Systemic lupus erythematosus

The Effect of Antiestrogen Agents on Risk of Autoimmune Disorders in Patients with Breast Cancer

Objective.

To investigate the relationship between antiestrogen therapy in women with breast cancer and risk of autoimmune disease.

Methods.

We used a national database to assess the incidence of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) following treatment with selective estrogen receptor modulators (SERM) or aromatase inhibitors (AI) in women with breast cancer. The total number of patients in our study was 190,620.

Results.

We observed highly significant, cumulative dose-dependent increased OR of incidence of both SLE and RA following treatment with SERM (p < 0.0001). The odds of developing RA were also increased following AI therapy (p < 0.001), but there was a trend for reduced odds of SLE, though this trend did not attain statistical significance (p = 0.070 for 2–11 months of treatment and p = 0.254 for 12+ months of treatment).

Conclusion.

Antiestrogen agents may have an important effect on risk of autoimmune disease.

Neuropsychiatric systemic lupus erythematosus and cognitive dysfunction: the MRL-lpr mouse strain as a model

Mouse models of autoimmunity, such as (NZB×NZW)F1, MRL/MpJ-Fas(lpr) (MRL-lpr) and BXSB mice, spontaneously develop systemic lupus erythematosus (SLE)-like syndromes with heterogeneity and complexity that characterize human SLE. Despite their inherent limitations, such models have highly contributed to our current understanding of the pathogenesis of SLE as they provide powerful tools to approach the human disease at the genetic, cellular, molecular and environmental levels. They also allow novel treatment strategies to be evaluated in a complex integrated system, a favorable context knowing that very few murine models that adequately mimic human autoimmune diseases exist. As we move forward with more efficient medications to treat lupus patients, certain forms of the disease that requires to be better understood at the mechanistic level emerge. This is the case of neuropsychiatric (NP) events that affect 50-60% at SLE onset or within the first year after SLE diagnosis. Intense research performed at deciphering NP features in lupus mouse models has been undertaken. It is central to develop the first lead molecules aimed at specifically treating NPSLE. Here we discuss how mouse models, and most particularly MRL-lpr female mice, can be used for studying the pathogenesis of NPSLE in an animal setting, what are the NP symptoms that develop, and how they compare with human SLE, and, with a critical view, what are the neurobehavioral tests that are pertinent for evaluating the degree of altered functions and the progresses resulting from potentially active therapeutics.

Systemic lupus erythematosus and thyroid disease: A 10-year study

BACKGROUND

This large-scale study aims to analyze the association of systemic lupus erythematosus (SLE) with thyroid diseases.

METHODS

In this retrospective, nationwide cohort study, 1633 newly diagnosed SLE patients from the National Health Insurance Research Database in 2000 were examined and data on patients with diagnoses of hyperthyroidism, hypothyroidism, and autoimmune thyroiditis were collected from 2000 to 2009. We subdivided these SLE patients by the presence of overlap syndrome. Comparison with 6532 age- and sex-matched controls was performed.

RESULTS

The cumulative incidence of thyroid disease in SLE patients was lower than in controls (8.1% vs. 16.9%, p < 0.001). Among SLE patients, 39.7% had overlap syndrome. The overlap syndrome group had a higher cumulative incidence of thyroid diseases (10.96% vs. 4.57%, p < 0.0001), hypothyroidism (3.86% vs. 1.93%, p = 0.017), and autoimmune thyroiditis (4.63% vs. 0.71%, p < 0.0001) than SLE patients without overlap syndrome. Comparing the data with the non-SLE-matched control group by logistic regression model revealed a decreased risk of thyroid diseases with odds ratios (ORs) of 0.25 and 0.62 [95% confidence interval (CI) 0.18-0.33, 0.48-0.80], and hyperthyroidism with ORs of 0.21 and 0.30 (95% CI 0.14-0.31, 0.20-0.45) in SLE patients without and with overlap syndrome. SLE patients without overlap syndrome had a lower risk of hypothyroidism with an OR of 0.53 (95% CI 0.53-0.86) and autoimmune thyroiditis with an OR of 0.26 (95% CI 0.12-0.56). SLE patients with overlap syndrome showed a similar risk of hypothyroidism with an OR of 0.92 (95% CI 0.66-1.53) and a higher risk of autoimmune thyroiditis with OR of 1.69 (95% CI 1.14-2.51).

