101
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Abstract
Hypertension is an important risk factor for cardiovascular morbidity and mortality and for events such as myocardial infarction, stroke, heart failure and chronic kidney disease and is a major determinant of disability-adjusted life-years. Despite the importance of hypertension, the pathogenesis of essential hypertension, which involves the complex interaction of several mechanisms, is still poorly understood. Evidence suggests that interplay between bone marrow, microglia and immune mediators underlies the development of arterial hypertension, in particular through mechanisms involving cytokines and peptides, such as neuropeptide Y, substance P, angiotensin II and angiotensin-(1-7). Chronic psychological stress also seems to have a role in increasing the risk of hypertension, probably through the activation of neuroimmune pathways. In this Review, we summarize the available data on the possible role of neuroimmune crosstalk in the origin and maintenance of arterial hypertension and discuss the implications of this crosstalk for recovery and rehabilitation after cardiac and cerebral injuries.
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102
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Abstract
Lysosomes are membrane-bound organelles with roles in processes involved in degrading and recycling cellular waste, cellular signalling and energy metabolism. Defects in genes encoding lysosomal proteins cause lysosomal storage disorders, in which enzyme replacement therapy has proved successful. Growing evidence also implicates roles for lysosomal dysfunction in more common diseases including inflammatory and autoimmune disorders, neurodegenerative diseases, cancer and metabolic disorders. With a focus on lysosomal dysfunction in autoimmune disorders and neurodegenerative diseases - including lupus, rheumatoid arthritis, multiple sclerosis, Alzheimer disease and Parkinson disease - this Review critically analyses progress and opportunities for therapeutically targeting lysosomal proteins and processes, particularly with small molecules and peptide drugs.
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Affiliation(s)
- Srinivasa Reddy Bonam
- CNRS-University of Strasbourg, Biotechnology and Cell Signalling, Illkirch, France
- Laboratory of Excellence Medalis, Team Neuroimmunology and Peptide Therapy, Institut de Science et d'Ingénierie Supramoléculaire (ISIS), Strasbourg, France
| | - Fengjuan Wang
- CNRS-University of Strasbourg, Biotechnology and Cell Signalling, Illkirch, France
- Laboratory of Excellence Medalis, Team Neuroimmunology and Peptide Therapy, Institut de Science et d'Ingénierie Supramoléculaire (ISIS), Strasbourg, France
| | - Sylviane Muller
- CNRS-University of Strasbourg, Biotechnology and Cell Signalling, Illkirch, France.
- Laboratory of Excellence Medalis, Team Neuroimmunology and Peptide Therapy, Institut de Science et d'Ingénierie Supramoléculaire (ISIS), Strasbourg, France.
- University of Strasbourg Institute for Advanced Study, Strasbourg, France.
- Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg University, Strasbourg, France.
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103
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Hopia L, Andersson M, Svenungsson E, Khademi M, Piehl F, Tomson T. Epilepsy in systemic lupus erythematosus: prevalence and risk factors. Eur J Neurol 2019; 27:297-307. [DOI: 10.1111/ene.14077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/21/2019] [Indexed: 12/17/2022]
Affiliation(s)
- L. Hopia
- Department of Clinical Neuroscience Unit of Neurology Karolinska Institutet och Karolinska Universitetssjukhuset Solna, StockholmSweden
| | - M. Andersson
- Department of Clinical Neuroscience Unit of Neurology Karolinska Institutet och Karolinska Universitetssjukhuset Solna, StockholmSweden
| | - E. Svenungsson
- Department of Medicine Unit of Rheumatology Karolinska Institutet and Karolinska University Hospital Solna, Stockholm Sweden
| | - M. Khademi
- Department of Clinical Neuroscience Unit of Neurology Karolinska Institutet och Karolinska Universitetssjukhuset Solna, StockholmSweden
| | - F. Piehl
- Department of Clinical Neuroscience Unit of Neurology Karolinska Institutet och Karolinska Universitetssjukhuset Solna, StockholmSweden
| | - T. Tomson
- Department of Clinical Neuroscience Unit of Neurology Karolinska Institutet och Karolinska Universitetssjukhuset Solna, StockholmSweden
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104
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Imam MH, Koriem HK, Hassan MM, El-Hadidi AS, Ibrahim NA. Pattern of peripheral neuropathy in systemic lupus erythematosus: clinical, electrophysiological, and laboratory properties and their association with disease activity. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/err.err_28_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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105
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Zeng J, Meng X, Zhou P, Yin Z, Xie Q, Zou H, Shen N, Ye Z, Tang Y. Interferon-α exacerbates neuropsychiatric phenotypes in lupus-prone mice. Arthritis Res Ther 2019; 21:205. [PMID: 31481114 PMCID: PMC6724270 DOI: 10.1186/s13075-019-1985-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022] Open
Abstract
Background Neuropsychiatric systemic lupus erythaematosus (NP-SLE) is one of the major manifestations of lupus. However, the mechanisms involved in NP-SLE are still largely unknown. The abnormal activation of the type I IFN signalling pathway is involved in SLE pathogenesis and is linked to NP-SLE, but the effect of IFN-α on NP-SLE encephalopathy has not been systematically studied. Methods An intravenous injection of Adv-IFN-α (10 mice, 10 × 109 vp) was administered to the IFN-α-treated group, and Adv-ctrl (10 mice, 10 × 109 vp) (ViGene Biosciences, China) was administered to the control group. Gene expression was determined by real-time quantitative polymerase chain reaction (RT-qPCR). Enzyme-linked immunosorbent assay (ELISA) was used to detect antibodies in the serum, and urinary protein levels were measured with a BCA Protein Assay kit. Haematoxylin-eosin (H&E) and periodic acid-Schiff (PAS)-light green staining were used for kidney histology. The elevated plus-maze test, novelty-suppressed feeding assay, open-field test, tail suspension test, social dominance tube test, three-chamber social interaction test, step-down passive avoidance test and novelty Y-maze task were used to assess behaviour. Results In this study, we performed a series of behavioural tests to assess the neuropsychiatric phenotypes of IFN-α-treated NZB/NZW F1 mice and found that these mice developed a series of mental disorders such as anxiety-like phenotypes, depression-like phenotypes, deficits in sociability and cognitive impairments, which mimic the neuropsychiatric manifestations of NP-SLE, with a consistent onset and progression. Conclusions Our research verified that IFN-α plays a critical role in NP-SLE and provides a comprehensive NP-SLE mouse model for dissecting the mechanisms of NP-SLE and developing novel therapies for intervention. Electronic supplementary material The online version of this article (10.1186/s13075-019-1985-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jing Zeng
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Shan Dong Road (c), Shanghai, China
| | - Xinyu Meng
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Shan Dong Road (c), Shanghai, China
| | - Ping Zhou
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Shan Dong Road (c), Shanghai, China
| | - Zhihua Yin
- Shenzhen Futian Hospital for Rheumatic Diseases, 22 Nong Lin Road, Shenzhen, China
| | - Qinglian Xie
- Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS), University of Chinese Academy of Sciences, 320 Yueyang Road, Shanghai, China
| | - Hong Zou
- Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS), University of Chinese Academy of Sciences, 320 Yueyang Road, Shanghai, China
| | - Nan Shen
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Shan Dong Road (c), Shanghai, China. .,Shenzhen Futian Hospital for Rheumatic Diseases, 22 Nong Lin Road, Shenzhen, China. .,Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS), University of Chinese Academy of Sciences, 320 Yueyang Road, Shanghai, China. .,State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, 2200 Lane 25 Xietu Road, Shanghai, China. .,Collaborative Innovation Center for Translational Medicine, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Er Road, Shanghai, China. .,Center for Autoimmune Genomics and Etiology (CAGE), Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA.
| | - Zhizhong Ye
- Shenzhen Futian Hospital for Rheumatic Diseases, 22 Nong Lin Road, Shenzhen, China.
| | - Yuanjia Tang
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 145 Shan Dong Road (c), Shanghai, China. .,Shenzhen Futian Hospital for Rheumatic Diseases, 22 Nong Lin Road, Shenzhen, China.
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106
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Kello N, Anderson E, Diamond B. Cognitive Dysfunction in Systemic Lupus Erythematosus: A Case for Initiating Trials. Arthritis Rheumatol 2019; 71:1413-1425. [PMID: 31102496 PMCID: PMC6716992 DOI: 10.1002/art.40933] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/14/2019] [Indexed: 12/25/2022]
Abstract
Cognitive dysfunction (CD) is an insidious and underdiagnosed manifestation of systemic lupus erythematosus (SLE) that has a considerable impact on quality of life, which can be devastating. Given the inconsistencies in the modes of assessment and the difficulties in attribution to SLE, the reported prevalence of CD ranges from 5% to 80%. Although clinical studies of SLE-related CD have been hampered by heterogeneous subject populations and a lack of sensitive and standardized cognitive tests or other validated objective biomarkers for CD, there are, nonetheless, strong data from mouse models and from the clinical arena that show CD is related to known disease mechanisms. Several cytokines, inflammatory molecules, and antibodies have been associated with CD. Proposed mechanisms for antibody- and cytokine-mediated neuronal injury include the abrogation of blood-brain barrier integrity with direct access of soluble molecules in the circulation to the brain and ensuing neurotoxicity and microglial activation. No treatments for SLE-mediated CD exist, but potential candidates include agents that inhibit microglial activation, such as angiotensin-converting enzyme inhibitors, or that protect blood-brain barrier integrity, such as C5a receptor blockers. Structural and functional neuroimaging data have shown a range of regional abnormalities in metabolism and white matter microstructural integrity in SLE patients that correlate with CD and could in the future become diagnostic tools and outcome measures in clinical trials aimed at preserving cognitive function in SLE.
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Affiliation(s)
- Nina Kello
- Institute of Molecular Medicine, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, USA
| | - Erik Anderson
- Elmezzi Graduate School, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, USA
| | - Betty Diamond
- Institute of Molecular Medicine, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, USA
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107
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Huang MW, Stock AD, Mike EV, Herlitz L, Kolbeck R, Putterman C. Anti-IFNAR treatment does not reverse neuropsychiatric disease in MRL/ lpr lupus mice. Lupus 2019; 28:1510-1523. [PMID: 31474191 DOI: 10.1177/0961203319872265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Many systemic lupus erythematosus patients display a type I interferon (IFN) signature, and IFNα levels positively correlate with disease severity. Previous studies blocking the type I IFN pathway systemically in lupus models showed some beneficial effects. However, its effects on neuropsychiatric manifestations have yet to be carefully assessed, even though IFNα has been associated with induction of depression. Our aim was to investigate whether disrupting the type I IFN pathway would attenuate the development of murine neuropsychiatric lupus. METHODS Female MRL/lpr mice were administered an antitype I IFN receptor (IFNAR) antibody or a control antibody intraperitoneally three times weekly for 12 weeks starting at age 4-5 weeks. Behavior was assessed during and at the end of the treatment schedule. RESULTS No significant differences were seen between the anti-IFNAR- and control-treated mice when assessing for depression-like behavior or cognitive dysfunction, although anti-IFNAR antibody-treated mice displayed significant decreases in levels of IFN-stimulated genes. Anti-IFNAR treatment also did not significantly improve brain histology, cellular infiltration, or blood-brain barrier integrity. CONCLUSIONS Surprisingly, our results showed no improvement in neuropsychiatric disease and suggest that the role of IFNAR signaling in the pathogenesis of neuropsychiatric lupus continues to need to be carefully assessed.
