agonists (GnRHa) in preventing chemotherapy-associated ovarian failure. The European St Gallen and United States National Comprehensive Cancer Network guidelines recommend the use of concurrent GnRHa to reduce the risk of ovarian failure for pre-menopausal women undergoing chemotherapy for breast cancer. The GnRHa goserelin, a monthly 3.6 mg depot subcutaneous injection, has recently been listed on the Australian Pharmaceutical Benefits Scheme to reduce risk of ovarian failure for pre-menopausal women receiving alkylating therapies for malignancy or autoimmune disease. The first dose of goserelin should ideally be administered at least 1 week before commencement of alkylating treatment and continued 4-weekly during chemotherapy. Concurrent goserelin use should now be considered for all pre-menopausal women due to commence alkylating chemotherapy (except those with incurable cancer), regardless of their childbearing status, in an effort to preserve their ovarian function. For women who have not completed childbearing, consideration of other fertility preservation options, such as cryopreservation of embryos or oocytes, is also important.

Antiphospholipid syndrome: a clinical review

Antiphospholipid syndrome is characterised by recurrent thrombosis (arterial, venous, microvascular) and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (lupus anticoagulant, anti-β2-glycoprotein 1 and anticardiolipin). It can be a primary disease or associated with another autoimmune disease (especially systemic lupus erythematosis). Testing for antiphospholipid antibodies should be considered in patients < 50 years of age with unprovoked venous or arterial thromboembolism, thrombosis at unusual sites or pregnancy complications. The mainstay of treatment is antithrombotic therapy and recommendations vary based on arterial, venous or pregnancy complications. If associated with systemic lupus erythematosis, hydroxychloroquine is recommended both as primary and secondary prophylaxis. Antithrombotic treatment is gold standard and effective.

The evaluation of cellular immune function in elderly patients with systemic lupus erythematosus

BACKGROUND/AIMS

To evaluate cellular immune function in systemic lupus erythematosus (SLE) patients over 60 years old, the association between antinuclear antibody (ANA) titers and the ratio of CD4+ /CD8+ was analyzed in this study. The distribution of ANAs and extractable nuclear antibodies (ENAs) in a healthy elderly population was also investigated.

METHODS

Serum ANA titers were assayed by indirect immunofluorescence (IIF) and the CD4+ /CD8+ T-cell ratio was determined by flow cytometry in 76 SLE patients and 30 healthy control individuals. IIF of cytoplasm and nuclear and nucleolar staining were performed on samples taken from 286 healthy elderly individuals. ENA levels were determined using a strip enzyme immunoassay among patients that tested positive for ANAs.

RESULTS

ANA titers were negative in the 30 control individuals, but were positive in the 76 SLE patients. Based on ANA titers, the SLE patients were stratified to low (≤ 1:320), medium (1:640 to 1:1,280), and high (≥ 1:2,560) titer groups. The average CD4+ /CD8+ ratio of the SLE group was significantly lower than that of the control group. Among the 286 healthy elderly volunteers, 59 (20.63%) tested positive for ANAs. A homogeneous pattern was present in 47.46% of those 59 patients and a granule pattern in the karyoplasm was present in 33.90%. Furthermore, of the 59 patients, ENAs immunoassay was positive in 18 (30.51%); Sjogren syndrome-related antigen A (SSA)/52 kd and Sjogren syndrome antigen B (SSB)/La were the two major antibodies.

CONCLUSION

The significantly lower CD4+ /CD8+ ratio among SLE patients over 60 years old is associated with deregulated immune responses and the development of SLE. A low ANA titer (1:160) is common in healthy elders, emphasizing the importance of considering age when determining if the evaluation of ANA titers is to be included in autoimmune disease diagnosis.

Systemic lupus erythematosus: what should family physicians know in 2018?

Systemic lupus erythematosus (SLE) is a complex multi-systemic autoimmune disease with considerable clinical and immunological heterogeneity. Family physicians should be familiar with the protean manifestations of SLE to aid early diagnosis and monitoring of disease progression. The role of family physicians in SLE includes education, counselling, psychological support, management of mild disease, and recognition of the need for referral to other specialists for more serious disease and complications. Surveillance of cardiovascular risk factors and osteoporosis and advice about vaccination and reproductive issues can be performed in the primary care setting under close collaboration with rheumatologists and other specialists. This review provides family physicians with the latest classification criteria for SLE, recommendations on SLE-related health issues, and pharmacological therapies for SLE.