CONCLUSION

SLE patients had a significantly lower rate of thyroid diseases and hyperthyroidism than matched controls. Among SLE patients, risks of hypothyroidism and autoimmune thyroiditis were different in the presence of overlap syndrome. This finding is novel and important for clinical practices.

Infections and systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that presents a protean spectrum of clinical manifestations, and may affect any organ. The typical course of SLE is insidious, slow, and progressive, with potential exacerbations and remissions, and even dramatically acute and rapidly fatal outcomes. Recently, infections have been shown to be highly associated with the onset and/or exacerbations of SLE, and their possible causative and/or protective role has been largely emphasized in the medical literature. However, the etiopathogenesis of SLE is still obscure and far from being completely elucidated. Among infections, particularly Epstein-Barr virus (EBV), parvovirus B19, retrovirus, and cytomegalovirus (CMV) infections might play a pivotal pathogenetic role. The multifaceted interactions between infections and autoimmunity reveal many possibilities for either causative or protective associations. Indeed, some infections, primarily protozoan infections, might confer protection from autoimmune processes, depending on the unique interaction between the microorganism and host. Further studies are needed in order to demonstrate that infectious agents might, indeed, be causative of SLE, and to address the potential clinical sequelae of infections in the field of autoimmunity.

Association of extended interleukin-10 promoter haplotypes with disease susceptibility and manifestations in German patients with systemic lupus erythematosus

OBJECTIVES

Associations of interleukin-10 (IL-10) promoter single nucleotide polymorphisms (SNPs) and their haplotypes with systemic lupus erythematosus (SLE) are unclear. We extended the analysis of established proximal IL-10 promoter haplotypes to a more distal SNP with functional capacity.

METHODS

Two hundred and ten German caucasian SLE patients fulfilling the ACR criteria and 160 ethnically, age and sex matched controls were genotyped for IL-10 -2849 G > A, -1082 A > G, -819 T > C and -592 C > A. Haplotypes were reconstructed via a mathematical model, then allele and haplotype distributions were compared between patients and controls and patients with different disease manifestations.

RESULTS

We detected at -2849, -1082, -819 and -592 the four predominant haplotypes GGCC (22% in patients vs. 29% in controls), AGCC (24% vs. 21%), GACC (30% vs. 25%) and GATA (24% vs. 24%). GGCC was underrepresented in SLE patients, suggesting a protective effect (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.48-0.94). AGCC was found significantly more frequently in patients with pathognomonic anti-dsDNA antibodies (26% vs. 15%; OR 1.98, 95% CI 1.04-3.75). As compared to patients with glomerulonephritis type V (WHO classification), the presumptive IL-10 high producer allele -2849 G was found significantly more often in patients with GN type III/IV (93% vs. 60%; OR 8.7, 95% CI 1.59-47.15).

CONCLUSION

Our data confirm that the complexity of the IL-10 promoter evokes the need for a meticulous analysis of its haplotypic structure in order to specify disease associations, particularly under functional aspects, thereby shedding light on the pathophysiology of SLE.