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Affiliation(s)
- M W Huang
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - A D Stock
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - E V Mike
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - L Herlitz
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - R Kolbeck
- Research and Early Development, Respiratory, Inflammation and Autoimmune, Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - C Putterman
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA.,Division of Rheumatology, Albert Einstein College of Medicine, Bronx, NY, USA
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108
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Abstract
Is systemic lupus erythematosus (SLE) is occurring more frequently now than in decades past? Despite improvements in the identification of patients with SLE, the development of new classification criteria, and the recognition of several biomarkers used alone or in combination, the diagnosis of SLE is still a challenge for clinicians, in particular early in the course of the disease, which makes the recognition of secular trends difficult to ascertain. Lacking a uniform definition of preclinical lupus or incomplete lupus, it is difficult to predict accurately which patients would go on to develop SLE. We will briefly review the classification criteria, early or preclinical SLE, the epidemiology of SLE, antinuclear antibodies-negative SLE, and biomarkers of the disease.
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Affiliation(s)
- M F Ugarte-Gil
- Rheumatology Department, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
- School of Medicine, Universidad Científica del Sur, Lima, Perú
| | - L A González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - G S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, USA
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Perú
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109
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de Amorim JC, Torricelli AK, Frittoli RB, Lapa AT, Dertkigil SSJ, Reis F, Costallat LT, França Junior MC, Appenzeller S. Mimickers of neuropsychiatric manifestations in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2019; 32:623-639. [PMID: 31203921 DOI: 10.1016/j.berh.2019.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Systemic lupus erythematosus (SLE), presenting with new onset or worsening neuropsychiatric (NP) symptoms, is a challenge in clinical practice. Mimickers such as infections, drug-induced side effects, metabolic abnormalities, malignancies, and alcohol-related disorders have to be excluded, before attributing the manifestations to disease activity. Proper diagnosis is essential to guide adequate management and reduce morbidity and mortality. In this review article, we will highlight clinical, laboratorial, and neuroradiological features that are helpful to assist in the differential diagnosis.
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Affiliation(s)
- Jaqueline Cristina de Amorim
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil; Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil
| | | | - Renan Bazuco Frittoli
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil; Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Brazil
| | - Aline Tamires Lapa
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil; Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil
| | | | - Fabiano Reis
- Department of Radiology, School of Medical Science, University of Campinas, Brazil
| | - Lilian Tl Costallat
- Rheumatology Unit, Department of Medicine, School of Medical Science, University of Campinas, Brazil
| | | | - Simone Appenzeller
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil; Rheumatology Unit, Department of Medicine, School of Medical Science, University of Campinas, Brazil.
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110
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Intracerebroventricular administration of lupus serum induces microglia activation and leukocyte adhesion in the cerebromicrovasculature of mice. J Neuroimmunol 2019; 334:576994. [PMID: 31207553 DOI: 10.1016/j.jneuroim.2019.576994] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 05/28/2019] [Accepted: 06/09/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Central nervous system (CNS) involvement is commonly seen in the patients with system lupus erythematosus (SLE). Mechanisms underlying CNS damage in SLE remain largely unknown. Accumulating evidence suggest that activation of microglia in CNS plays an important role in the inflammatory responses in neurological diseases. The aim of this study is to examine the involvement of microglia in the CNS inflammatory responses induced by circulating serum of SLE patients. METHODS We performed intracerebroventricular (ICV) injection of serums collected from SLE patients or healthy controls to mice, and examined phenotypic changes of microglia, the levels of cytokines, chemokine and adhesion molecules in the brain. Intravital microscopy was used to observe leukocyte rolling and adhesion in the cerebromicrovasculature. We further examined whether minocycline can block inflammatory responses induced by SLE serum. In vitro experiments were conducted to examine whether IgGs from the sera of SLE patients or healthy control can activate the primary cultured microglia. RESULTS We found that ICV injection of SLE serum increases morphological activation of microglia in the cortex and hippocampus. Inflammatory mediators including pro-inflammatory cytokines (IL-1, IL-6 and TNF-α), chemokine (CCL2 and CCL5) and adhesion molecules (P-selectin and ICAM-1) were significantly elevated in the brains of SLE-serum-treated mice. Using intravital microscopy, we demonstrated that SLE serum promotes leukocyte rolling and adhesion. Furthermore, suppression of microglia activation by systemically using minocycline could decrease the levels of inflammatory molecular, and prevent leukocyte rolling and adhesion. The in vitro experiments revealed that IgG from SLE sera could be engulfed by microglia and stimulated the microglia to secret pro-inflammatory cytokines. CONCLUSION Our data suggest that the activation of microglia, which promotes leukocyte adhesion to the brain microvasculature, is an important pathological mechanism of CNS involvement in SLE.
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111
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Sordia-Ramírez J, Infante-Valenzuela A, Hernández-Galarza IDJ, Costilla-Esquivel A. Neuropsychiatric symptoms in a patient with Dyke-Davidoff-Masson syndrome and systemic lupus erythematosus: a case report. J Med Case Rep 2019; 13:111. [PMID: 31030671 PMCID: PMC6487517 DOI: 10.1186/s13256-019-2039-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/04/2019] [Indexed: 01/19/2023] Open
Abstract
Background Dyke–Davidoff–Masson syndrome is an uncommon constellation of radiological and clinical findings. Few reports describe co-occurring psychiatric manifestations. Systemic lupus erythematosus is a systemic disease with vascular, neurologic, and psychiatric involvement. To the best of our knowledge, no case reports have been made associating these entities. Case presentation We present the case of a 21-year-old Mexican mestizo woman with a history of systemic lupus erythematosus diagnosed at 4 years of age, who developed focal impaired awareness seizures when she was 8-years old, which became treatment-resistant at age 15. Two years prior to our evaluation, she developed deep vein thrombosis; clinical and laboratory criteria were met to diagnose secondary antiphospholipid syndrome. After being treated with anticonvulsants, glucocorticoids, and immunosuppressants with only a partial response, she developed a severe major depressive episode 1 year prior to our assessment, including two suicide attempts. She was referred to the out-patient clinic of our department for evaluation; intellectual disability, depressive symptoms, and behavioral symptoms were documented. Imaging studies revealed structural abnormalities in the left cerebral hemisphere: cortical atrophy, enlargement of sulci and cisternal spaces, and hyperpneumatization of the frontal sinus. Treatment with an antidepressant was initiated and maintained for 1 year, added to anticonvulsants and immunosuppressants. Depressive and behavioral symptoms diminished and no suicidal ideation has been noted at follow-up. Conclusions Dyke–Davidoff–Masson syndrome was diagnosed, accompanied by clinical symptoms previously reported as epilepsy and intellectual disability. This case report illustrates the complexity of syndrome presentation in an adult female, constituting a diagnostic and therapeutic challenge. This constellation of symptoms and structural brain abnormalities should be kept in mind in patients with neuropsychiatric manifestations and systemic diseases with central nervous system involvement, especially when diagnosed at a young age.
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Affiliation(s)
- José Sordia-Ramírez
- Department of Psychiatry, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Nuevo León, México.
| | - Adrián Infante-Valenzuela
- Neurology Service, Internal Medicine Department, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Nuevo León, México
| | - Iván de Jesús Hernández-Galarza
- Rheumatology Service, Internal Medicine Department, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Nuevo León, México
| | - Antonio Costilla-Esquivel
- Department of Psychiatry, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Nuevo León, México
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112
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Li X, Xiang X, Sun J, Liu S, Liu Y, Feng L, Li C, Li Z. Prevalence, outcome and prognostic factors of neuropsychiatric systemic lupus erythematosus: A real world single center study. Mod Rheumatol 2019; 30:321-326. [PMID: 30836042 DOI: 10.1080/14397595.2019.1589912] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objectives: To investigate the prevalence, outcome and prognostic factors of neuropsychiatric systemic lupus erythematosus (NPSLE).Methods: SLE inpatients from 2005 to 2016 were included. Information on survival duration and causes of death was collected. Data were analyzed using Kaplan-Meier curves, log-rank tests and Cox proportional hazards modeling.Results: Among 1589 SLE patients, 101 (6.4%) were diagnosed with NPSLE. The overall survival rates of the NPSLE patients were 89%, 85% and 84% at 1, 3 and 5 years, respectively. The standardized mortality ratio of NPSLE patients was 11.14. The most common cause of death was NPSLE related conditions (7, 47%), including intracranial hypertension syndrome, cerebrovascular disease and motor neuron disease. The following variables were associated with death: cardiac involvement, renal involvement, diffuse NPSLE, acute confusional state, more than one NPSLE manifestation, low lymphocyte count, elevated C-reactive protein, abnormal cerebrospinal fluid (CSF) and high systemic lupus erythematosus disease activity index. Acute confusional state (p = .001), elevated intracranial pressure (p = .010) and C-reactive protein (CRP) (p = .032) were independently predictive factors of death.Conclusion: Our study demonstrates an 11.14-fold increased mortality of NPSLE patients compared with general population. NPSLE related disorders are main causes of death. Acute confusional state is the most significant predictive factor for poor prognosis.
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Affiliation(s)
- Xue Li
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking University People's Hospital, Beijing, P. R. China
| | - Xiaohong Xiang
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking University People's Hospital, Beijing, P. R. China
| | - Jingjing Sun
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, P. R. China
| | - Shanshan Liu
- Peking University Third Hospital, Beijing, P. R. China
| | - Ying Liu
- Department of Geriatrics, Jilin University Fourth Hospital, Jilin, P. R. China
| | - Lianghua Feng
- Department of Rheumatology and Immunology, Xiamen Fifth Hospital, Xiamen, P. R. China
| | - Chun Li
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking University People's Hospital, Beijing, P. R. China
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking University People's Hospital, Beijing, P. R. China
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113
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Duarte-Delgado NP, Vásquez G, Ortiz-Reyes BL. Blood-brain barrier disruption and neuroinflammation as pathophysiological mechanisms of the diffuse manifestations of neuropsychiatric systemic lupus erythematosus. Autoimmun Rev 2019; 18:426-432. [DOI: 10.1016/j.autrev.2018.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 12/21/2018] [Indexed: 12/29/2022]
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114
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Kitagori K, Yoshifuji H, Oku T, Ayaki T, Kuzuya A, Nakajima T, Akizuki S, Nakashima R, Murakami K, Ohmura K, Hirayama Y, Takahashi R, Mimori T. Utility of osteopontin in cerebrospinal fluid as a diagnostic marker for neuropsychiatric systemic lupus erythematosus. Lupus 2019; 28:414-422. [DOI: 10.1177/0961203319828818] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The whole protein of osteopontin (OPN full) and its cleaved form (OPN N-half) are involved in the immune response and the migration of immune cells to an inflammatory lesion. We have reported that serum OPN full and urine OPN N-half are elevated in lupus nephritis (LN). Neuropsychiatric systemic lupus erythematosus (NPSLE) is a refractory complication of SLE. To investigate whether OPN full and OPN N-half could serve as diagnostic markers for NPSLE, and to elucidate their role in NPSLE pathogenesis, the concentrations of OPN full and OPN N-half in cerebrospinal fluid (CSF) were measured in NPSLE and non-NPSLE patients. We found that the concentration of OPN full in the CSF was significantly higher in NPSLE than in non-NPSLE, and it decreased after treatment. When the cutoff value of OPN full in CSF was set to 963.4 ng/ml, the sensitivity and specificity for the diagnosis of NPSLE were 70% and 100%, respectively. The correlation analysis of OPN full, OPN N-half and various cytokines/chemokines suggested that the cytokines/chemokines could be divided into two clusters: cluster A, which contains OPN full and cluster B, which contains interleukin-6. OPN full in CSF could be a novel diagnostic marker for NPSLE.
