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Islam R, Das S, Chattopadhyay S, Basu S. Neuropsychiatric lupus with posterior reversible encephalopathy syndrome: a rare presentation. BMJ Case Rep 2021; 14:e241494. [PMID: 34135075 PMCID: PMC8211072 DOI: 10.1136/bcr-2020-241494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 11/03/2022] Open
Abstract
Systemic lupus erythematosus presenting with neuropsychiatric symptoms (NPSLE) along with posterior reversible encephalopathy syndrome (PRES) is rare. A young woman of 29 years presented with various neuropsychiatric symptoms along with low-grade fever, occasional headache, skin rash, arthralgias and gradually became non-ambulatory over last 6 months. After admission, she had an episode of generalised tonic-clonic seizure, followed by drowsiness. She was normotensive. Investigations revealed no evidence of any underlying infection, normal renal functions and electrolytes; but other parameters were supportive to a diagnosis of NPSLE. MRI brain showed vasogenic oedema characterised by symmetrical hyperintensities over posterior brain regions in T2 and fluid attenuated inversion recovery images with no restricted diffusion in diffusion weighted image suggestive of PRES. A diagnosis of NPSLE presenting with PRES, particularly in the absence of hypertension and abnormal renal functions was made, which is a rare presentation. She responded well to immunomodulatory therapy with methylprednisolone and monthly cyclophosphamide.
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Affiliation(s)
- Ramiz Islam
- Internal Medicine, KPC Medical College and Hospital, Jadavpur, West Bengal, India
| | - Sayonee Das
- Internal Medicine, KPC Medical College and Hospital, Jadavpur, West Bengal, India
| | | | - Sagar Basu
- Neurology, KPC Medical College and Hospital, Jadavpur, West Bengal, India
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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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3
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Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with variable clinical manifestations. While the clearest guidelines for the treatment of SLE exist in the context of lupus nephritis, patients with other lupus manifestations such as neuropsychiatric, hematologic, musculoskeletal, and severe cutaneous lupus frequently require immunosuppression and/or biologic therapy. Conventional immunosuppressive agents such as mycophenolate mofetil, azathioprine, and cyclophosphamide are widely used in the management of SLE with current more rationalized treatment regimens optimizing the use of these agents while minimizing potential toxicity. The advent of biologic therapies has advanced the treatment of SLE particularly in patients with refractory disease. The CD20 monoclonal antibody rituximab and the anti-BLyS agent belimumab are now widely in use in clinical practice. Several other biologic agents are in ongoing clinical trials. While immunosuppressive and biologic agents are the foundation of inflammatory disease control in SLE, the importance of managing comorbidities such as cardiovascular risk factors, bone health, and minimizing susceptibility to infection should not be neglected.
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Affiliation(s)
- Natasha Jordan
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - David D'Cruz
- Louise Coote Lupus Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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4
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Treatment strategies for vasculitis that affects the nervous system. Drug Discov Today 2013; 18:818-35. [DOI: 10.1016/j.drudis.2013.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 05/08/2013] [Accepted: 05/15/2013] [Indexed: 01/04/2023]
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Abstract
The location of both autoimmune processes and other causes of brain inflammation is important in determining the impact of inflammation on brain function. This chapter focuses on autoimmune and infectious diseases leading to inflammatory brain disease resulting in cognitive defects with a special focus on systemic lupus erythematosus (SLE). Collectively called neuropsychiatric SLE (NPSLE), NPSLE occurs in 20-95% of pediatric patients with SLE (pSLE). The incidence of cognitive dysfunction is difficult to ascertain in pediatric patients as few studies have been performed. Using formal neurocognitive testing of unselected pediatric SLE patients, the rate of cognitive abnormalities was approximately 50% and impairment was associated with longer disease duration in one study. A second small study showed global depression on performance and academic scores while a larger study using a neuropsychiatric inventory showed a 55% rate of dysfunction. These diverging findings may result from the lack of a standardized cognitive assessment battery. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) group of pediatric rheumatologists proposed a 2 hour 40 minutes battery for assessment of cognitive testing of SLE patients from age 9 to 18 years. Further assessments using this battery should provide a better neurocognitive profile of pSLE.