Pathogenesis and prevention of rheumatic disease: focus on preclinical RA and SLE

Established and emerging data demonstrate that a 'preclinical' period of disease precedes the onset of clinical rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), as well as other autoimmune rheumatic diseases (ARDs).This preclinical stage of development of disease is characterized by abnormalities in disease-related biomarkers before the onset of the clinically apparent signs and symptoms. Numerous genetic and environmental risk factors for ARDs have also been identified, and many of these factors are likely to act before the clinical appearance of tissue injury to initiate and/or propagate autoimmunity and autoimmune disease. Thus, biomarkers representative of these autoimmune processes could potentially be used in conjunction with other clinical parameters during the preclinical period of ARDs to predict the future development of clinically apparent disease. This Review focuses on the preclinical stages of RA and SLE, as our current understanding of these diseases can be used to present an overall model of the development of ARDs that might ultimately be used to develop screening programmes and preventive strategies. Important considerations for the future development of such approaches, in particular, the issues that require additional research and how they might be addressed, are also discussed.

Sudden death due to lupus-induced pancarditis diagnosed after necropsy: a case report

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disease affecting many organs and which is predominant in females. Although various manifestations of SLE may result in sudden death, pancarditis is very rarely encountered in forensic practice. We report on a case of sudden death caused by lupus-induced pancarditis. A 24-year-old male had pneumonia and intractable fever as initial signs when he was admitted to hospital. The patient had no symptoms associated with the cardiovascular system up to 3 days before he died. The echocardiogram and electrocardiogram were normal and diagnosis was not made until necropsy. This case is reported to broaden our understanding about the complexity of manifestations associated with SLE and inform clinicians and medical examiners of the potential for this type of lupus-induced pancarditis.

Clinical aspects of autoimmune rheumatic diseases

Multisystem autoimmune rheumatic diseases are heterogeneous rare disorders associated with substantial morbidity and mortality. Efforts to create international consensus within the past decade have resulted in the publication of new classification or nomenclature criteria for several autoimmune rheumatic diseases, specifically for systemic lupus erythematosus, Sjögren's syndrome, and the systemic vasculitides. Substantial progress has been made in the formulation of new criteria in systemic sclerosis and idiopathic inflammatory myositis. Although the autoimmune rheumatic diseases share many common features and clinical presentations, differentiation between the diseases is crucial because of important distinctions in clinical course, appropriate drugs, and prognoses. We review some of the dilemmas in the diagnosis of these autoimmune rheumatic diseases, and focus on the importance of new classification criteria, clinical assessment, and interpretation of autoimmune serology. In this era of improvement of mortality rates for patients with autoimmune rheumatic diseases, we pay particular attention to the effect of leading complications, specifically cardiovascular manifestations and cancer, and we update epidemiology and prognosis.

Neuropsychiatric systemic lupus erythematosus: magnetic resonance imaging findings and correlation with clinical and immunological features

Neuropsychiatric (NP) syndromes are a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). The aims of this work were to describe the brain abnormalities in a group of SLE patients during their first episode of NP manifestations using a conventional magnetic resonance imaging (MRI) technique and to investigate the possible correlation between these findings and the clinical and immunological characteristics of these patients. We performed an observational retrospective cross-sectional study that included all patients with NP symptoms who underwent MRI at the Hospital Clinic of Barcelona between the years 2003 and 2012 because of suspecting NP syndromes due to SLE (NPSLE). We studied 43 patients in which 11 types of NPSLE were present, being headache the most frequent, followed by cerebrovascular disease, epileptic crises and cranial neuropathy. A statistically significant association was found between myelopathy and low complement (C4) levels (p=0.035) and disease activity measured as SLE Disease Activity Index (SLEDAI) >4 (p=0.00006). Eighteen (41.9%) patients presented MRI abnormalities. We found an association between myelopathy and the presence of inflammatory or mixed (vascular and inflammatory) type lesions (p=0.003). This pattern was also associated with a high SLEDAI score (p=0.002) and low complement (CH50) levels (p=0.032). We found no relationship between MRI changes and age, time of evolution, or the presence of antiphospholipid or anti-dsDNA antibodies. These results suggest that MRI, although it is the imaging modality of choice in the present moment, by itself does not establish or exclude the diagnosis of NPSLE. In addition, the presence of certain disease activity features (SLEDAI and low complement levels) seems to be associated with the presence of an inflammatory pattern on MRI.