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Affiliation(s)
- K Kitagori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - H Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - T Oku
- Center for Innovation in Immunoregulative Technology and Therapeutics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Candidate Discovery Science Labs, Astellas Pharma Inc, Ibaraki, Japan
| | - T Ayaki
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - A Kuzuya
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - T Nakajima
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - S Akizuki
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - R Nakashima
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - K Murakami
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - K Ohmura
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Y Hirayama
- Center for Innovation in Immunoregulative Technology and Therapeutics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Candidate Discovery Science Labs, Astellas Pharma Inc, Ibaraki, Japan
| | - R Takahashi
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - T Mimori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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115
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Lillis TA, Tirone V, Gandhi N, Weinberg S, Nika A, Sequeira W, Hobfoll SE, Block JA, Jolly M. Sleep Disturbance and Depression Symptoms Mediate Relationship Between Pain and Cognitive Dysfunction in Lupus. Arthritis Care Res (Hoboken) 2019; 71:406-412. [PMID: 29726637 DOI: 10.1002/acr.23593] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/24/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine whether sleep disturbance and symptoms of depression mediate the relationship between pain and cognitive dysfunction (CD) in a sample of 115 patients with systemic lupus erythematosus (SLE). METHODS A total of 115 patients with SLE completed questionnaires regarding pain, perceived stress, depression, sleep, and CD. Relationships among pain, sleep, depression, and CD were assessed using bootstrap mediation models, controlling for race/ethnicity, fibromyalgia diagnosis, current corticosteroid use, disease activity and damage, and perceived stress. RESULTS Mediation analyses indicated that the effect of pain on CD was mediated by sleep disturbance (β = 0.30) and depression symptoms (β = 0.33). These effects were maintained even after controlling for the aforementioned covariates, of which only disease activity (β = 0.20) and stress (β = 0.22) remained significantly linked to CD (overall model R2 = 0.53; all P < 0.05). CONCLUSION After controlling for disease activity and perceived stress, the relationship between pain and CD was explained by sleep disturbance and depression symptoms. Although these relationships need validation in longitudinal studies with additional measurement modalities, our findings may indicate promising, nonpharmacologic intervention avenues for SLE patients with pain and CD. Specifically, cognitive behavioral therapies for depression and sleep are known to reduce distress and enhance functioning across various psychosocial domains. Given the symptom burden of SLE, interventions that maximize potential benefits without the use of additional pharmacologic treatments may be of particular utility.
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Affiliation(s)
| | | | | | | | - Ailda Nika
- Rush University Medical Center, Chicago, Illinois
| | | | | | - Joel A Block
- Rush University Medical Center, Chicago, Illinois
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116
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Lüngen EM, Maier V, Venhoff N, Salzer U, Dersch R, Berger B, Riering AN, Nickel K, Fiebich BL, Süß P, Maier SJ, Egger K, Tebartz van Elst L, Endres D. Systemic Lupus Erythematosus With Isolated Psychiatric Symptoms and Antinuclear Antibody Detection in the Cerebrospinal Fluid. Front Psychiatry 2019; 10:226. [PMID: 31105597 PMCID: PMC6494960 DOI: 10.3389/fpsyt.2019.00226] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/26/2019] [Indexed: 12/19/2022] Open
Abstract
Background: Organic psychiatric disorders can be caused by immunological disorders, such as autoimmune encephalitis or systemic lupus erythematosus (SLE). SLE can affect most organs, as well as the central nervous system (CNS). In this paper, we describe a patient with an isolated psychiatric syndrome in the context of SLE and discuss the role of antibody detection in the cerebrospinal fluid (CSF). Case presentation: The 22-year-old German male high school graduate presented with obsessive-compulsive and schizophreniform symptoms. He first experienced obsessive-compulsive symptoms at the age of 14. At the age of 19, his obsessive thoughts, hallucinations, diffuse anxiety, depressed mood, severe dizziness, and suicidal ideation became severe and did not respond to neuroleptic or antidepressant treatment. Due to increased antinuclear antibodies (ANAs) with anti-nucleosome specificity in serum and CSF, complement activation, multiple bilateral white matter lesions, and inflammatory CSF alterations, we classified the complex syndrome as an isolated psychiatric variant of SLE. Immunosuppressive treatment with two times high-dose steroids, methotrexate, and hydroxychloroquine led to a slow but convincing improvement. Conclusion: Some patients with psychiatric syndromes and increased ANA titers may suffer from psychiatric variants of SLE, even if the American College of Rheumatology criteria for SLE are not met. Whether the psychiatric symptoms in our patient represent a prodromal stage with the later manifestation of full-blown SLE or a subtype of SLE with isolated CNS involvement remains unclear. Regardless, early diagnosis and initiation of immunosuppressive treatment are essential steps in preventing further disease progression and organ damage. Intrathecal ANAs with extractable nuclear antigen differentiation may be a more sensitive marker of CNS involvement compared with serum analyses alone.
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Affiliation(s)
- Eva M Lüngen
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktoria Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Salzer
- Department of Rheumatology and Clinical Immunology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rick Dersch
- Department of Neurology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Department of Neurology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anne N Riering
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd L Fiebich
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrick Süß
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon J Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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117
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Yoon S, Kang DH, Choi TY. Psychiatric Symptoms in Systemic Lupus Erythematosus: Diagnosis and Treatment. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.2.93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Seoyoung Yoon
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Hun Kang
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Tae Young Choi
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
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118
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Magro-Checa C, Steup-Beekman GM, Huizinga TW, van Buchem MA, Ronen I. Laboratory and Neuroimaging Biomarkers in Neuropsychiatric Systemic Lupus Erythematosus: Where Do We Stand, Where To Go? Front Med (Lausanne) 2018; 5:340. [PMID: 30564579 PMCID: PMC6288259 DOI: 10.3389/fmed.2018.00340] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/19/2018] [Indexed: 01/18/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multi-systemic involvement. Nervous system involvement in SLE leads to a series of uncommon and heterogeneous neuropsychiatric (NP) manifestations. Current knowledge on the underlying pathogenic processes and their subsequent pathophysiological changes leading to NP-SLE manifestations is incomplete. Several putative laboratory biomarkers have been proposed as contributors to the genesis of SLE-related nervous system damage. Alongside the laboratory biomarkers, several neuroimaging tools have shown to reflect the nature of tissue microstructural damage associated with SLE, and thus were suggested to contribute to the understanding of the pathophysiological changes and subsequently help in clinical decision making. However, the number of useful biomarkers in NP-SLE in clinical practice is disconcertingly modest. In some cases it is not clear whether the biomarker is truly involved in pathogenesis, or the result of non-specific pathophysiological changes in the nervous system (e.g., neuroinflammation) or whether it is the consequence of a concomitant underlying abnormality related to SLE activity. In order to improve the diagnosis of NP-SLE and provide a better targeted care to these patients, there is still a need to develop and validate a range of biomarkers that reliably capture the different aspects of disease heterogeneity. This article critically reviews the current state of knowledge on laboratory and neuroimaging biomarkers in NP-SLE, discusses the factors that need to be addressed to make these biomarkers suitable for clinical application, and suggests potential future research paths to address important unmet needs in the NP-SLE field.
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Affiliation(s)
- César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands.,Department of Rheumatology, Zuyderland Medical Center, Heerlen, Netherlands
| | | | - Tom W Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands.,Department of Radiology, C.J. Gorter Center for High Field MRI, Leiden University Medical Center, Leiden, Netherlands
| | - Itamar Ronen
- Department of Radiology, C.J. Gorter Center for High Field MRI, Leiden University Medical Center, Leiden, Netherlands
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119
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Shimizu F, Nishihara H, Kanda T. Blood-brain barrier dysfunction in immuno-mediated neurological diseases. Immunol Med 2018; 41:120-128. [PMID: 30938273 DOI: 10.1080/25785826.2018.1531190] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The blood-brain barrier (BBB) is the brain-specific endothelial cell barrier that is important for maintaining brain homeostasis and preventing the entry of toxic substances. Pathological BBB dysfunction is a critical step of the disease process in several immuno-mediated neurological diseases, including multiple sclerosis (MS), neuromyelitis optica (NMO), neuropsychiatric systemic lupus erythematosus (NPSLE) and neuro-Behçet diseases. The pathological findings from patients with secondary progressive (SP) MS, NMO and NPSLE showed leaky BBB in the active lesions. NMO is a disease with strong evidence of disease-specific and pathogenic autoantibodies (aquaporin 4 [AQP4] autoantibodies). In the development of NMO, circulating AQP4 autoantibodies need to pass through the BBB in order to reach AQP4 on the astrocyte endfeet. Strong evidence suggests that NPSLE is associated with the disruption of the BBB and NPSLE patients frequently have antibodies bound to endothelial cells in their sera. We recently identified two BBB-reactive autoantibodies in immuno-mediated neurological diseases: galectin-3 autoantibodies in SPMS and GRP78 autoantibodies in NMO. In the present review article, we describe the basic structure and cellular biology of the BBB, discuss recent insights regarding the pathophysiology of the BBB breakdown in the setting of immuno-mediated neurological diseases, and describe our recent findings of autoantibody-mediated BBB breakdown.
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Affiliation(s)
- Fumitaka Shimizu
- a Department of Neurology and Clinical Neuroscience , Yamaguchi University Graduate School of Medicine , Ube , Japan
| | - Hideaki Nishihara
- a Department of Neurology and Clinical Neuroscience , Yamaguchi University Graduate School of Medicine , Ube , Japan
| | - Takashi Kanda
- a Department of Neurology and Clinical Neuroscience , Yamaguchi University Graduate School of Medicine , Ube , Japan
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120
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Bendorius M, Po C, Muller S, Jeltsch-David H. From Systemic Inflammation to Neuroinflammation: The Case of Neurolupus. Int J Mol Sci 2018; 19:E3588. [PMID: 30428632 PMCID: PMC6274746 DOI: 10.3390/ijms19113588] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 12/17/2022] Open
Abstract
It took decades to arrive at the general consensus dismissing the notion that the immune system is independent of the central nervous system. In the case of uncontrolled systemic inflammation, the relationship between the two systems is thrown off balance and results in cognitive and emotional impairment. It is specifically true for autoimmune pathologies where the central nervous system is affected as a result of systemic inflammation. Along with boosting circulating cytokine levels, systemic inflammation can lead to aberrant brain-resident immune cell activation, leakage of the blood⁻brain barrier, and the production of circulating antibodies that cross-react with brain antigens. One of the most disabling autoimmune pathologies known to have an effect on the central nervous system secondary to the systemic disease is systemic lupus erythematosus. Its neuropsychiatric expression has been extensively studied in lupus-like disease murine models that develop an autoimmunity-associated behavioral syndrome. These models are very useful for studying how the peripheral immune system and systemic inflammation can influence brain functions. In this review, we summarize the experimental data reported on murine models developing autoimmune diseases and systemic inflammation, and we explore the underlying mechanisms explaining how systemic inflammation can result in behavioral deficits, with a special focus on in vivo neuroimaging techniques.