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Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of disease manifestations that can involve any organ system, and can lead to significant morbidity and even mortality. This article reviews the epidemiology, common clinical features, and complications of the disease, and briefly discusses the available treatment options. In addition, important medical and psychosocial issues relevant to the pediatrician caring for children and adolescents with SLE are discussed.
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Affiliation(s)
- Deborah M. Levy
- Assistant Professor, Pediatrics, University of Toronto Staff Rheumatologist, Hospital for Sick Children
| | - Sylvia Kamphuis
- Pediatric rheumatologist/immunologist, Sophia Children’s Hospital, Erasmus University MC, SP 3429, PO Box 2060, 3000 CB Rotterdam, tel: 0031-10-7036104 (secr), fax: 0031-10-7036943,
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Mixed connective tissue disease: An overview of clinical manifestations, diagnosis and treatment. Best Pract Res Clin Rheumatol 2012; 26:61-72. [PMID: 22424193 DOI: 10.1016/j.berh.2012.01.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/03/2012] [Accepted: 01/04/2012] [Indexed: 11/23/2022]
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von Geldern G, McPharlin T, Becker K. Immune mediated diseases and immune modulation in the neurocritical care unit. Neurotherapeutics 2012; 9:99-123. [PMID: 22161307 PMCID: PMC3271148 DOI: 10.1007/s13311-011-0096-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This chapter will review the spectrum of immune-mediated diseases that affect the nervous system and may result in an admission to the neurological intensive care unit. Immunomodulatory strategies to treat acute exacerbations of neurological diseases caused by aberrant immune responses are discussed, but strategies for long-term immunosuppression are not presented. The recommendations for therapeutic intervention are based on a synthesis of the literature, and include recommendations by the Cochrane Collaborative, the American Academy of Neurology, and other key organizations. References from recent publications are provided for the disorders and therapies in which randomized clinical trials and large evidenced-based reviews do not exist. The chapter concludes with a brief review of the mechanisms of action, dosing, and side effects of commonly used immunosuppressive strategies in the neurocritical care unit.
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Affiliation(s)
- Gloria von Geldern
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Thomas McPharlin
- University of Washington School of Pharmacy, Seattle, WA 98104 USA
| | - Kyra Becker
- Department of Neurology, University of Washington School of Medicine, Seattle, WA 98104 USA
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Gonadotropin Releasing Hormone Agonists May Minimize Cyclophosphamide Associated Gonadotoxicity in SLE and Autoimmune Diseases. Semin Arthritis Rheum 2011; 41:346-52. [DOI: 10.1016/j.semarthrit.2011.05.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 05/25/2011] [Accepted: 05/25/2011] [Indexed: 01/08/2023]
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Craig JV, Pain CE, Beresford MW. Disease modifying immunosuppressant drugs for juvenile-onset systemic lupus erythematosus. Hippokratia 2010. [DOI: 10.1002/14651858.cd008617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jean V Craig
- School of Medicine, Health Policy and Practice; NIHR Research Design Service for the East of England (Norfolk and Suffolk); University of East Anglia Norwich UK NR4 7TJ
| | - Clare E Pain
- Alderhey Children's Hospital NHS Foundation Trust; Rheumatology Department F3; Eaton Rd Liverpool Merseyside UK L12 2AP
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Abstract
Acute optic neuritis (ON) has various etiologies. The most common presentation is inflammatory, demyelinating, idiopathic, or "typical" ON, which may be associated with multiple sclerosis. This must be differentiated from "atypical" causes of ON, which differ in their clinical presentation, natural history, management, and prognosis. Clinical "red flags" for an atypical cause of ON include absent or persistent pain, exudates and hemorrhages on fundoscopy, very severe, bilateral, or progressive visual loss, and failure to recover. In typical ON, steroids shorten the duration of the attack, but do not influence visual outcome. This is in contrast to atypical ON associated with conditions such as sarcoidosis and neuromyelitis optica, which require aggressive immunosuppression and sometimes plasma exchange. The visual prognosis of typical ON is generally good. The prognosis in atypical ON is more variable. New developments aimed at designing better treatments for patients who fail to recover are discussed, focusing on recent research elucidating mechanisms of damage and recovery in ON. Future therapeutic directions may include enhancing repair processes, such as remyelination or adaptive neuroplasticity, or alternative methods of immunomodulation. Pilot studies investigating the safety and proof-of-principle of stem cell treatment are currently underway.