Are RASopathies new monogenic predisposing conditions to the development of systemic lupus erythematosus? Case report and systematic review of the literature

OBJECTIVE

RASopathies (Noonan syndrome (NS) and Noonan-related syndromes) are neurodevelopmental syndromes resulting from germline mutations in genes that participate in the rat sarcoma/mitogen-activated protein kinases (RAS/MAPK) pathway (PTPN11, SOS1, RAF, KRAS or NRAS, and SHOC2). Some monogenic conditions are associated with the development of systemic lupus erythematosus (SLE), and a few reports described the association of SLE with NS. We aim to search for a relationship between RASopathy and the development of SLE.

METHODS

We reported for the first time a case of 13-year-old boy with NS with loose anagen hair (NSLAH) resulting from mutation in SHOC2 who developed an autoimmune disorder that fulfilled four American College of Rheumatology (ACR) criteria for the classification of SLE (polyarthritis, pericarditis, antinuclear antibodies, and anti-DNA antibodies). The case report then prompted a literature review by a systematic search for English and French articles on the subjects of RASopathies and SLE that had English abstracts in PubMed from 1966 to 2012.

RESULTS

We identified seven additional patients with RASopathy and SLE. The male-to-female ratio was 1:1 and age at onset of SLE ranged from 5 to 32 years. The most common features were polyarthritis (7/8 patients), autoimmune cytopenia (4/8 patients), and pericarditis (4/8 patients) while only one patient presented with skin involvement.

CONCLUSION

The association of two rare diseases in eight patients suggests that RASopathies may be associated with the development of SLE, which is characterized by a higher male-to-female ratio, a lower rate of skin involvement, and a higher rate of pericarditis than "classic" SLE.

Mood, anxiety and personality disorders in patients with systemic lupus erythematosus

OBJECTIVE

This study presents the current prevalence of mood, anxiety and personality disorders and factors associated with the existence of psychiatric disorders in patients with systemic lupus erythematosus (SLE).

METHODS

The study sample was comprised of 45 patients with SLE and 60 control subjects. Mood and anxiety disorders were ascertained by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version. Personality disorders were diagnosed with the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders. The disease activity was assessed with SLE Disease Activity Index.

RESULTS

Of the 45 patients, 21 (46.7%) had at least one mood or anxiety disorder, and 16 (35.6%) had at least one personality disorder. The most common Axis I and Axis II diagnoses in the patient group were major depression (22.2%) and obsessive-compulsive personality disorder (20.0%), respectively. Specifically, major depression, generalized anxiety disorder and obsessive-compulsive personality disorder were more prevalent in the SLE group compared to the control group. The existence of Axis I disorders was associated with a more severe disease activity of SLE.

CONCLUSION

Mood and anxiety disorders, particularly major depression and generalized anxiety disorder, are frequently observed in patients with SLE.

Biomarkers for systemic lupus erythematosus

In recent years, biomarkers have shown significant promise in helping decision-making in drug development. Systemic lupus erythematosus (SLE) is a complicated and highly heterogeneous disease that involves all organs. Only one drug, belimumab, has been approved by the US Food and Drug Administration to treat SLE during the last 50 years and there remains a high unmet medical need to develop new and effective therapies to benefit different patient populations in SLE. Due to the extreme heterogeneity of the disease and the complex and rigorous process to validate individual biomarkers, there is currently a very limited number of consensus biomarkers to aid the treatment decision-making in SLE. This review provides a snapshot of some biomarkers in the field that have the potential to make a big impact on drug development and/or treatment decisions by physicians. These include: type I interferon (IFN) gene signature as a pharmacodynamic marker and potential predictive marker for anti-type I IFN therapy; anti-double stranded DNA as a disease marker and potential predictive marker for flares; the complements and neutrophil signatures as disease marker of SLE; and TWEAK (a tumor necrosis factor family member produced by macrophages) and MCP-1 as potential markers to predict renal flares. Most of these markers need carefully planned and prospective studies with high statistical power to confirm their respective utilities. With the development and application of powerful new technologies, more successful biomarkers will emerge in SLE. This could improve the management of patients in the clinic and facilitate the development of novel and more effective therapeutics for this difficult-to-treat disease.