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Affiliation(s)
- Mykolas Bendorius
- UMR 7242 Biotechnologie et Signalisation Cellulaire, École Supérieure de Biotechnologie de Strasbourg (ESBS), Laboratoire d'Excellence Médalis, Université de Strasbourg/CNRS, 67412 Illkirch, France.
| | - Chrystelle Po
- ICube UMR 7357, Université de Strasbourg/CNRS, Fédération de Médecine Translationnelle de Strasbourg, 67000 Strasbourg, France.
| | - Sylviane Muller
- UMR 7242 Biotechnologie et Signalisation Cellulaire, École Supérieure de Biotechnologie de Strasbourg (ESBS), Laboratoire d'Excellence Médalis, Université de Strasbourg/CNRS, 67412 Illkirch, France.
- University of Strasbourg Institute for Advanced Study (USIAS), 67000 Strasbourg, France.
| | - Hélène Jeltsch-David
- UMR 7242 Biotechnologie et Signalisation Cellulaire, École Supérieure de Biotechnologie de Strasbourg (ESBS), Laboratoire d'Excellence Médalis, Université de Strasbourg/CNRS, 67412 Illkirch, France.
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121
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Noris-García E, Arce S, Nardin P, Lanigan ME, Acuña V, Gutierrez F, Robinson-Agramonte MA, Gonçalves CA. Peripheral levels of brain-derived neurotrophic factor and S100B in neuropsychiatric systemic lupus erythematous. Lupus 2018; 27:2041-2049. [PMID: 30376438 DOI: 10.1177/0961203318804899] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to investigate serum S100B and brain-derived neurotrophic factor (BDNF) in systemic lupus erythematous (SLE) patients, with and without neuropsychiatric (NP) manifestation activity. METHODS We assessed 47 SLE patients and 20 selected healthy individuals. Disease activity was assessed according to the SLE disease activity index (SLEDAI). Serum BDNF and S100B were measured by enzyme-linked immunosorbent assay. RESULTS Serum S100B protein was significantly higher in SLE patients. BDNF levels were significantly decreased in active SLE, when compared with inactive SLE, but not when compared with controls. S100B was clearly higher in the NPSLE group, when compared with the non-NPSLE or control groups. Receiver operating characteristic analysis of S100B revealed an area under the curve of 0.706 that discriminated NPSLE patients with peripheral polyneuropathy. CONCLUSIONS Our findings reinforce the use of serum S100B as a biomarker in SLE, particularly for NPSLE. Moreover, we found a strong association between serum S100B and peripheral neuropathy, indicating a specific utility for this biomarker in SLE that warrants clinical investigation.
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Affiliation(s)
- E Noris-García
- 1 Department of Immunology, Nephrology Institute, Havana, Cuba
| | - S Arce
- 1 Department of Immunology, Nephrology Institute, Havana, Cuba
| | - P Nardin
- 2 Faculty of Pharmaceutical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - M E Lanigan
- 3 Department of Psychiatric, Joaquín Albarrán Hospital, Havana, Cuba
| | - V Acuña
- 3 Department of Psychiatric, Joaquín Albarrán Hospital, Havana, Cuba
| | - F Gutierrez
- 3 Department of Psychiatric, Joaquín Albarrán Hospital, Havana, Cuba
| | - M A Robinson-Agramonte
- 4 Department of Neuroimmunology, International Center for Neurological Restoration, Havana, Cuba
| | - C-A Gonçalves
- 5 Department of Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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122
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Appelgren D, Dahle C, Knopf J, Bilyy R, Vovk V, Sundgren PC, Bengtsson AA, Wetterö J, Muñoz LE, Herrmann M, Höög A, Sjöwall C. Active NET formation in Libman–Sacks endocarditis without antiphospholipid antibodies: A dramatic onset of systemic lupus erythematosus. Autoimmunity 2018; 51:310-318. [DOI: 10.1080/08916934.2018.1514496] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Daniel Appelgren
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Charlotte Dahle
- Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Jasmin Knopf
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3 – Rheumatology and Immunology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Rostyslav Bilyy
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3 – Rheumatology and Immunology, Universitätsklinikum Erlangen, Erlangen, Germany
- Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Volodymyr Vovk
- Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Pia C. Sundgren
- Department of Diagnostic Radiology, Lund University Center for Medical Imaging and Physiology Skåne University Hospital, Clinical Sciences Lund, Lund, Sweden
| | - Anders A. Bengtsson
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Rheumatology, Lund, Sweden
| | - Jonas Wetterö
- Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Luis E. Muñoz
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3 – Rheumatology and Immunology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Martin Herrmann
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3 – Rheumatology and Immunology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Anders Höög
- Department of Oncology-Pathology, Karolinska Institute Karolinska University Hospital Cancer Center Karolinska, Stockholm, Sweden
- Department of Pathology, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Abstract
Systemic lupus erythematosus is a chronic autoimmune condition with variable organ system involvement; manifestations can range from mild to potentially life threatening. Early diagnosis is important, as progression of disease can be halted. Diagnosis is made by review of signs and symptoms, imaging, and serology.
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Affiliation(s)
- Ruba Kado
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Suite 7C27 North Ingalls Building, 300 North Ingalls SPC 5422, Ann Arbor, MI 48109-5422, USA.
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124
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Mike EV, Makinde HM, Der E, Stock A, Gulinello M, Gadhvi GT, Winter DR, Cuda CM, Putterman C. Neuropsychiatric Systemic Lupus Erythematosus Is Dependent on Sphingosine-1-Phosphate Signaling. Front Immunol 2018; 9:2189. [PMID: 30319641 PMCID: PMC6168636 DOI: 10.3389/fimmu.2018.02189] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/04/2018] [Indexed: 12/16/2022] Open
Abstract
About 40% of patients with systemic lupus erythematosus experience diffuse neuropsychiatric manifestations, including impaired cognition and depression. Although the pathogenesis of diffuse neuropsychiatric SLE (NPSLE) is not fully understood, loss of brain barrier integrity, autoreactive antibodies, and pro-inflammatory cytokines are major contributors to disease development. Fingolimod, a sphingosine-1-phosphate (S1P) receptor modulator, prevents lymphocyte egress from lymphoid organs through functional antagonism of S1P receptors. In addition to reducing the circulation of autoreactive lymphocytes, fingolimod has direct neuroprotective effects such as preserving brain barrier integrity and decreasing pro-inflammatory cytokine secretion by astrocytes and microglia. Given these effects, we hypothesized that fingolimod would attenuate neurobehavioral deficits in MRL-lpr/lpr (MRL/lpr) mice, a validated neuropsychiatric lupus model. Fingolimod treatment was initiated after the onset of disease, and mice were assessed for alterations in cognitive function and emotionality. We found that fingolimod significantly attenuated spatial memory deficits and depression-like behavior in MRL/lpr mice. Immunofluorescent staining demonstrated a dramatic lessening of brain T cell and macrophage infiltration, and a significant reduction in cortical leakage of serum albumin, in fingolimod treated mice. Astrocytes and endothelial cells from treated mice exhibited reduced expression of inflammatory genes, while microglia showed differential regulation of key immune pathways. Notably, cytokine levels within the cortex and hippocampus were not appreciably decreased with fingolimod despite the improved neurobehavioral profile. Furthermore, despite a reduction in splenomegaly, lymphadenopathy, and circulating autoantibody titers, IgG deposition within the brain was unaffected by treatment. These findings suggest that fingolimod mediates attenuation of NPSLE through a mechanism that is not dependent on reduction of autoantibodies or cytokines, and highlight modulation of the S1P signaling pathway as a novel therapeutic target in lupus involving the central nervous system.
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Affiliation(s)
- Elise V Mike
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Hadijat M Makinde
- Division of Rheumatology, Northwestern University School of Medicine, Chicago, IL, United States
| | - Evan Der
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Ariel Stock
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Maria Gulinello
- Dominick P. Purpura Department of Neuroscience Animal Behavioral Core, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Gaurav T Gadhvi
- Division of Rheumatology, Northwestern University School of Medicine, Chicago, IL, United States
| | - Deborah R Winter
- Division of Rheumatology, Northwestern University School of Medicine, Chicago, IL, United States
| | - Carla M Cuda
- Division of Rheumatology, Northwestern University School of Medicine, Chicago, IL, United States
| | - Chaim Putterman
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States.,Division of Rheumatology, Albert Einstein College of Medicine, Bronx, NY, United States
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125
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Toko H, Tsuboi H, Umeda N, Honda F, Ohyama A, Takahashi H, Abe S, Yokosawa M, Asashima H, Hagiwara S, Hirota T, Kondo Y, Matsumoto I, Sumida T. Intractable Hemophagocytic Syndrome Associated with Systemic Lupus Erythematosus Resistant to Corticosteroids and Intravenous Cyclophosphamide That Was Successfully Treated with Cyclosporine A. Intern Med 2018; 57:2747-2752. [PMID: 29780126 PMCID: PMC6191589 DOI: 10.2169/internalmedicine.0571-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic syndrome (HPS) associated with systemic lupus erythematosus (SLE), dubbed acute lupus hemophagocytic syndrome (ALHS), is an intractable complication of SLE. A 24-year-old man who had been diagnosed with SLE three months previously, presented with fever, rash, hallucination, and pancytopenia accompanied with hyperferritinemia and bone marrow hemophagocytosis. He was diagnosed with ALHS and neuropsychiatric (NP)-SLE. Although 4 courses of methylprednisolone pulse therapy and 1 course of intravenous cyclophosphamide (IVCY) improved his NP-SLE, his ALHS did not respond. However, the addition of cyclosporine A (CsA) led to a rapid remission from ALHS. This suggests the usefulness of CsA in the treatment of intractable, corticosteroid- and IVCY-resistant ALHS.