[Analysis of 20-year survival rate and prognostic indicators of systemic lupus erythematosus]

Objective: To analyze the 20-year survival rate, causes of death and predictors of systemic lupus erythematosus (SLE). Methods: A retrospective analysis was performed on 217 newly SLE patients who were diagnosed and treated by Peking University People's Hospital before June 2008. The clinical features and serologic data were studied. Survival rate of SLE patients over time, living conditions, causes of death and prognostic indicators of mortality were studied. Results: The 10-, 15-and 20-year cumulative survival rate was 90.3%,88.1%and 79.6%, respectively. Infection and lupus encephalopathy were the main causes of death. Cox regression analysis revealed that lupus nephritis, neuropsychiatric systemic lupus erythematosus and age at the diagnosis were independent risk determinants for mortality. Conclusion: Prognosis of SLE remains to be improved. Early diagnosis, control of SLE organ damage and infection prevention are critical to improve survival of SLE patients.

Difficult-to-diagnose diabetes in a patient treated with cyclophosphamide - the contradictory roles of immunosuppressant agents: a case report

Background

Cyclophosphamide may induce autoimmune diabetes through a decrease in suppressor T cells and increase of proinflammatory T helper type 1 response in animal models. In humans, this association is not as clear due to the presence of other risk factors for hyperglycemia, but it could be a precipitant for acute complications.

Case presentation

A 31-year-old Mestizo-Mexican woman with a history of systemic lupus erythematosus presented with severe diabetic ketoacidosis, shortly after initiating a multi-drug immunosuppressive therapy. She did not meet the diagnostic criteria for type 1 or type 2 diabetes and had no family history of hyperglycemic states. She persisted with hyperglycemia and high insulin requirements until the discontinuation of cyclophosphamide. After this episode, she recovered her endogenous insulin production and the antidiabetic agents were successfully withdrawn. After 1 year of follow up she is still normoglycemic.

Conclusion

Cyclophosphamide may be an additional risk factor for acute hyperglycemic crisis. Glucose monitoring could be recommended during and after this treatment.

[The 466th case:myasthenia,fever,blurred vision and pancytopenia]

A 45-year-old woman was admitted to the Department of Rheumatology and Immunology, Peking Union Medical College Hospital, due to weakness of the upper limbs, fever, and blurred vision. She was clinically diagnosed as systemic lupus erythematosus overlapped primary biliary cirrhosis, with renal, retinal, hematological and musculoskeletal involvement, combined with severe pulmonary infection and respiratory failure. Treated with glucocorticoids, ursodeoxycholic acid, antibiotics and respiratory support, the patient got better. A couple of days later, her fever recurred and platelets count dropped to 30×10(9)/L, hemoglobin to 78 g/L, fibrinogen to<1.5 g/L, ferritin to 1 640 ng/ml, natural killer (NK) cell count to 8/μl, the activity of NK cells 2% (reference value 9.5%-23.5%), considering the occurrence of hemophagocytic lymphohistiocytosis (HLH). Cytomegalovirus pp65 antigenemia test: 13 positive cells/2×10(5) WBC. Considered the possibility of HLH caused by cytomegalovirus infection and treated by 250 mg ganciclovir intravenous drip twice a day for a full course. The temperature of the patient was gradually reduced to 36.5 ℃, the count of platelets were increased to 229 ×10(9)/L, the hemoglobin was increased to 94 g/L, and the fibrinogen was increased to 3.26 g/L. When there were unexplained critical signs of the primary disease during systemic lupus erythematosus treatment, severe complications such as infection, HLH, thrombotic thrombocytopenic purpura should be taken into account.

[Neuroimmunology and rheumatology: overlap and differential diagnoses]

Multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) are chronic inflammatory diseases of the central nervous system (CNS). They may cause inflammation in the brain, spinal cord and optic nerve. Both conditions must be differentiated from CNS manifestations of other systemic autoimmune diseases such as systemic lupus erythematosus (SLE), Sjögren's syndrome, autoinflammtory diseases and sarcoidosis, since amongst others myelitis and optic nerve inflammation may also occur in these conditions. Nevertheless, coexistence of MS or NMOSD with rheumatic disorders such as SLE or Sjögren's syndrome has also been reported especially in NMOSD. Since the therapeutic approach is different it is important to determine a clear diagnosis. In addition some drugs used in rheumatic disease such as anti-tumor necrosis factor biologics may induce inflammatory disease of the CNS and should be avoided in MS. An interdisciplinary approach between neuroimmunology and rheumatology is important for optimal care and treatment in such patients.

