Survivorship in systemic lupus erythematosus: effect of antibody to extractable nuclear antigen

Damage index assessment and quality of life in systemic lupus erythematosus patients (with long-term disease) in Northeastern Brazil

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects mainly young women. During the disease course, many organs and systems can suffer non-reversible damage that decreases both the patient's life span and also their quality of life. To determine the chronic damage and its correlation with quality of life, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was used in 63 patients who met the ACR criteria for SLE. Quality of life (QOL) was measured through the Medical Outcomes Survey short form 36 (SF-36), sociodemographic data were assessed using specific questionnaires, and disease activity was measured by the systemic lupus erythematosus disease activity index. Overall, 32% of the patients presented damage. Neuropsychiatric (25%) and vascular (20%) involvement were the most frequently related. Organic damages were associated with disease duration (p < 0.03). General health status and social aspects of quality of life were also associated with disease duration (p < 0.05 and p < 0.038, respectively). Socioeconomic status and disease activity were not associated with organic damages and quality of life. This study concluded that disease activity, cumulative damage, and quality of life had some influence in the overall view of lupus but those parameters are distinct domains of health status in SLE. Our analysis identified that disease duration had an important association with damage index and general health status.

Mucocutaneous disease in Arabs with systemic lupus erythematosus: clinical expression and relevance to autoantibodies

Both criterial and non-criterial mucocutaneous manifestations of 42 Arabs with systemic lupus erythematosus are reviewed. Photosensitivity occurred in 40.5%, malar rash in 35.75% and oral ulcers in 26% of patients. Subcutaneous nodules and subcutaneous lupus erythematosus (SCLE) were not seen, and there were few cases of discoid rash (DLE), Raynaud's phenomenon, livedo reticularis and SLE-related sicca and anticardiolipin syndromes. In the clinical relevance of autoantibodies in these patients, there was a significant association between anti-Sm antibodies and oral ulcers (P= 0.033) and, interestingly, between anti-cardiolipin (aCL) antibodies and lack of photosensitivity (P = 0.014). The report also reviews previously presented data on mucocutaneous LE in Arab and non-Arab patients and emphasises the presence of intra- and inter-racial variations of SLE expression including the clinical relevance to autoantibodies.

Study of critically ill patients with systemic lupus erythematosus

OBJECTIVES

To determine the presenting features, prognostic factors, course, and outcome of critically ill patients with systemic lupus erythematosus admitted to the intensive care unit (ICU).

DESIGN

Retrospective patient record review.

SETTING

Two academic teaching hospitals.

PATIENTS

All patients with systemic lupus erythematosus admitted to the ICUs between January 1982 and July 1993.

MEASUREMENTS AND MAIN RESULTS

There were 28 female and two male patients. Fifteen patients were white, 11 patients were black, and four patients were Asian. The median age was 29 yrs. The reasons for admission to the ICU were multifactorial. However, most patients were admitted for infective, renal, cardiac, or coagulation complications. Despite aggressive management, 16 (53%) patients died in the ICU or shortly after discharge. The median ICU survival rate (admission to death) was 22 days. The only pretreatment factor that predicted a poor outcome was the presence of renal involvement due to systemic lupus erythematosus.

CONCLUSIONS

Our study suggests that patients with systemic lupus erythematosus admitted to an ICU often have florid disease manifestations with multifactorial reasons precipitating the admission. The prognosis for such patients is poor, particularly in the presence of renal involvement.

Follow-up of 151 patients with high-titer U1RNP antibodies

We performed a longitudinal follow-up study of clinical findings in 151 patients with high-titer antibodies against U1 ribonucleoprotein (U1RNP) as measured by haemagglutination. Formal connective tissue disease (CTD) diagnoses were assigned and diagnostic transitions analysed. One-hundred eighteen females and 33 males entered the study; the mean duration of follow-up was 7.1 years. Mean age at entry was 34.7 years; 73% of the patients had early disease (duration < 2 years). Fifty-six patients (37%) presented with a definite diagnosis, most often mixed connective tissue disease (MCTD, n = 40), followed by systemic lupus erythematosus (SLE, n = 11) and systemic sclerosis (SSc, n = 5). Of 84 patients (56%) presenting with nonspecific symptoms of possible, "undifferentiated" CTD, 58 developed MCTD, 4 SSc and 2 SLE. By the end of the follow-up period. 127 patients had developed a well-defined CTD; final diagnoses were: MCTD (n = 97), SLE (n = 18), SSc (n = 12). We conclude that CTD in the context of high-titer anti-U1RNP antibodies may be transitive and sequential in nature, although the diagnostic criteria for MCTD previously proposed by our group seem to delimit a clinically stable condition in most patients in this subgroup.