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Affiliation(s)
- Hirofumi Toko
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Hiroto Tsuboi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Naoto Umeda
- Department of Rheumatology, Tsuchiura Kyodo General Hospital, Japan
| | - Fumika Honda
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Ayako Ohyama
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Hidenori Takahashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Saori Abe
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Masahiro Yokosawa
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Hiromitsu Asashima
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Shinya Hagiwara
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Tomoya Hirota
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Yuya Kondo
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Isao Matsumoto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Takayuki Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
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126
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Brain white matter structural networks in patients with non-neuropsychiatric systemic lupus erythematosus. Brain Imaging Behav 2018; 12:142-155. [PMID: 28190161 DOI: 10.1007/s11682-017-9681-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Previous neuroimaging studies have revealed cognitive dysfunction in patients with systemic lupus erythematosus (SLE) and suggested that it may be related to disrupted brain white matter (WM) connectivity. However, no study has examined the topological properties of brain WM structural networks in SLE patients, especially in patients with non-neuropsychiatric SLE (non-NPSLE). In this study, we acquired DTI datasets from 28 non-NPSLE patients and 24 healthy controls, constructed their brain WM structural networks by using a deterministic fiber tracking approach, estimated the topological parameters of their structural networks, and compared their group differences. We reached the following results: 1) At the global level, the non-NPSLE patients showed significantly increased characteristic path length, normalized clustering coefficient and small-worldness, but significantly decreased global efficiency and local efficiency compared to the controls; 2) At the nodal level, the non-NPSLE patients had significantly decreased nodal efficiency in regions related to movement control, executive control, and working memory (bilateral precentral gyri, bilateral middle frontal gyri, bilateral inferior parietal lobes, left median cingulate gyrus and paracingulate gyrus, and right middle temporal gyrus). In addition, to pinpointing the injured WM fiber tracts in the non-NPSLE patients, we reconstructed the major brain WM pathways connecting the abnormal regions at the nodal level with the corticospinal tract (CST), superior longitudinal fasciculus-parietal terminations (SLFP), and superior longitudinal fasciculus-temporal terminations (SLFT). By analyzing the diffusion parameters along these WM fiber pathways, we detected abnormal diffusion parameters in the bilateral CST and right SLFT in the non-NPSLE patients. These results seem to indicate that injured brain WM connectivity exists in SLE patients even in the absence of neuropsychiatric symptoms.
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Chiu NC, Lin YJ, Tzang RF, Li YS, Lin HJ, Das S, Chen CG, Chen CC, Hsu K. Optimization of an Anti-NMDA Receptor Autoantibody Diagnostic Bioassay. Front Neurol 2018; 9:661. [PMID: 30186218 PMCID: PMC6113861 DOI: 10.3389/fneur.2018.00661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/24/2018] [Indexed: 12/21/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is one of the most frequently encountered autoimmune encephalitis. The pathogenesis of both anti-NMDAR encephalitis and schizophrenia involve down-regulation of NMDA receptors. Whether autoantibody-mediated destruction of neuronal NMDA receptors is associated with schizophrenia or first-episode psychosis (FEP) remains unclear, as the current findings from different groups are inconsistent. The main culprits are likely due to heterogeneity of autoantibodies (autoAbs) in a patient's blood or cerebrospinal fluid (CSF), as well as due to limitation of the current detection methods for anti-NMDAR autoAbs. Here, we optimized the current diagnostic method based on the only commercially-available anti-NMDAR test kit. We first increased detection sensitivity by replacing reporter fluorophore fluorescein isothiocyanate (FITC) in the kit with Alexa Fluor 488, which is superior in resisting photobleaching. We also found that using an advanced imaging system could increase the detection limit, compared to using a simple fluorescence microscope. To improve test accuracy, we implemented secondary labeling with a well-characterized mouse anti-NR1 monoclonal antibody (mAb) after immunostaining with a patient's sample. The degree of colocalization between mouse and human antisera in NMDAR-expressing cells served to validate test results to be truly anti-NMDAR positive or false-positive. We also incorporated DNA-specific DAPI to simultaneously differentiate autoAbs targeting the plasma membrane from those targeting cell nuclei or perinuclear compartments. All the technical implementation could be integrated in a general hospital laboratory setting, without the need of specialized expertise or equipment. By sharing our experience, we hope this may help improve sensitivity and accuracy of the mainstream method for anti-NMDAR detection.
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Affiliation(s)
- Nan-Chang Chiu
- Division of Pediatric Neurology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan.,MacKay Junior College of Medicine, Nursing and Management, New Taipei City, Taiwan.,MacKay Medical College, New Taipei City, Taiwan
| | - Yi-Jie Lin
- Division of Pediatric Neurology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Ruu-Fen Tzang
- MacKay Junior College of Medicine, Nursing and Management, New Taipei City, Taiwan.,MacKay Medical College, New Taipei City, Taiwan.,Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ying-Syuan Li
- MacKay Memorial Hospital Transfusion Medicine & Immunogenetics Laboratories, Tamsui, Taiwan
| | - Hui-Ju Lin
- MacKay Memorial Hospital Transfusion Medicine & Immunogenetics Laboratories, Tamsui, Taiwan
| | - Subir Das
- Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan
| | - Caleb G Chen
- MacKay Medical College, New Taipei City, Taiwan.,Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chiao-Chicy Chen
- MacKay Medical College, New Taipei City, Taiwan.,Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
| | - Kate Hsu
- MacKay Memorial Hospital Transfusion Medicine & Immunogenetics Laboratories, Tamsui, Taiwan
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Zardi EM, Giorgi C, Zardi DM. Diagnostic approach to neuropsychiatric lupus erythematosus: what should we do? Postgrad Med 2018; 130:536-547. [PMID: 29940795 DOI: 10.1080/00325481.2018.1492309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Neuropsychiatric systemic lupus erythematosus is a diagnostic challenge due to the multifarious neurological and psychiatric manifestations that define it but, when suspected, diagnostic imaging can give a fundamental help. The advancements and variety of neuroimaging techniques allow us to perform more and more accurate evaluations of structure, perfusion, and metabolism of the brain and to detect cerebral and spinal lesions. Moreover, vascular districts of the neck and the brain, as well as the electrical brain and peripheral muscle activity may be accurately investigated, thus giving us a wide panoramic view. Although magnetic resonance is recognized as a fundamental neuroimaging technique to reach a correct diagnosis, the juxtaposition of other diagnostic techniques has improved the possibility to make diagnoses but has also increased the confusion about deciding which of them to use and when. Our aim was to combine the number of available techniques with the need to simplify the diagnostic path. Therefore, through the construction of an algorithm from an evidence based approach, we believe we are providing some added improvements to facilitate and expedite the diagnosis of NPSLE.
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Affiliation(s)
| | - Chiara Giorgi
- b Radiology Department , S Maria della Misericordia Hospital , Urbino , Italy
| | - Domenico Maria Zardi
- c Division of Cardiology, Faculty of Medicine and Psychology , University of Rome "Sapienza", Sant'Andrea Hospital , Rome , Italy
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Cognitive Impairment in Patients With Neuropsychiatric and Non-neuropsychiatric Systemic Lupus Erythematosus: A Systematic Review and Meta-analysis. J Int Neuropsychol Soc 2018; 24:629-639. [PMID: 29553037 DOI: 10.1017/s1355617718000073] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Its most prevalent manifestation is neuropsychiatric SLE (NP-SLE), which is characterized by increased involvement of the nervous system, with relevant symptoms, such as marked cognitive deficits, which are directly involved in subsequent functional disability. The objective of this study is to identify and compare the profile of cognitive deficits in patients with NP-SLE and patients with non-neuropsychiatric SLE (nonNP-SLE) by means of a systematic review and meta-analysis. METHODS We performed a systematic literature search based on the key words "cogn* OR neurocogn* AND lupus AND neuropsychiatry*" and included articles published between April 1999 and December 2016. A total of 244 articles were retrieved. We excluded reviews and meta-analyses, experiments not performed in humans, and single case reports. We included studies that used standardized cognitive measures and had included at least the subgroups NP-SLE and non NP-SLE. RESULTS The meta-analysis was finally based on six studies, and 10 neuropsychological variables were examined. Significant differences were observed between the groups for six variables. In the remaining four variables, we observed marked heterogeneity between the groups or a low number of studies. CONCLUSIONS The data obtained indicate greater cognitive impairment among NP-SLE patients than among nonNP-SLE patients, at least for the cognitive domains of visuomotor coordination, attention, executive function, visual learning and memory, and phonetic fluency. The identification and definition of cognitive deficits in SLE patients is necessary to develop adequate cognitive remediation programs to improve functional outcomes. (JINS, 2018, 24, 629-639).
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McGlasson S, Wiseman S, Wardlaw J, Dhaun N, Hunt DPJ. Neurological Disease in Lupus: Toward a Personalized Medicine Approach. Front Immunol 2018; 9:1146. [PMID: 29928273 PMCID: PMC5997834 DOI: 10.3389/fimmu.2018.01146] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/07/2018] [Indexed: 12/11/2022] Open
Abstract
The brain and nervous system are important targets for immune-mediated damage in systemic lupus erythematosus (SLE), resulting in a complex spectrum of neurological syndromes. Defining nervous system disease in lupus poses significant challenges. Among the difficulties to be addressed are a diversity of clinical manifestations and a lack of understanding of their mechanistic basis. However, despite these challenges, progress has been made in the identification of pathways which contribute to neurological disease in SLE. Understanding the molecular pathogenesis of neurological disease in lupus will inform both classification and approaches to clinical trials.
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Affiliation(s)
- Sarah McGlasson
- MRC Institute of Genetics and Molecular Medicine, Edinburgh, United Kingdom
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- The Anne Rowling Clinic, University of Edinburgh, Edinburgh, United Kingdom
| | - Stewart Wiseman
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna Wardlaw
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David P. J. Hunt
- MRC Institute of Genetics and Molecular Medicine, Edinburgh, United Kingdom
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- The Anne Rowling Clinic, University of Edinburgh, Edinburgh, United Kingdom
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Suzuki K, Miyamoto M, Miyamoto T, Matsubara T, Inoue Y, Iijima M, Mizuno S, Horie J, Hirata K, Shimizu T, Kanbayashi T. Cerebrospinal fluid orexin-A levels in systemic lupus erythematosus patients presenting with excessive daytime sleepiness. Lupus 2018; 27:1847-1853. [PMID: 29848165 DOI: 10.1177/0961203318778767] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective Involvement of the hypothalamus is rare in patients with systemic lupus erythematosus (SLE). In this study, we measured cerebrospinal fluid (CSF) orexin-A levels in SLE patients with hypothalamic lesions to investigate whether the orexin system plays a role in SLE patients with hypothalamic lesions who present with excessive daytime sleepiness (EDS). Methods Orexin-A levels were measured in CSF from four patients with SLE who presented with hypothalamic lesions detected by MRI. Three patients underwent repeated CSF testing. All patients met the updated American College of Rheumatology revised criteria for SLE. Results Tests for serum anti-aquaporin-4 antibodies, CSF myelin basic protein and CSF oligoclonal bands were negative in all patients. All patients presented with EDS. Low to intermediate CSF orexin-A levels (92-180 pg/ml) were observed in three patients in the acute stage, two of whom (patients 1 and 2) underwent repeated testing and showed increased CSF orexin-A levels, reduced abnormal hypothalamic lesion intensities detected by MRI and EDS dissipation at follow-up. In contrast, CSF orexin-A levels were normal in one patient (patient 4) while in the acute stage and at follow-up, despite improvements in EDS and MRI findings. Patient 4 showed markedly increased CSF interleukin-6 levels (1130 pg/ml) and a slightly involved hypothalamus than the other patients. Conclusions Our findings suggest that the orexinergic system has a role in EDS in SLE patients with hypothalamic lesions. Furthermore, cytokine-mediated tissue damage might cause EDS without orexinergic involvement.
