Diagnosis and pathogenesis of CNS lupus

Structural and neurochemical markers of brain injury in the migraine diathesis of systemic lupus erythematosus

OBJECTIVE

To determine whether migraine in systemic lupus erythematosus (SLE) is associated with accentuated brain injury and disease activity.

METHODS

Forty SLE patients (11 without headache, 11 with non-migraine headache, and 18 with migraine) underwent clinical evaluation, magnetic resonance imaging (MRI), and spectroscopy (MRS).

RESULTS

Recurrent headache occurred in 75% of SLE patients. MRI abnormalities and reduced N-acetylaspartate were common. However, migraine in SLE was not associated with increased disease activity or severity, neuropsychiatric manifestations, or end-organ involvement compared to patients without migraine (p > 0.05). There were no differences in the prevalence or severity of MRI or MRS abnormalities between SLE patients with migraine, with non-migraine headache, or without headache (p > 0.05).

CONCLUSIONS

Headache does not identify SLE patients at risk for brain injury, increased disease activity, or increased end-organ involvement. Aggressive immunosuppressive therapy for headache alone is not indicated in SLE.

Brain glucose utilization in systemic lupus erythematosus with neuropsychiatric symptoms: a controlled positron emission tomography study

In contrast to morphological imaging [such as magnetic resonance imaging (MRI) or computed tomography], functional imaging may be of advantage in the detection of brain abnormalities in cases of neuropsychiatric systemic lupus erythematosus (SLE). Therefore, we studied 13 patients (aged 40+/-14 years, 11 female, 2 male) with neuropsychiatric SLE who met four of the American Rheumatism Association criteria for the classification of SLE. Ten clinically and neurologically healthy volunteers served as controls (aged 40+/-12 years, 5 female, 5 male). Both groups were investigated using fluorine-18-labelled fluorodeoxyglucose brain positron emission tomography (PET) and cranial MRI. The normal controls and 11 of the 13 patients showed normal MRI scans. However, PET scan was abnormal in all 13 SLE patients. Significant group-to-group differences in the glucose metabolic index (GMI=region of interest uptake/global uptake at the level of the basal ganglia and thalamus) were found in the parieto-occipital region on both sides: the GMI of the parieto-occipital region on the right side was 0.922+/-0.045 in patients and 1.066+/-0.081 in controls (P<<0.0001, Mann Whitney U test), while on the left side it was 0.892+/-0.060 in patients and 1. 034+/-0.051 in controls (P=0.0002). Parieto-occipital hypometabolism is a conspicuous finding in mainly MRI-negative neuropsychiatric SLE. As the parieto-occipital region is located at the boundary of blood supply of all three major arteries, it could be the most vulnerable zone of the cerebrum and may be affected at an early stage of the cerebrovascular disease.

An association between increased serum-soluble interleukin-2 receptors and a disturbance in muscle force in schizophrenic patients

1. Serum-soluble interleukin-2 receptors (SIL-2Rs), a sign of immune activation, are increased in approximately 30% of schizophrenic subjects. 2. In a recent publication the authors found that SIL-2Rs were particularly elevated in schizophrenic subjects with tardive dyskinesia (TD). 3. This paper investigates the relationship between muscle force instability and SIL-2Rs in 32 schizophrenic patients, 10 of whom were neuroleptic-naive. 4. The authors hypothesized that there would be a positive correlation between increased levels of SIL-2Rs and muscle force instability. 5. Serum SIL-2Rs and muscle force instability were positively correlated (r = 0.54, p < .001) in the schizophrenic patients, and this correlation held even for the subset of neuroleptic-naive patients (r = .73, df 8, p = .016). 6. These findings suggest that there is an important correlation between immune activation and muscle force instability in schizophrenic patients.

Autonomic nerve dysfunction in systemic lupus erythematosus: evidence for a mild involvement

Neurologic manifestations are known to occur in patients with systemic lupus erythematosus (SLE) and significantly affect the clinical course of the disease. Nevertheless, the prevalence, pattern and severity of autonomic impairment in such patients have yet to be defined. In the present study a series of 38 female SLE patients was assessed for the presence of autonomic dysfunction. Five noninvasive standardized cardiovascular reflex tests were used. The grading system proposed by Ewing and Clarke was applied to classifying autonomic impairment according to severity. Seventeen out of 38 patients, that is 44.7%, had evidence of autonomic impairment. Most of the patients had a mild degree of dysfunction. No correlation was found for the duration of the disease while an apparent lack of the commonly described chronological sequence of autonomic involvement was observed. We suggest that in SLE patients the prevalence of autonomic impairment, when investigated, does not significantly differ from that of other SLE-associated neurological events. The contribution of a direct immunological damage to components of neural pathways in the pathogenesis of the autonomic involvement can be postulated. Clinical consequences of autonomic impairment in patients with systemic lupus erythematosus need to be elucidated.