Spectrum of central nervous system involvement in rheumatic diseases: pictorial essay

The rheumatic diseases, which include systemic lupus erythematosus, rheumatoid arthritis, Behçet's disease, scleroderma, and ankylosing spondylitis, are characterized by involvement of connective tissue, with multiple manifestations. In those diseases, there can be involvement of the peripheral or central nervous system, and that involvement can be primary, presenting as a major feature of the clinical presentation, or secondary, as an effect of the drugs used in order to control a given disease or its complications. Knowledge of the wide variety of imaging findings is crucial to the diagnosis of a rheumatic disease, especially in the early stages, enabling effective treatment and minimizing disability. This pictorial essay, presenting cases from the records of two tertiary teaching hospitals, encompasses cases of patients diagnosed with rheumatic disease and illustrates the neuroradiological findings on magnetic resonance imaging and computed tomography, in order to emphasize the importance of these methods for properly diagnosing rheumatic diseases.

Could Lymphocyte Profiling be Useful to Diagnose Systemic Autoimmune Diseases?

Considering the implications of B, T, and natural killer (NK) cells in the pathophysiology of systemic autoimmune diseases, the assessment of their distribution in the blood could be helpful for physicians in the complex process of determining a precise diagnosis. In primary Sjögren's syndrome, transitional and active naive B cells are increased and memory B cells are decreased compared to healthy controls and other systemic diseases. However, their utility to improve the accuracy of classification criteria has not been proven. In early untreated rheumatoid arthritis, proportions of regulatory T cells are constantly reduced, but other patterns are difficult to determine given the heterogeneity of published studies. In systemic lupus erythematosus, the lack of studies using large cohorts of patients and the diversity of the possible pathological mechanisms involved are also important impediments. Nevertheless, transitional B cell and plasma cell proportions are increased in most of the studies, the CD4/CD8 ratio is decreased, and the number of NK cells is reduced. Despite the low number of studies, anomalies of lymphocyte subset distribution was also described in ANCA-associated vasculitis, systemic scleroderma, and myositis. For now, flow cytometric analysis of lymphocyte subsets has focused mainly on specific subpopulations and is more useful for basic and translational research than for diagnostics in clinical practice. However, new modern methods such as mass cytometry and bioinformatics analyses may offer the possibility to simultaneously account for the relative proportions of multiple lymphocyte subsets and define a global profile in homogeneous groups of patients. The years to come will certainly incorporate such global lymphocyte profiling in reclassification of systemic autoimmune diseases.

[Expression and Clinical Significance of Semaphorin 3A in serum and mononuclear cells in patients with systemic lupus erythematosus]

Objective: To determine the expression of Sema3A in serum and peripheral blood mononuclear cells (PBMC) of patients with systemic lupus erythematosus (SLE), to analysis the correlation of Sema3A expression and SLE clinical manifestations and laboratory indexes, and to evaluate the diagnostic value of Sema3A in patients with SLE. Methods: The concentration of serum Sema3A was detected by enzyme-linked immuno sorbent assay (ELISA) in patients with SLE, healthy controls (HC) and diseases controls. In addition, the mRNA expression level of Sema3A was examined in PBMC by real-time polymerase chain reaction. The correlation of serum Sema3A level and clinical and laboratory features of SLE patients were analyzed. Unpaired t test, Kruskal-Wallis test, Mann-Whitney U test, χ(2) test, Pearson and Spearman correlation analysis were used to statistical analysis by using SPSS 13.0. Results: (1) Serum Sema3A concentration in patients with SLE was significantly lower than that in HC groups (P<0.01). (2) Consistent with the serum level, the Sema3A mRNA level in SLE was lower than that in HC (P=0.001). And the mRNA expression of Nrp-1 in SLE was also lower than that in HC (P<0.01). (3) The serum Sema3A level in patients with SLE was positively correlated with haemoglobin (HGB) (r=0.271, P<0.013), platelet (PLT) (r=0.600, P<0.011), complement 3 (C3) (r=0.234, P=0.0027) and complement 4 (C4) (r=0.159, P=0.434) levels. Whereas, the expression of Sema3A was negatively correlated with SLE disease activity index (SLEDAI) (r=-0.286, P=0.036). (4) Area under curve illustrated by ROC curve was 0.876 (95% CI: 0.846-0.906). The best cut-off value for the diagnosis of SLE was 6.31 μg/L, with the sensitivity of 80.6% and the specificity of 77.5%. The Youden index was 0.581. Above results indicated good validity of Sema3A as a diagnostic marker for SLE. (5) The HGB, PLT, C3 and C4 levels in the group of Sema3A- positiveSLE patients (≤6.31 μg/L) were lower than that in negative group (>6.31 μg/L), while CRP level and SLEDAI of positive group was higher than that in negative group(P<0.05). In addition, the positive rate of antinuclear antibodies (P=0.046) and anticardiolipin antibody (P=0.018) in the Sema3A-negative group were also significantly higher than that of negative group. Conclusions: Sema3A and Nrp-1 was both decreased in serum and PBMC of SLE patients, suggesting that the circulating expression of Sema3A and Nrp-1 was seriously defected in SLE. Circulating Sema3A was significantly correlated with disease activity and blood damage in patients with SLE. The result of ROC curve showed that Sema3A had the potential to be a new diagnostic biomarker in SLE.