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Affiliation(s)
- K Suzuki
- 1 Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - M Miyamoto
- 2 Department of Clinical Medicine for Nursing, Dokkyo Medical University School of Nursing, Tochigi, Japan
| | - T Miyamoto
- 3 Department of Neurology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - T Matsubara
- 1 Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Y Inoue
- 4 Department of Neurology, Toyama Prefectural Rehabilitation Hospital and Support Center for Children with Disabilities, Toyama, Japan
| | - M Iijima
- 5 Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - S Mizuno
- 5 Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - J Horie
- 1 Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - K Hirata
- 1 Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - T Shimizu
- 6 Department of Neuropsychiatry, Akita University School of Medicine, Akita, Japan
- 7 International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Tsukuba, Japan
| | - T Kanbayashi
- 6 Department of Neuropsychiatry, Akita University School of Medicine, Akita, Japan
- 7 International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Tsukuba, Japan
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133
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Zhou H, Hu B, Huang N, Mo X, Li W, Zhang B, Wei B, Gao M, Wang Y, Liu X, Liao J. Aberrant T cell subsets and cytokines expression profile in systemic lupus erythematosus. Clin Rheumatol 2018; 37:2405-2413. [PMID: 29785672 DOI: 10.1007/s10067-018-4124-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/20/2018] [Accepted: 04/20/2018] [Indexed: 01/18/2023]
Abstract
To assess T cell subsets and levels of chemokines and cytokines in patients with SLE and determine their relationships between disease activity and organ involvement. Blood samples from SLE patients (n = 24) and healthy controls (n = 36) were analyzed. Frequency of circulating follicular help T cells (Tfh), central memory T cells (Tcm), effector memory T cells (Tem), and naïve T cell subsets was enumerated and their surface markers expression of inducible T cell co-stimulator (ICOS) and programmed death 1(PD-1) protein was examined by flow cytometry. The disease state in SLE patients was evaluated using the SLE Disease Activity Index (SLEDAI). Concentrations of autoantibodies, serum C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), lgG, complement 3, complement 4, cytokines, and chemokines, such as IL-21, IL-17A, and IL-1β, were measured. The frequencies of circulating Tfh and Tcm cell subsets were significantly lower than those in healthy controls. However, the percentages of circulating PD1+ICOS+Tfh, PD1+ICOS+Tcm, and PD1+ICOS+Tem of PBMCs from SLE patients were higher than those in healthy controls. Furthermore, increased levels of serum IL-1β, IL-4, IL-6, MCP-1, IL-21, and IL-17A were detected in the patients with SLE compared to healthy controls. In addition, patients with immune thrombocytopenia displayed elevated proportions of serum IL-10, IL-17A, and IL-1β. Aberrant T cell subsets and cytokines expression profile were observed in SLE patients. PD1+ICOS+Tem cell subset was clearly influenced by disease activity and serum IL-10, IL-17A, and IL-1β were significantly increased in patients with immune thrombocytopenia. Therefore, PD1+ICOS+Tem cells might serve as an important tool for recognition and serum IL-10, IL-17A, and IL-1β might be an effective monitor for SLE patients with immune thrombocytopenia.
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Affiliation(s)
- Haiyan Zhou
- Department of Clinical Research Centre, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China.
- Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China.
| | - Bailong Hu
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China
| | - Niwen Huang
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China
| | - Xiangang Mo
- Department of Cardiovascular Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China
| | - Wei Li
- Department of Cardiovascular Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China
| | - Bei Zhang
- Department of Cardiovascular Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China
| | - Bo Wei
- Department of Cardiovascular Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China
| | - Mingzhu Gao
- Department of Laboratory Medicine, Wuxi Second People's Hospital of Nanjing Medical University, Wuxi, 214002, People's Republic of China
| | - Yiming Wang
- Department of Psychiatry, Guizhou Medical University Hospital, Guiyang, 550004, Guizhou Province, People's Republic of China.
| | - Xingde Liu
- Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China.
- Department of Cardiovascular Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China.
| | - Joshua Liao
- Key Lab of Endemic and Ethnic Diseases of the Ministry of Education of China in Guizhou Medical University, Guiyang, 550004, Guizhou Province, People's Republic of China.
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Shimizu F, Schaller KL, Owens GP, Cotleur AC, Kellner D, Takeshita Y, Obermeier B, Kryzer TJ, Sano Y, Kanda T, Lennon VA, Ransohoff RM, Bennett JL. Glucose-regulated protein 78 autoantibody associates with blood-brain barrier disruption in neuromyelitis optica. Sci Transl Med 2018; 9:9/397/eaai9111. [PMID: 28679661 DOI: 10.1126/scitranslmed.aai9111] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 05/19/2017] [Indexed: 12/15/2022]
Abstract
Neuromyelitis optica (NMO) is an inflammatory disorder mediated by antibodies to aquaporin-4 (AQP4) with prominent blood-brain barrier (BBB) breakdown in the acute phase of the disease. Anti-AQP4 antibodies are produced mainly in the periphery, yet they target the astrocyte perivascular end feet behind the BBB. We reasoned that an endothelial cell-targeted autoantibody might promote BBB transit of AQP4 antibodies and facilitate NMO attacks. Using monoclonal recombinant antibodies (rAbs) from patients with NMO, we identified two that strongly bound to the brain microvascular endothelial cells (BMECs). Exposure of BMECs to these rAbs resulted in nuclear translocation of nuclear factor κB p65, decreased claudin-5 protein expression, and enhanced transit of macromolecules. Unbiased membrane proteomics identified glucose-regulated protein 78 (GRP78) as the rAb target. Using immobilized GRP78 to deplete GRP78 antibodies from pooled total immunoglobulin G (IgG) of 50 NMO patients (NMO-IgG) reduced the biological effect of NMO-IgG on BMECs. GRP78 was expressed on the surface of murine BMECs in vivo, and repeated administration of a GRP78-specific rAb caused extravasation of serum albumin, IgG, and fibrinogen into mouse brains. Our results identify GRP78 antibodies as a potential component of NMO pathogenesis and GRP78 as a candidate target for promoting central nervous system transit of therapeutic antibodies.
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Affiliation(s)
- Fumitaka Shimizu
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Kristin L Schaller
- Departments of Neurology and Ophthalmology, Program in Neuroscience, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA
| | - Gregory P Owens
- Departments of Neurology and Ophthalmology, Program in Neuroscience, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA
| | - Anne C Cotleur
- Neuroimmunology and Acute Neurology, Biogen, Cambridge, MA 02142, USA
| | - Debra Kellner
- Neuroimmunology and Acute Neurology, Biogen, Cambridge, MA 02142, USA
| | - Yukio Takeshita
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Birgit Obermeier
- Neuroimmunology and Acute Neurology, Biogen, Cambridge, MA 02142, USA
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Yasuteru Sano
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Minamikogushi, Ube, Yamaguchi 7558505, Japan
| | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Program in Neuroscience, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA.
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Wang J, Liu Y, Cheng X, Zhang X, Liu F, Liu G, Qiao S, Ni M, Zhou W, Zhang Y, Li F. The Effects of LW-AFC on the Hippocampal Transcriptome in Senescence-Accelerated Mouse Prone 8 Strain, a Mouse Model of Alzheimer's Disease. J Alzheimers Dis 2018; 57:227-240. [PMID: 28222521 DOI: 10.3233/jad-161079] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The senescence-accelerated mouse prone 8 (SAMP8) strain is considered a robust experimental model for developing preventative and therapeutic treatments for Alzheimer's disease (AD), a neurodegenerative disease which cannot be effectively prevented, halted, or cured. Our previous studies showed that LW-AFC, a new formula derived from the classical traditional Chinese medicinal prescription Liuwei Dihuang decoction, ameliorates cognitive deterioration in PrP-hAβPPswe/PS1ΔE9 transgenic mice and SAMP8 mice. This study aims to investigate the mechanism that mediates how LW-AFC improves cognitive deficit on the basis of the transcriptome. We conducted a genome-wide survey of gene expression in the hippocampus in mice from the senescence accelerated mouse resistant 1 (SAMR1) strain, from SAMP8 and from LW-AFC treated SAMP8. The results showed that LW-AFC reversed the transcriptome in the hippocampus of SAMP8 mice. The specific investigation of altered gene expression in subtypes defined by cognitive profiles indicated that the systemic lupus erythematosus pathway, spliceosomes, amyotrophic lateral sclerosis, and the insulin signaling were involved in the improvement of cognitive ability by LW-AFC. The expression of genes Enpp2, Etnk1, Epdr1, and Gm5900 in the hippocampus were correlated with that of LW-AFC's ameliorating cognitive impairment in SAMP8 mice. Because LW-AFC is composed of polysaccharides, glycosides, and oligosaccharides, we infer that LW-AFC has direct or indirect effects on altering gene expressions and regulating pathways in the hippocampus of SAMP8 mice. These data are helpful for the enhanced identification of LW-AFC as new therapeutic modalities to AD.
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Affiliation(s)
- Jianhui Wang
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Yang Liu
- Department of Biotechnology, Beijing Institute of Radiation Medicine, Beijing, China
| | - Xiaorui Cheng
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Xiaorui Zhang
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Feng Liu
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Gang Liu
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Shanyi Qiao
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Ming Ni
- Department of Biotechnology, Beijing Institute of Radiation Medicine, Beijing, China
| | - Wenxia Zhou
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Yongxiang Zhang
- Department of TCM and Neuroimmunopharmacology, Beijing Institute of Pharmacology and Toxicology, Beijing, China.,State Key Laboratory of Toxicology and Medical Countermeasures, Beijing, China
| | - Fei Li
- Department of Biotechnology, Beijing Institute of Radiation Medicine, Beijing, China
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Mader S, Jeganathan V, Arinuma Y, Fujieda Y, Dujmovic I, Drulovic J, Shimizu Y, Sakuma Y, Stern JNH, Aranow C, Mackay M, Yasuda S, Atsumi T, Hirohata S, Diamond B. Understanding the Antibody Repertoire in Neuropsychiatric Systemic Lupus Erythematosus and Neuromyelitis Optica Spectrum Disorder. Arthritis Rheumatol 2018; 70:277-286. [DOI: 10.1002/art.40356] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/17/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Simone Mader
- The Feinstein Institute for Medical Research Manhasset New York
| | | | | | | | - Irena Dujmovic
- Clinical Center of Serbia University School of Medicine Belgrade Serbia
| | - Jelena Drulovic
- Clinical Center of Serbia University School of Medicine Belgrade Serbia
| | | | - Yuko Sakuma
- Kitasato University School of Medicine Kanagawa Japan
| | | | - Cynthia Aranow
- The Feinstein Institute for Medical Research Manhasset New York
| | - Meggan Mackay
- The Feinstein Institute for Medical Research Manhasset New York
| | | | | | | | - Betty Diamond
- The Feinstein Institute for Medical Research Manhasset New York
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137
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Ferreira I, Croca S, Raimondo MG, Matharu M, Miller S, Giles I, Isenberg D, Ioannou Y, Hanly JG, Urowitz MB, Anderson N, Aranow C, Askanase A, Bae SC, Bernatsky S, Bruce IN, Buyon J, Clarke AE, Dooley MA, Fortin P, Ginzler E, Gladman D, Gordon C, Inanc M, Jacobsen S, Kalunian K, Kamen D, Khamashta M, Lim S, Manzi S, Merrill J, Nived O, Peschken C, Petri M, Ramsey-Goldman R, Ruiz-Irastorza G, Sanchez-Guerrero J, Steinson K, Sturfelt GK, van Vollenhoven R, Wallace DJ, Zoma A, Rahman A. Nitrated nucleosome levels and neuropsychiatric events in systemic lupus erythematosus; a multi-center retrospective case-control study. Arthritis Res Ther 2017; 19:287. [PMID: 29273092 PMCID: PMC5741886 DOI: 10.1186/s13075-017-1495-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 12/08/2017] [Indexed: 11/20/2022] Open
Abstract
Background In patients with systemic lupus erythematosus (SLE) there is no serological test that will reliably distinguish neuropsychiatric (NP) events due to active SLE from those due to other causes. Previously we showed that serum levels of nitrated nucleosomes (NN) were elevated in a small number of patients with NPSLE. Here we measured serum NN in samples from a larger population of patients with SLE and NP events to see whether elevated serum NN could be a marker for NPSLE. Methods We obtained serum samples from patients in the Systemic Lupus International Collaborative Clinics (SLICC) inception cohort. This included 216 patients with NP events and two matched controls with SLE but no NP events for each of these patients. For the NP patients we tested samples taken before, during and after the NP event. Results Twenty-six patients had events attributed to SLE according to the most stringent SLICC attribution rule. In these patients there was no association between onset of event and elevated serum NN. In 190 patients in whom events were not attributed to SLE by the SLICC rules, median serum NN was elevated at the onset of event (P = 0.006). The predominant clinical features in this group of 190 patients were headache, mood disorders and anxiety. Conclusions Serum NN levels rise at the time of an NP event in a proportion of patients with SLE. Further studies are needed to determine the value of serum NN as a biomarker for NPSLE.