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Affiliation(s)
- Thomas M Jenkins
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | - Ahmed T Toosy
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
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Espinosa G, Mendizábal A, Mínguez S, Ramo-Tello C, Capellades J, Olivé A, Cervera R. Transverse Myelitis Affecting More Than 4 Spinal Segments Associated with Systemic Lupus Erythematosus: Clinical, Immunological, and Radiological Characteristics of 22 Patients. Semin Arthritis Rheum 2010; 39:246-56. [DOI: 10.1016/j.semarthrit.2008.09.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 08/16/2008] [Accepted: 09/11/2008] [Indexed: 11/26/2022]
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García Melchor E, Mora Peris B, Espinosa Garriga G. Focalidad neurológica en una paciente con lupus eritematoso sistémico. Rev Clin Esp 2009; 209:313-5. [DOI: 10.1016/s0014-2565(09)71481-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Shen SY, Fu XD, Zhang YW, Dong XL, Zhao LJ, Cai H. [Relationship between lupus headache and headache due to internal injury in traditional Chinese medicine]. ZHONG XI YI JIE HE XUE BAO = JOURNAL OF CHINESE INTEGRATIVE MEDICINE 2009; 7:407-410. [PMID: 19435552 DOI: 10.3736/jcim20090502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In 1999, the nomenclature and case definitions for neuropsychiatric lupus syndromes were published by American College of Rheumatology (ACR), and the cognition of neuropsychiatric damage of systemic lupus erythematosus (SLE) was gradually unified and standardized. Lupus headache is an intractable problem in SLE, especially in SLE patients complicated with multiple organ injury. In general, vascular headache is common in most SLE patients, and a small number of SLE patients complicated with nervous headache are found in clinic. Moreover, its pathophysiological mechanism is far from being understood. Although early diagnosis is essential for good outcomes, the diagnosis method is rather confused in the world. There still exist some limitations in the proposal of clinical classification of headache from ACR and International Headache Society (IHS), and the proposal does not mention the classification of headache related to psychiatric damage. Current therapeutic regimens are almost exclusively based on empirical evidence. Treatment approaches include symptomatic treatment, immunosuppressive, anticoagulant and anti-aggregant therapies. It provides enormous and hopeful space in research of combined therapy strategy, especially in the field of traditional Chinese medicine. The authors discussed the relationship between lupus headache and headache due to internal injury in the view of integrated traditional Chinese and Western medicine, and suggested that the treatment strategy for lupus headache should be made in argument with the headache due to internal injury. Syndrome differentiation treatment according to deficiency in the root and excess in the branch and the therapy for activating blood to dredge collaterals maybe have great advantages in treatment of the headache in SLE.
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Affiliation(s)
- Si-yu Shen
- Department of Integrated Traditional Chinese and Western Medicine, Nanjing General Hospital of Nanjing Military Command, Nanjing 210002, Jiangsu Province, China
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Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with variable clinical manifestations that is characterized by flares and periods of relative quiescence. The disease occurs approximately 10 times more frequently in women and is more prevalent among certain ethnic groups. The etiology is complex and dependent upon an interaction of genetic, hormonal, and environmental factors. Corticosteroids and immunosuppressive agents have transformed the outlook for patients with lupus. Unfortunately, the increased lifespan unmasked an accelerated process of atherosclerosis and cardiovascular disease. Early mortality is usually attributable to active lupus, but deaths late in the disease process are often secondary to thrombotic events. Advancements in the understanding of molecular and cellular mechanisms involved in the pathogenesis have resulted in development of novel therapies. Immunomodulatory drugs developed for other diseases are being investigated for use in specific manifestations of lupus. Individualization of treatment and lifelong monitoring are required in most patients.
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