Antinuclear antibodies in routine analysis: the relevance of putative clinical associations

Defined antinuclear antibodies (ANA), such as antibodies to Ro/SS-A, La/SS-B, Sm, and nRNP, are often present in serum samples from patients with systemic lupus erythematosus (SLE) or other connective tissue diseases (CTD). Most data on associations between the presence of these antibodies and defined disease features have been obtained with the use of predefined groups of patients. In this work the issue of disease associations was approached from a different angle: patients suspected of having CTD were selected on the presence of these ANA in their serum samples and clinical data were subsequently scored according to a defined protocol. It was then tried to relate measured ANA and clinical symptoms. No correlation was observed between the presence of antibodies to Ro/SS-A and specific clinical symptoms. The presence of antibodies to La/SS-B was associated with the diagnosis of Sjögren's syndrome combined with leukocytopenia. In patients positive for antibodies to Sm a significantly increased incidence of skin lesions, such as butterfly rashes and discoid lesions, was seen, together with signs of myocarditis. Myocarditis was also found to be associated with the presence of antibodies to nRNP. The data presented in this study show that previously reported associations of these ANA with clinical symptoms are not confirmed when unselected patients are used.

Racial differences in the frequencies of scleroderma-related autoantibodies

OBJECTIVE

To determine demographic differences in scleroderma-related autoantibodies.

METHODS

One hundred fifty-six patients with systemic sclerosis were prospectively examined for anticentromere antibodies (ACA), anti-topoisomerase I (anti-topo I, or Scl-70), antinucleolar, and anti-U1 RNP autoantibodies.

RESULTS

ACA was found in 36% of Caucasians and 4% of American blacks (P = 0.002, odds ratio [OR] 15). Anti-topo I was found in 37% of American blacks, compared with 17% of Caucasians (P = 0.04, OR 3). No significant differences in the frequencies of antinucleolar and anti-U1 RNP autoantibodies were found.

CONCLUSION

These data suggest important demographic differences in scleroderma-associated autoantibodies.

Prognosis in systemic lupus erythematosus. Negative impact of increasing age at onset, black race, and thrombocytopenia, as well as causes of death

To assess the impact of demographic and clinical factors on prognosis in patients with systemic lupus erythematosus (SLE), we examined survivorship by life-table analysis in 389 patients. There were approximately equal numbers of Caucasian patients and American black patients in this study group. On both univariate and multivariate analyses, we found that both American black race and increasing age at SLE onset independently worsened the probability of survival. Of all the clinical factors we analyzed, thrombocytopenia emerged as the only independent risk factor for a worse prognosis in SLE. In all clinical and demographic groups considered, the leading cause of death was infection.

High-grade atrioventricular heart block in an adult with systemic lupus erythematosus: the association of nuclear RNP (U1 RNP) antibodies, a case report, and review of the literature

High-grade atrioventricular heart block (HGAVB) occurring as a manifestation of systemic lupus erythematosus is an exceedingly rare event. We describe a patient with HGAVB who had myositis and antibodies to nuclear RNP (previously associated with myocarditis). A review of the literature on HGAVB associated with systemic lupus erythematosus is also presented.

Immunoblotting profiles in 55 systemic lupus erythematosus sera lacking precipitating antibodies to extractable nuclear antigens

Serum samples from 55 patients with systemic lupus erythematosus (SLE) were selected for the absence of anti-extractable nuclear antigen antibodies after routine immunodiffusion tests. These sera were immunoblotted for anti-Sm and anti-RNP antibodies on a HeLa cell nuclear extract. Ten (18%) were negative and 45 (82%) produced complex patterns: 10 (18%) suggestive of anti-Sm, three (5%) anti-RNP, and 32 (58%) a combination of anti-Sm and anti-RNP antibodies. These data were very similar to those obtained from sera from a control group of 28 SLE sera selected for positivity of anti-Sm and anti-RNP precipitins with the immunodiffusion test. IgM isotype antibodies to the D peptide were significantly more prevalent than IgG isotype antibodies, whereas antibodies to the 68 kD polypeptide were of both IgM and IgG isotypes. Sera with an anti-Sm/RNP immunoblotting pattern stemmed from a group of patients with SLE with a higher titre of anti-dsDNA antibodies. Among clinical symptoms, the incidence of haemolytic anaemia was higher in the group of patients with the anti-Sm immunoblotting profile. Patients with an anti-RNP immunoblotting profile showed a higher incidence of cutaneous symptoms. It is concluded that immunoblotting for anti-Sm or anti-RNP antibody determination is a very sensitive diagnostic tool in patients with SLE.

Is MCTD a distinct entity? Comparison of clinical and laboratory findings in MCTD, SLE, PSS, and RA patients

Eighteen patients diagnosed as suffering from MCTD were reexamined during follow-up (mean duration 4.6 years). The clinical features of these patients were compared with those of 19 patients with systemic lupus erythematosus (SLE), 11 with progressive systemic sclerosis (PSS) and 22 with rheumatoid arthritis (RA). Considerable overlapping of abnormal features was found between MCTD and the other syndromes. At the end of the follow-up period, 70 per cent of the cases initially diagnosed as MCTD evolved to a more classical connective tissue disease, i.e., either PSS or SLE. Generally, however, the clinical evolution of the individual MCTD patient was not predictable. Abnormal aortic valve calcifications were found in the MCTD group. Four of the 18 MCTD patients were anti-RNP negative at reexamination. There was a tendency for HLA antigens B7 and B8 to be increased in the MCTD group, but this difference was not statistically significant. Three MCTD patients died before they could be reexamined (two of them from pulmonary hypertension with proliferative endarteritis of the lung vessels and one from septicaemia and multiple cerebral infarctions.