Balance between regulatory T and Th17 cells in systemic lupus erythematosus: the old and the new

Pathogenic mechanisms underlying the development of systemic lupus erythematosus (SLE) are very complex and not yet entirely clarified. However, the pivotal role of T lymphocytes in the induction and perpetuation of aberrant immune response is well established. Among T cells, IL-17 producing T helper (Th17) cells and regulatory T (Treg) cells represent an intriguing issue to be addressed in SLE pathogenesis, since an imbalance between the two subsets has been observed in the course of the disease. Treg cells appear to be impaired and therefore unable to counteract autoreactive T lymphocytes. Conversely, Th17 cells accumulate in target organs contributing to local IL-17 production and eventually tissue damage. In this setting, targeting Treg/Th17 balance for therapeutic purposes may represent an intriguing and useful tool for SLE treatment in the next future. In this paper, the current knowledge about Treg and Th17 cells interplay in SLE will be discussed.

Occupational risk factors for systemic lupus erythematosus: a nationwide study based on hospitalizations in Sweden

OBJECTIVE

To investigate possible associations between occupation and hospitalization for systemic lupus erythematosus (SLE) in a nationwide study.

METHODS

A nationwide database was constructed in Sweden by linking the Swedish Census to the Hospital Discharge Register to obtain data on all first hospitalizations with a primary or secondary diagnosis of SLE in adults during the study period (1970 to 2008). Standardized incidence ratios (SIR) and 95% CI were calculated for different occupations. Two cohorts were defined based on occupational titles recorded in Swedish census data in 1970 and 1980.

RESULTS

A total of 8921 male and 42290 female hospitalizations for SLE were retrieved in individuals aged over 15 years. High education (> 12 yrs) was associated with a lower risk of hospitalization for SLE among both women (SIR = 0.73) and men (SIR = 0.72). Among men with the same occupation in 2 consecutive censuses, increased risks (SIR) > 2.0 were present among artistic workers (2.52); shop managers and assistants (3.63); miners and quarry workers (6.04); shoe and leather workers (6.93); plumbers (2.21); other construction workers (2.08); glass, ceramic and tile workers (4.43); chimney sweeps (4.54); and military personnel (3.01). Among women with the same occupation in 2 consecutive censuses, no occupation was associated with SIR > 2.0.

CONCLUSION

Occupation may carry significantly increased risk of hospital admission for SLE. Especially among men, several occupations were associated with increased risks for SLE.

What's out there making us sick?

Throughout the continuum of medical and scientific history, repeated evidence has confirmed that the main etiological determinants of disease are nutritional deficiency, toxicant exposures, genetic predisposition, infectious agents, and psychological dysfunction. Contemporary conventional medicine generally operates within a genetic predestination paradigm, attributing most chronic and degenerative illness to genomic factors, while incorporating pathogens and psychological disorder in specific situations. Toxicity and deficiency states often receive insufficient attention as common source causes of chronic disease in the developed world. Recent scientific evidence in health disciplines including molecular medicine, epigenetics, and environmental health sciences, however, reveal ineluctable evidence that deficiency and toxicity states feature prominently as common etiological determinants of contemporary ill-health. Incorporating evidence from historical and emerging science, it is evident that a reevaluation of conventional wisdom on the current construct of disease origins should be considered and that new knowledge should receive expeditious translation into clinical strategies for disease management and health promotion.

An analysis of almost any scientific problem leads automatically to a study of its history.

—Ernst Mayr