Molecular, metabolic and immune evidence suggest that systemic autoimmune disease is antigen-mediated

Patients with systemic lupus erythematosus generate a sustained immune response against self. The tools of modern molecular biology have been applied to cell activities and elements/signals of the immune system, but a structural or regulatory defect has not been found. When deoxyribonucleic acids for autoantibodies were cloned and sequenced, they were like other autoantibody DNA sequences; when genetic materials for autoantibodies were inserted into transgenic mice, cells secreting the antibodies were subject to normal control mechanisms and eliminated. A failure to clear self-reactive antibody producing thymocytes has not been demonstrated in human systemic lupus erythematosus. Molecular analyses of the efferent side of the immune response have been largely normal in systemic lupus erythematosus. The structure of autoantibodies suggests that they have been generated by selection pressures and the presence of endogenous antigens. If the immune system attack on self was secondary, structural changes and metabolic reactions capable of generating antigens should be found in systemic lupus erythematosus cells. Structural changes have been found in deoxyribonucleic acid from phytohaemagglutinin-stimulated systemic lupus erythematosus lymphocytes in the form of S1 nuclease-sensitive deoxyribonucleic acid breaks. Altered cellular macromolecules could result from endogenous metabolic processes, particularly oxygen free radicals and arachidonic acid metabolites. Excess free-radical species, generating positive nitroblue tetrazolium-reacting material and positive chemiluminescence, have been found in most but not all phytohaemagglutinin-stimulated lupus lymphocyte samples. If endogenous metabolic processes act on endogenous deoxyribonucleic acid, endogenous cell DNA breakdown may lead to low molecular weight deoxyribonucleic acids and deoxyribonucleic acid/immune complexes in systemic lupus erythematosus sera that are potentially immunogenic. These combined findings suggest that the exaggerated immune responses of systemic lupus erythematosus may be a normal response to protect the host from a perceived antigenic threat.

Multifocal white matter lesions

There is a long differential diagnosis for multifocal white matter lesions on MR. The most common causes are prominent Virchow-Robin spaces, white matter ischemic change, and multiple sclerosis, but many other causes have been reported. Most of these are related to vascular or other demyelinating etiologies, but infectious/inflammatory disease, trauma, and neoplastic and other unusual causes may also be responsible. Typical imaging features of the more common multifocal white matter disorders are outlined, and the rarer causes are discussed briefly. An approach to imaging differential diagnosis is given, with emphasis on the differences between white matter ischemic lesions and multiple sclerosis.

DSM-III-R classification of psychiatric symptoms in systemic lupus erythematosus

DSM-III-R criteria applied in the evaluation of 88 systemic lupus erythematosus patients revealed a point prevalence rate of 18.2% for psychiatric disorders, the most common diagnosis being adjustment disorder (11.4%). No patients had disorders compatible with a functional psychosis. Psychiatric morbidity was not associated with increased disease activity, corticosteroid use, brain magnetic resonance imaging abnormalities, or electroencephalogram abnormalities. High scores on a life event scale were associated with psychiatric disorders, suggesting that psychosocial stress is etiologically important. Cognitive testing showed that poor performance on the Stroop Colour-Word Inference Test was associated with psychiatric disorders.

Very severe amnesia with acute onset after isolated hippocampal damage due to systemic lupus erythematosus

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Neurologic manifestations of pediatric systemic lupus erythematosus

Central nervous system involvement is a common but rarely reviewed feature of pediatric systemic lupus erythematosus (SLE). We retrospectively reviewed the charts of 91 patients with pediatric SLE and using a standardized data abstraction form documented 40 patients with central nervous system (CNS-SLE) involvement. The mean age of onset of SLE was 13.3 years. In 19 patients the CNS manifestation was a presenting symptom, in 12 patients CNS involvement was present within the first year of diagnosis, and in 9 patients it took up to 7 years for CNS disease to become evident. Nineteen children (48%) manifested neuropsychiatric SLE, which included depression, concentration or memory problems, and frank psychosis. Seizures were present in 8 patients (20%), 6 had cerebral ischemic events (15%), 1 had chorea (3%), 2 had papilledema (5%), and 2 patients had a peripheral neuropathy (5%). Nine patients (22%) had severe headache consistent with lupus headache. Seven children had more than one CNS manifestation. In the investigation of CNS-SLE, computed tomography and/or magnetic resonance imaging scans were helpful in patients with focal ischemic lesions and venous sinus thrombosis. Electroencephalography was abnormal only in 33% of patients with seizure disorders and rarely helpful in patients with diffuse neuropsychiatric symptoms. Single-photon emission computed tomography scans were abnormal in most patients with neuropsychiatric SLE, especially in those with frank psychosis. The lupus anticoagulant was present in the patient with chorea and was frequently present in patients with cerebral vascular events. Long-term outcome was good: only 1 child died of cerebral hemorrhagic infarction and 3 others had significant persistent CNS deficits. The majority of patients (90%) had excellent recovery from CNS-SLE.