[The microbiome and autoimmunity]

An abundant and diverse set of commensal microbial communities covers the body's surfaces, collectively so-called microbiome. It has a functional impact on various immune processes and modulates many health-related processes, including autoimmunity. An active site of microorganism-host interplay is the intestinal mucosa. Growing evidence has helped us to learn how a specific microbiota composition and its functionality determine the intestinal barrier function and, furthermore, modulate pro-inflammatory and anti-inflammatory immune mechanisms in remote organs. In addition, the microbial composition of the skin is important for the functionality of the skin barrier and autoimmune skin diseases. Here, we review the importance of the microbiome for the local and systemic immune system and how a disturbed microbiome-host interaction can affect the development and progression of autoimmune diseases. Understanding these associations will help to unravel new diagnostic and therapeutic approaches for those diseases.

[Imaging findings of bone infarction in children with systemic lupus erythematosus]

OBJECTIVE

To investigate diagnostic value of MRI, X ray and CT for bone infarction in children with systemic lupus erythematosus.

METHODS

Eleven systemic lupus erythematosus children with bone infarction were retrospectively analyzed from January 2015 to January 2017 , and tested by MRI, X-ray and CT. Among them, including 1 male and 10 females aged from 6 to 16 years old with an average of 13 years old. All patients were detected by MRI, 9 patients were detected by X-ray and 3 patients were detected by CT, imaging findings were analyzed.

RESULTS

The location of bone infarction involved 60 sits, 30 sites located on metaphyseal-diaphyseal region, 8 located on patella, 21 located on epiphysis, and 1 located on talus. Focus of 11 patients were detected by MRI, the main manifestation showed geographic change, long T1 and T2 signal could seen around focus, and showed double ring sign and three ring sign; 5 of 9 patients by X-ray examination detected focus;2 of 3 patients by CT examination detected focus. No abnormity seen at early stage by X-ray and CT examination, and low density focus around harden edge at chronic stage.

CONCLUSIONS

MRI could display bone fracture at early stage, X-ray and CT could only display lesion at chronic stage, MRI is the most effective method in diagnosing bone infarction.

[Opportunistic infection in systemic lupus erythematosus patients: the disease spectrum and the characteristics of peripheral lymphocyte subsets]

Objective: To investigate the common opportunistic infections and the characteristics of peripheral lymphocyte subsets in patients with systemic lupus erythematosus (SLE). Methods: From December 2013 to December 2016, peripheral lymphocyte subsets were consecutively detected by flow cytometry in treated SLE patients with or without opportunistic infections (OIs) . The lymphocyte subsets in healthy donors were used as normal control group. Results: A total of 145 treated SLE patients were enrolled including 108 with OIs and 37 without OIs. The common OIs were cytomegalovirus (CMV) diseases (66/108), Pneumocystis jirovecii pneumonia (PJP, 16/108), other fungal infections (16/108), Epstein-Barr virus (EBV, 15/108) and tuberculosis (14/108). Compared with treated SLE without OIs, total lymphocyte, CD(4+) T, and CD(8+) T lymphocyte counts were significantly reduced in SLE with OIs [1 260 (780, 1 810) cells/μl vs. 565 (399, 1 043) cells/μl, P<0.001; 485 (280, 811) cells/μl vs. 173 (95, 327) cells/μl, P<0.001; 464 (339, 764) cells/μl vs. 265 (158, 424) cells/μl, P=0.003, respectively]. Conclusions: The common OIs in treated SLE patients were CMV diseases, PJP, other fungi, EBV and tuberculosis. OIs are prone to develop in SLE patients with severe lymphocytopenia, especially CD(4+) T cell depletion.