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Affiliation(s)
- Isabel Ferreira
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK
| | - Sara Croca
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK
| | - Maria Gabriella Raimondo
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK
| | - Manjit Matharu
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Sarah Miller
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Ian Giles
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK
| | - David Isenberg
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK.,Arthritis Research UK Centre for Adolescent Rheumatology, UCL/UCLH/Great Ormond Street Hospital, London, UK
| | - Yiannis Ioannou
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK.,Arthritis Research UK Centre for Adolescent Rheumatology, UCL/UCLH/Great Ormond Street Hospital, London, UK
| | - John G Hanly
- Division of Rheumatology, Dalhousie University and Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada
| | - Murray B Urowitz
- Lupus Program, Centre for Prognosis Studies in The Rheumatic Disease and Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Nicole Anderson
- Lupus Program, Centre for Prognosis Studies in The Rheumatic Disease and Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Anca Askanase
- Rheumatology, Columbia University, New York, NY, USA
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Sasha Bernatsky
- Divisions of Clinical Epidemiology and Rheumatology, McGill University Health Centre, Montreal, QC, Canada
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, The University of Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jill Buyon
- New York School of Medicine, New York, NY, USA
| | - Ann E Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mary Anne Dooley
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Paul Fortin
- Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada
| | - Ellen Ginzler
- Downstate Medical Center Rheumatology, Brooklyn, New York, NY, USA
| | - Dafna Gladman
- Lupus Program, Centre for Prognosis Studies in The Rheumatic Disease and Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Murat Inanc
- Department of Internal Medicine, Istanbul University, Istanbul, Turkey
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Centre For Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | - Diane Kamen
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Sam Lim
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Susan Manzi
- Allegheny Health Network, Pittsburgh, PA, USA
| | - Joan Merrill
- Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Ola Nived
- Department of Rheumatology, Lund University, Lund, Sweden
| | - Christine Peschken
- Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute. Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Bizkaia, Spain
| | - Jorge Sanchez-Guerrero
- Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kristjan Steinson
- Department of Rheumatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Ronald van Vollenhoven
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Sweden
| | - Daniel J Wallace
- Cedars-Sinai Medical Center/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Asad Zoma
- Department of Rheumatology Hairmyres Hospital, East Kilbride, Scotland, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, University College London, Fourth Floor Rayne Institute, 5 University Street, London, WC1E 6JF, UK.
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138
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Zhang N, Cao J, Zhao M, Sun L. The introspection on the diagnosis and treatment process of a case of Guillain-Barré syndrome (GBS) attributed to systemic lupus erythematosus (SLE): A case report. Medicine (Baltimore) 2017; 96:e9037. [PMID: 29245299 PMCID: PMC5728914 DOI: 10.1097/md.0000000000009037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an autoimmune inflammatory connective tissue disorder. It may cause neurologic damage which is mainly characterized by central and mental system, while peripheral sexual damage is relatively rare in which Guillain-Barré Syndrome (GBS) as the first performance is more rare . GBS is an autoimmune peripheral neuropathy usually triggered by an antecedent bacterial or viral infection, with SLE being a rare cause. PATIENT CONCERNS A 65-year-old male presented to the hospital with progressive numbness and adynamia in extremities. His vital signs were stable. 5 days later, his condition aggravated and mechanical ventilation was necessitated owing to severe dyspnea. DIAGNOSES Based on the clinical symptoms and results of the lumbar puncture and electromyography, he was first diagnosed as GBS, however, after treatment his condition was deteriorate and the blood test showed abnormal immune indices, then renal biopsy was performed, which confirmed the diagnosis of peripheral nervous system in patients with systemic lupus erythematosus (PNS-SLE). INTERVENTIONS Firstly he was treated with intravenous immunoglobulin (IVIG) for 5 days. After his condition deterioration, he was conducted endotracheal intubation and, finally, a tracheostomy was performed. Later on he was treated with steroid therapy for several weeks. OUTCOMES The patient showed remarkable recovery and was able to walk on his own by the time of discharge. LESSONS PNS-SLE can, by itself, be one of the main causes of morbidity and mortality. Electromyography and renal biopsy should be considered when relevant. Peripheral neuropathy in SLE should be given greater recognition, and rarer forms of presentation should be taken seriously in the differential diagnosis when the clinical picture is atypical. Glucocorticoids may play an important role in the treatment of PNS-SLE.
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Affiliation(s)
- Nan Zhang
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
- Department of Neurology, Yidu Central Hospital, Weifang, Shandong, China
| | - Jie Cao
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
| | - Meng Zhao
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
| | - Li Sun
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
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139
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Sharaf-Eldin WE, Kishk NA, Gad YZ, Hassan H, Ali MAM, Zaki MS, Mohamed MR, Essawi ML. Extracellular miR-145, miR-223 and miR-326 expression signature allow for differential diagnosis of immune-mediated neuroinflammatory diseases. J Neurol Sci 2017; 383:188-198. [PMID: 29246612 DOI: 10.1016/j.jns.2017.11.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/17/2017] [Accepted: 11/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although misdiagnosis of neuromyelitis optica spectrum disorder (NMOSD) with neuropsychiatric systemic lupus erythematosus (NPSLE) or multiple sclerosis (MS) is not infrequent, reliable biomarkers remains an unmet need. Extracellular microRNAs (miRNAs) represent a worthy avenue to identify biomarkers for differential diagnosis. We aimed to explore the potential role of some selected circulating miRNAs as biomarkers for the differential diagnosis in immune-mediated neuroinflammatory diseases. METHODS A total of 80 subjects were enrolled in the present study, including 37 patients with MS (relapsing-remitting MS [RRMS; n=18] and secondary progressive MS [SPMS; n=19]), 10 patients with NMOSD and 10 patients with NPSLE as well as 23 healthy subjects. Serum expression levels of three selected miRNAs (miR-145, miR-223 and miR-326) were measured using quantitative real-time polymerase chain reaction (qRT-PCR). Whole blood expression levels of cellular immune response-relevant target genes, including signaling mother against decapentaplegic peptide 3 (SMAD3) and specificity protein 1 (SP1), were also measured using qRT-PCR. RESULTS In comparison to healthy subjects, only miR-145 and miR-223 were significantly up-regulated in MS patients, whereas, all the analyzed miRNAs revealed insignificant upregulation in NMOSD patients. All the examined miRNAs were significantly down-regulated in NPSLE patients compared to healthy subjects. miR-145, miR-223 and miR-326 expression profile is a promising diagnostic biomarker for MS and NPSLE, but not for NMOSD. This expression profile is capable of differentiating not only among MS, NMOSD and NPSLE, but also between RRMS and SPMS. CONCLUSION Specific circulating miRNAs expression signature may have the potential to differentially diagnose immune-mediated neuroinflammatory diseases.
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Affiliation(s)
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yehia Z Gad
- Medical Molecular Genetics Department, National Research Centre, Cairo, Egypt
| | - Heba Hassan
- Medical Molecular Genetics Department, National Research Centre, Cairo, Egypt
| | - Mohamed A M Ali
- Department of Biochemistry, Faculty of Science, Ain Shams University, Cairo, Egypt.
| | - Maha S Zaki
- Clinical Genetics Department, National Research Centre, Cairo, Egypt
| | - Mohamed R Mohamed
- Department of Biochemistry, Faculty of Science, Ain Shams University, Cairo, Egypt
| | - Mona L Essawi
- Medical Molecular Genetics Department, National Research Centre, Cairo, Egypt
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140
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Systemic autoimmune diseases complicated with hydrocephalus: pathogenesis and management. Neurosurg Rev 2017; 42:255-261. [PMID: 29130124 DOI: 10.1007/s10143-017-0917-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/10/2017] [Accepted: 09/27/2017] [Indexed: 01/17/2023]
Abstract
Systemic autoimmune diseases (SAIDs) represent a group of syndromes involving at least two organ systems. Classical SAIDs include connective tissue diseases, vasculitis, and granulomatous diseases, many of which involve the nervous system and result in different neurological manifestations. Hydrocephalus can be a rare but lethal complication of various SAIDs, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), sarcoidosis, and primary vasculitis. However, the pathogenesis of SAIDs complicated with different types of hydrocephalus is varied and difficult to determine using the existing published data, and various manifestations and expressive forms of the conditions bring a substantial challenge to a timely clinical diagnosis and treatment. The commonly used medical management programs based on the etiology of hydrocephalus are anti-inflammatory or anti-infectious therapies, while surgical management such as ventriculoperitoneal shunts is effective most of the time. Further research should be directed toward improving our understanding of the pathogenesis of these conditions and determining the most effective method for treating this life-threatening condition.