18FDG PET and acetazolamide-enhanced 99mTc-HMPAO SPET in systemic lupus erythematosus

In systemic lupus erythematosus (SLE), brain and kidney are the most frequently affected organs. Measurements of cerebral blood flow and metabolism by means of positron emission tomography (PET) and single-photon emission tomography (SPET) can contribute to the diagnostic assessment of the involvement of the central nervous system (CNS) in SLE. Functional imaging has been proven to be more sensitive than morphological imaging (magnetic resonance imaging and computed tomography). In this report, we present the case of a 70-year-old female patient, suffering from SLE without symptoms of CNS involvement. In addition to a SPET study using technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) and a PET scan with fluorine-18 deoxyglucose (18FDG), a SPET study after acetazolamide injection was performed in order to assess the cerebral perfusion reserve. While the PET scan showed no major abnormalities, and the baseline SPET study revealed only minor changes, the acetazolamide-enhanced SPET study revealed a marked reduction of the cortical perfusion reserve, particularly in both frontal lobes. It is concluded that "preclinical" CNS involvement, mainly caused by pathological mechanisms involving the cerebral blood vessels, can be considered to exist in this patient with SLE.

Subdural fluid collections: an unusual manifestation of CNS disease in a connective tissue disorder

We describe a case of autoimmune cerebritis/meningitis presenting as altered mental status that was associated with subdural fluid collections in a connective tissue disorder patient. The fluid collections cleared following high dose corticosteroid therapy and the patient's clinical status improved promptly. Subdural fluid collections have not been previously reported as a manifestation of autoimmune CNS disease.

Central nervous system involvement in systemic lupus erythematosus: a new therapeutic approach with intrathecal dexamethasone and methotrexate

In systemic lupus erythematosus (SLE), neurological involvement has been reported to occur with frequencies ranging from 14% (severe cases) to 83% (mild forms included). In spite of early diagnosis and aggressive treatment, neuropsychiatric SLE may represent a serious problem of management. We describe three cases, one with acute transverse myelitis, one with hemiparesis, and one with signs of focal and diffuse cerebral dysfunction, in whom improvement following intrathecal therapy with methotrexate and dexamethasone was observed.

Recurrent opticomyelitis associated with anti-DNA antibody

Two patients had frequent attacks of acute myelitis and optic neuritis. One patient lacked any other organ involvement whereas the other developed systemic manifestations of systemic lupus erythematosus 14 years after the onset. Both patients developed antinuclear and antidouble strand DNA antibodies after the onset of neurological involvement. These patients, whose neurological manifestations were indistinguishable from multiple sclerosis, were thus considered to have systemic lupus erythematosus related collagen disease.

Lupus nephritis in childhood and adolescence

Lupus nephritis in childhood usually presents after the age of 10 years, and presentation under 5 years is very rare. More males (F:M ratio 4.5:1) are affected than in adult-onset cases, but the ratio is the same in prepubertal and pubertal children. The incidence of clinically evident renal disease is greater at onset than in adults (82%), the usual presentation being with proteinuria, 50% having a nephrotic syndrome. Half the children show World Health Organisation class IV nephritis in renal biopsies. Neuropsychiatric lupus is present at onset in 30%, may complicate 50% at some point and remains a major problem. Prognosis has improved greatly over the past 30 years, at least in part the result of immunosuppressive treatment. Treatment of the initial phase may be guided by the severity of the renal biopsy appearances, more aggressive treatment including cytotoxic agents, i.v. methylprednisolone and perhaps plasma exchange, although the value of exchange is not established. Controversy persists as to the most effective cytotoxic treatment in the acute phase, both oral and i.v. cyclophosphamide and azathioprine being used in different units. In the chronic maintenance phase it seems established both clinically and histologically that addition of a cytotoxic agent improves outcome, but again the drug and route of administration are contentious. Azathioprine has the advantage of being safe for pregnancy and not gonadotoxic, whilst i.v. cyclophosphamide has been demonstrated to improve results over prednisolone alone in controlled trials and has advantages in non-compliant patients. No trial comparing the two regimes has been carried out, and one is needed. Today children much less commonly go into renal failure, and the main causes of actual death (15% of patients over 10 years) are now infections and extra-renal manifestations of lupus, principally neurological. Morbidity of the disease and the treatment remain a major problem, especially when treatment exacerbates complications of the disease itself, such as infections, osteonecrosis, thrombosis, vascular disease and possibly neoplasia.