Role of interferons in SLE

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease that affects many different organ systems, with excessive production of type I interferons (IFNs) and autoantibodies against nucleic acids as hallmarks. Activation of the type I IFN system in SLE is due to continuous stimulation of plasmacytoid dendritic cells by endogenous nucleic acids, leading to sustained type I IFN production. This is reflected by an overexpression of type I IFN-regulated genes or an IFN signature. Type I IFNs have effects on both the innate and adaptive immune systems, which contribute to both loss of tolerance and the autoimmune disease process. In this review, we discuss the current understanding of IFNs in SLE, focusing on their regulation, the influence of genetic background, and environmental factors and therapies that are under development aiming to inhibit the type I IFN system in SLE.

A novel data-driven workflow combining literature and electronic health records to estimate comorbidities burden for a specific disease: a case study on autoimmune comorbidities in patients with celiac disease

BACKGROUND

Data collected in EHRs have been widely used to identifying specific conditions; however there is still a need for methods to define comorbidities and sources to identify comorbidities burden. We propose an approach to assess comorbidities burden for a specific disease using the literature and EHR data sources in the case of autoimmune diseases in celiac disease (CD).

METHODS

We generated a restricted set of comorbidities using the literature (via the MeSH® co-occurrence file). We extracted the 15 most co-occurring autoimmune diseases of the CD. We used mappings of the comorbidities to EHR terminologies: ICD-10 (billing codes), ATC (drugs) and UMLS (clinical reports). Finally, we extracted the concepts from the different data sources. We evaluated our approach using the correlation between prevalence estimates in our cohort and co-occurrence ranking in the literature.

RESULTS

We retrieved the comorbidities for 741 patients with CD. 18.1% of patients had at least one of the 15 studied autoimmune disorders. Overall, 79.3% of the mapped concepts were detected only in text, 5.3% only in ICD codes and/or drugs prescriptions, and 15.4% could be found in both sources. Prevalence in our cohort were correlated with literature (Spearman's coefficient 0.789, p = 0.0005). The three most prevalent comorbidities were thyroiditis 12.6% (95% CI 10.1-14.9), type 1 diabetes 2.3% (95% CI 1.2-3.4) and dermatitis herpetiformis 2.0% (95% CI 1.0-3.0).

CONCLUSION

We introduced a process that leveraged the MeSH terminology to identify relevant autoimmune comorbidities of the CD and several data sources from EHRs to phenotype a large population of CD patients. We achieved prevalence estimates comparable to the literature.

[The application and influence factors of FACIT Fatigue Scale in SLE patients]

Objective: To evaluate the application and influence factors of the Functional Assessment of Chronic Illness Therapy (FACIT-Fatigue) scale in patients with systemic lupus erythematosus (SLE). Methods: SF-36 questionnaires were used to estimate the health-related quality of life (HRQOL) of SLE patients in Chinese Han population.FACIT-Fatigue scale was applied to measure fatigue.Disease activity was determined by SLE disease activity index (SLEDAI), meanwhile demographic parameters such as gender, disease duration, etc. were recorded. Results: A total of 223 patients with SLE were enrolled in the survey.FACIT-Fatigue scale was negatively correlated with SF-36 (P<0.05). FACIT-Fatigue scale of patients with SLE were correlated with education, erythrocyte sedimentation rate (ESR), C3, and SLEDAI score (P<0.05). The degree of bodily pain, the status of mental health and the amount of complement C3 were the independent factors of FACIT-Fatigue (P<0.1). Conclusion: FACIT-Fatigue scale is related to disease activity, quality of life, age and ESR in patients with SLE.There fore, reduce the disease activity and improve the quality of life of SLE patients may be helpful to reduce the fatigue of patients with SLE.