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141
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Brain magnetic resonance imaging, cerebrospinal fluid, and autoantibody profile in 118 patients with neuropsychiatric lupus. Clin Rheumatol 2017; 37:227-233. [DOI: 10.1007/s10067-017-3891-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 10/10/2017] [Accepted: 10/24/2017] [Indexed: 11/08/2022]
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142
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Jafri K, Patterson SL, Lanata C. Central Nervous System Manifestations of Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2017; 43:531-545. [DOI: 10.1016/j.rdc.2017.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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143
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Atzeni F, Pipitone N, Iaccarino L, Masala IF, Weiss R, Alciati A, Doria A, Chapmanand J, Sarzi-Puttini P. Rheumatic diseases and autoimmune vascular dementia. Autoimmun Rev 2017; 16:1265-1269. [PMID: 29037904 DOI: 10.1016/j.autrev.2017.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/02/2017] [Indexed: 11/17/2022]
Abstract
Vascular dementia (VD) comes second after Alzheimer's disease (AD) as a cause of impaired cognition. VD is not a specific nosological entity, but rather a syndrome encompassing a number of diseases caused by impaired supply of blood to the brain. Systemic autoimmune disorders such as systemic lupus erythematosus, rheumatoid arthritis, vasculitis and antiphospholipid syndrome (APS) can be associated with dementia. VD is often related to the presence of traditional cardiovascular risk factors, but it may also be associated with a host of disorders affecting the brain blood vessels, neuronal cells, or both. It is important to entertain in the differential diagnosis of VD, to recognize and to cure them accurately in order to preserve life's quality of our patients.
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Affiliation(s)
| | - Nicolò Pipitone
- Rheumatology Department, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | | | | | - Ronen Weiss
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Alessandra Alciati
- Department of Clinical Neurosciences, Villa San Benedetto Menni, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Como, Italy
| | - Andrea Doria
- Division of Rheumatology, University of Padoa, Italy
| | - Joab Chapmanand
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Robert and Martha Harden Chair in Mental and Neurological Diseases, Sackler Faculty of Medicine, Tel Aviv University, Israel
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144
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Psychoneuroimmunology of mental disorders. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2017; 11:115-124. [PMID: 28993125 DOI: 10.1016/j.rpsm.2017.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/04/2017] [Accepted: 07/31/2017] [Indexed: 12/30/2022]
Abstract
The immune system is a key element in the organism's defence system and participates in the maintenance of homeostasis. There is growing interest in the aetiopathogenic and prognostic implications of the immune system in mental disorders, as previous studies suggest the existence of a dysregulation of the immune response and a pro-inflammatory state in patients with mental disorders, as well as an increased prevalence of neuropsychiatric symptoms in patients suffering from autoimmune diseases or receiving immune treatments. This study aims to conduct a narrative review of the scientific literature on the role of Psychoneuroimmunology in mental disorders, with special focus on diagnostic, prognostic and therapeutic issues. The development of this body of knowledge may bring in the future important advances in the vulnerability, aetiopathogenic mechanisms, diagnosis and treatment of some mental disorders.
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145
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Assessment of the Hospital Anxiety and Depression Scale (HADS) performance for the diagnosis of anxiety in patients with systemic lupus erythematosus. Rheumatol Int 2017; 37:1999-2004. [DOI: 10.1007/s00296-017-3819-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
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146
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Muller S, Brun S, René F, de Sèze J, Loeffler JP, Jeltsch-David H. Autophagy in neuroinflammatory diseases. Autoimmun Rev 2017; 16:856-874. [DOI: 10.1016/j.autrev.2017.05.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/20/2017] [Indexed: 12/12/2022]
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147
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Koga T, Otomo K, Mizui M, Yoshida N, Umeda M, Ichinose K, Kawakami A, Tsokos GC. Calcium/Calmodulin-Dependent Kinase IV Facilitates the Recruitment of Interleukin-17-Producing Cells to Target Organs Through the CCR6/CCL20 Axis in Th17 Cell-Driven Inflammatory Diseases. Arthritis Rheumatol 2017; 68:1981-8. [PMID: 26945541 DOI: 10.1002/art.39665] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 02/25/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The recruitment of interleukin-17 (IL-17)-producing T helper (Th17) cells to inflammatory sites has been implicated in the development of organ damage in inflammatory and autoimmune diseases including systemic lupus erythematosus (SLE). To define the mechanism of calcium/calmodulin-dependent kinase IV (CaMKIV) activation of Th17 cell recruitment to target tissues, we performed anti-glomerular basement membrane antibody-induced glomerulonephritis (AIGN) experiments in mice and studied samples from patients with SLE. METHODS We induced experimental AIGN in CaMKIV-sufficient or CaMKIV-deficient mice and compared histology, Th17 cell-related chemokine expression, and numbers of IL-17-producing cells in kidneys. We also evaluated the efficacy of the CaMKIV inhibitor KN-93 in AIGN-induced kidney disease. The expression of CCR6 in memory CD4+ T cells before AIGN induction was analyzed by flow cytometry. We investigated the correlation between CCR6 expression in peripheral blood and the severity of glomerulonephritis in patients with SLE. RESULTS CaMKIV-deficient mice displayed less glomerular injury after induction of AIGN. Kidney infiltration by IL-17-producing CD4+ T cells along with CCR6 and CCL20 expression were significantly decreased in CaMKIV-deficient mice. Similarly, treatment of mice with KN-93 improved clinical and pathologic outcomes. Expression and function of CCR6 in peripheral blood memory CD4+ T cells was decreased in CaMKIV-deficient mice. Expression of CCR6 correlated positively with severity of organ damage in SLE patients. CONCLUSION CaMKIV inhibition represents a novel therapeutic strategy for treatment of Th17 cell-mediated tissue damage in inflammatory diseases.
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Affiliation(s)
- Tomohiro Koga
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, and Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kotaro Otomo
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Masayuki Mizui
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Nobuya Yoshida
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Masataka Umeda
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kunihiro Ichinose
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Atsushi Kawakami
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - George C Tsokos
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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148
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Vasculitis in the Central Nervous System. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017. [PMID: 28667559 DOI: 10.1007/978-3-319-57613-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Central nervous system (CNS) vasculitides are a heterogeneous group of disorders characterized by an inflammatory cell infiltration and necrosis of blood vessel walls in the brain, spinal cord, and the meninges. The CNS complications are likely to be fatal without judicious use of immunosuppression; thus, early diagnosis may prevent from damage and disability. This chapter updates our knowledge on CNS vasculitis-related immunological mechanisms, neurological complications, diagnosis, and management.
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149
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Wang F, Li B, Schall N, Wilhelm M, Muller S. Assessing Autophagy in Mouse Models and Patients with Systemic Autoimmune Diseases. Cells 2017; 6:E16. [PMID: 28657591 PMCID: PMC5617962 DOI: 10.3390/cells6030016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 06/26/2017] [Accepted: 06/26/2017] [Indexed: 12/19/2022] Open
Abstract
Autophagy is a tightly regulated mechanism that allows cells to renew themselves through the lysosomal degradation of proteins, which are misfolded or produced in excess, and of damaged organelles. In the context of immunity, recent research has specially attempted to clarify its roles in infection, inflammation and autoimmunity. Autophagy has emerged as a spotlight in several molecular pathways and trafficking events that participate to innate and adaptive immunity. Deregulation of autophagy has been associated to several autoimmune diseases, in particular to systemic lupus erythematosus. Nowadays, however, experimental data on the implication of autophagy in animal models of autoimmunity or patients remain limited. In our investigations, we use Murphy Roths Large (MRL)/lymphoproliferation (lpr) lupus-prone mice as a mouse model for lupus and secondary Sjögren's syndrome, and, herein, we describe methods applied routinely to analyze different autophagic pathways in different lymphoid organs and tissues (spleen, lymph nodes, salivary glands). We also depict some techniques used to analyze autophagy in lupus patient's blood samples. These methods can be adapted to the analysis of autophagy in other mouse models of autoinflammatory diseases. The understanding of autophagy implication in autoimmune diseases could prove to be very useful for developing novel immunomodulatory strategies. Our attention should be focused on the fact that autophagy processes are interconnected and that distinct pathways can be independently hyper-activated or downregulated in distinct organs and tissues of the same individual.
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Affiliation(s)
- Fengjuan Wang
- Centre National de la Recherche Scientifique (CNRS), Immunopathology and Therapeutic Chemistry/Laboratory of Excellence Medalis, Institut de Biologie Moléculaire et Cellulaire, Strasbourg 67000, France.
| | - Baihui Li
- Centre National de la Recherche Scientifique (CNRS), Immunopathology and Therapeutic Chemistry/Laboratory of Excellence Medalis, Institut de Biologie Moléculaire et Cellulaire, Strasbourg 67000, France.
| | - Nicolas Schall
- Centre National de la Recherche Scientifique (CNRS), Immunopathology and Therapeutic Chemistry/Laboratory of Excellence Medalis, Institut de Biologie Moléculaire et Cellulaire, Strasbourg 67000, France.
| | - Maud Wilhelm
- Centre National de la Recherche Scientifique (CNRS), Immunopathology and Therapeutic Chemistry/Laboratory of Excellence Medalis, Institut de Biologie Moléculaire et Cellulaire, Strasbourg 67000, France.
| | - Sylviane Muller
- Centre National de la Recherche Scientifique (CNRS), Immunopathology and Therapeutic Chemistry/Laboratory of Excellence Medalis, Institut de Biologie Moléculaire et Cellulaire, Strasbourg 67000, France.
- University of Strasbourg Institute for Advanced Study (USIAS), Strasbourg 67000, France.
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150
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Macêdo EA, Appenzeller S, Costallat LTL. Depression in systemic lupus erythematosus: gender differences in the performance of the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CES-D), and Hospital Anxiety and Depression Scale (HADS). Lupus 2017; 27:179-189. [PMID: 28587586 DOI: 10.1177/0961203317713142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The prevalence of depressive symptoms in patients with systemic lupus erythematosus (SLE) varies widely between different cohorts (17-75%), primarily due to factors such as the heterogeneity of the samples and the instruments used to detect depressive symptoms. Most of these instruments are self-administered questionnaires that have different characteristics and approaches to depressive symptoms. This study aimed to evaluate gender differences in the performance of three questionnaires used to assess depressive symptoms in patients with SLE: the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CES-D), and Hospital Anxiety and Depression Scale (HADS). This study included 54 male and 54 female SLE patients. Depressive symptoms were assessed using BDI (cutoffs 13 and 15), CES-D and HADS. The gold standard method used was the diagnostic criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Regarding the performance of the BDI questionnaire, no significant differences in sensitivity or specificity were found between the genders. The specificity of the CES-D questionnaire was significantly greater for the male group (83% vs. 62.5%, p = 0.0309), and its sensitivity was non-significantly higher for the female group (92.9% for women and 71.4% for men; p = 0.2474). Regarding the performance of the HADS, we found similar sensitivities between the genders (71.4%) but a higher specificity among the men (95.7% in men and 82.5% in women, p = 0.0741). In conclusion, our results suggest the presence of gender differences in the performance of the questionnaires in SLE patients. The BDI had the most similar performances between the male and female groups. In contrast, the CES-D and HADS-D showed considerable variation in performances between men and women with SLE.
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Affiliation(s)
- E A Macêdo
- Department of Medicine, Rheumatology Unit, School of Medical Science, State University of Campinas, Brazil
| | - S Appenzeller
- Department of Medicine, Rheumatology Unit, School of Medical Science, State University of Campinas, Brazil
| | - L T L Costallat
- Department of Medicine, Rheumatology Unit, School of Medical Science, State University of Campinas, Brazil
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