Co-twin control study on cerebral manifestations of systemic lupus erythematosus

All available twin pairs systemic lupus erythematosus (SLE) derived from the Finnish Twin Cohort were studied by clinical evaluation, magnetic resonance imaging (MRI), anticardiolipin (aCL), and antineurofilament (ANFA) antibodies. One of the five monozygotic and one of the eight dizygotic pairs were concordant for SLE. 10 of the 15 patients showed clinical neurological abnormalities, and 11 had abnormal MRI of the brain. Altogether, 12 patients were considered to have neuropsychiatric lupus (NPSLE). Seven of the 11 patients with long-term corticosteroid treatment had either central or cortical atrophy. High or moderate aCL level was found in eight patients and two co-twins. Of them, six patients had at least two manifestations of the antiphospholipid syndrome. ANFAs were found in five patients and four co-twins. Five co-twins fulfilled some of the SLE criteria. Of them, three MZ twins and one additional DZ co-twin with no ARA criteria had findings suggesting central nervous system (CNS) involvement. The results indicate that the majority of SLE patients has cerebral abnormalities either as a result of SLE, or concomitant risk factors. The co-twins without clinical SLE often have minor signs of SLE, and even they may have neurological and MRI abnormalities. However, their aCL and ANFA levels seem not to correlate with MRI abnormalities.

Nervous system involvement in systemic lupus erythematosus, Sjögren syndrome and scleroderma

INTRODUCTION

The purpose of this study was to determine, whether there are any differences in the occurrence of nervous system involvement in different systemic rheumatic diseases. The further aim of the present study was to identify and distinguish primary involvement of the nervous system by these diseases and involvement that may be secondary to confounding factors.

MATERIAL AND METHODS

The patient population consisted of 122 patients with a connective tissue disease (42 with systemic lupus erythematosus (SLE), 48 with Sjögren's syndrome and 32 with scleroderma). The methods included neurological examination and standard electrophysiological tests.

RESULTS

At least one neurological defect was diagnosed in 69% of SLE patients, in 71% of Sjögren's syndrome patients and in 66% of scleroderma patients. Secondary factors might have contributed to the pathogenesis of neurological symptoms and signs in up to 25-34% of events.

CONCLUSION

No significant differences were noted in the occurrence of neurological events in patients with SLE, Sjögren's syndrome and scleroderma. The necessity to differentiate between neurological phenomena directly attributed to the systemic rheumatic disease and those which are totally unrelated or secondary events resulting indirectly from involvement of other organ systems is emphasized.

Single-photon-emission computed tomography analysis of cerebral blood flow in the evaluation of central nervous system involvement in patients with systemic lupus erythematosus

OBJECTIVE

Single-photon-emission computed tomography (SPECT) scanning was used to detect potential central nervous system (CNS) involvement in patients with systemic lupus erythematosus (SLE), by determining cerebral blood flow abnormalities.

METHODS

SPECT scans were performed on 35 SLE patients, grouped into 3 categories: those without neuropsychiatric symptoms (n = 10), those with definite neurologic or psychiatric disorders (n = 10), and those with mild symptoms such as headache or memory disturbances (n = 15). SPECT scan features were classified as normal or as focal or diffuse defects in uptake.

RESULTS

SPECT findings were normal in 9 of the 10 patients without CNS symptoms, and abnormal in 9 of the 10 patients with overt neuropsychiatric disease (with motor or sensory deficits). Interestingly, only 4 of the 15 patients (26.7%) with mild symptoms suggestive of CNS disease had normal SPECT findings; the 11 remaining patients showed focal (53.3%) or diffuse (20%) uptake defects. An association between SPECT findings and disease duration was also observed, but there was no correlation of SPECT results with overall disease activity, serologic findings, or medications used.

CONCLUSION

Our data suggest that in a substantial proportion of patients, SPECT analysis may provide additional information on potential CNS involvement, and may therefore be useful in therapeutic decision-making and disease monitoring in order to prevent CNS damage.

Brain reactive monoclonal auto-antibodies: production and characterization

To determine the role of auto-antibodies in the pathogenesis of neuropsychiatric manifestations of systemic lupus erythematosus (NP-SLE), it will be necessary to characterize the diversity of auto-antibodies that exist. This can be done by producing a library of monoclonal, brain-reactive auto-antibodies. From such a library the antigens to which the antibodies bind, and whether there are any interesting relations between these antigens, can be determined. Behavioral effects can also be investigated. Toward these ends, brain-reactive monoclonal auto-antibodies (BRMA) were produced. The production and characterization of two monoclonal antibodies is presented in this study.