Treatment of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease with clinical manifestations involving a multitude of tissue sites. This article describes the pathophysiology, etiology, clinical manifestations, and therapy of SLE, and focuses mainly on drugs used in SLE treatment. The reader will be able to identify which pharmacologic agents are used in SLE and list the drugs that are useful for specific clinical manifestations. The reader will also be able to describe the common adverse drug reactions seen from SLE treatment and the potential risks involved with these therapies. Information on expected outcomes from drug therapy that will aid in monitoring patients receiving treatment for SLE is provided.

Systemic lupus erythematosus: follow-up study of 148 patients. I: Classification, clinical and laboratory findings, course and outcome

The present paper is a description of 148 patients with circulating antinuclear antibodies and multisystemic disease filed during 18 years by one of the authors and followed up to date in 1981-83. Seventy-eight per cent of the patients satisfied the 1971 ARA criteria for the classification of systemic lupus erythematosus and 92 per cent fulfilled the 1982 ARA criteria. Eighty-five per cent were women, the mean age at onset of SLE was 32 years. Malar rash and arthritis were early manifestations in 80 per cent of the patients whereas the onset of nephropathy, CNS manifestations, serositis, and peripheral cytopenia was delayed in about half of the patients. Nephropathy and thrombocytopenia were observed particularly in the youngest patients. The mean duration of the observation period was 8 years. The 10-year-survival was 80 per cent. Half of the deaths were presumably unrelated to SLE. The mean ages at entry of patients who died of SLE and of unrelated causes were 30 and 52 years respectively. Eighteen per cent of the deaths were caused by uremia and 18 per cent by infections. The total and the SLE related mortalities were evenly distributed throughout the observation period. The morbidity (incidence of new ARA criteria and other findings indicating active disease) decreased during the first year of observation but rarely subsided completely during the following years. All patients observed for more than 10 years showed evidence of active disease during the rest of the observation period and most showed evidence of renal disease.

HLA and genetic predisposition to lupus erythematosus and other dermatologic disorders

Human leukocyte antigen (HLA) associations with different clinical and serologic subsets of lupus erythematosus are providing important clues to genetic predisposition and pathogenesis. The evolving complexity of the HLA-D region is described, and currently recognized HLA-region associations with systemic lupus erythematosus, subacute cutaneous lupus erythematosus, homozygous C2-deficient lupus, Sjögren's syndrome, and the neonatal lupus syndrome are reviewed. The striking relationship between the Ro/SSA-La/SSB antibody responses and HLA-DR2 and DR3 are emphasized. Other dermatologic conditions associated with HLA are also noted.

Incidence and clinical significance of anti-ENA antibodies in systemic lupus erythematosus. Estimation by counterimmunoelectrophoresis

Eighty-two patients with systemic lupus erythematosus (SLE) were investigated for the presence and significance of serum antibodies to Extractable Nuclear Antigen (ENA) and its major components, RNP, Sm and SS-B (or Ha). The counterimmunoelectrophoresis assay allowed independent detection and measurement of antibodies to the different components. Forty patients had anti-ENA antibodies, 25 (30%) were of anti-RNP type alone or anti-RNP associated with anti-Sm, and 12 (15%) were of anti-RNP type alone. Anti-ENA antibodies distinguished a subset of patients with less common incidence of renal disease, positive Coombs test, anticoagulant serum factors and high titres of anti-DNAds antibodies, with higher incidence of Raynaud's phenomenon, swollen hands, hypergammaglobulinemia and high titres of antinuclear antibodies with speckled pattern on immunofluorescence. SLE patients with anti-RNP antibodies had in addition a high frequency of normal complement values. All but one SLE patient with only anti-RNP antibodies fulfilled at least four or more criteria for the diagnosis of SLE. We conclude that anti-ENA antibodies in SLE patients are associated with a low prevalence of nephritis and a clinical and laboratory profile similar to that of the MCTD syndrome. These findings demonstrate the difficulty of inferring rigid differences between MCTD and SLE. The MCTD syndrome probably represents only one segment of the whole clinical spectrum of SLE.

Relationship of precipitating antibodies to soluble cellular antigens and histologically defined renal lesions in systemic lupus erythematosus

Antibodies to nuclear ribonucleoprotein (nRNP), Sm, SS-A, and SS-B, were studied by a quantitative immunodiffusion technique in 48 patients with systemic lupus erythematosus (SLE). There was no correlation between the presence or titre of antibodies to any of these antigens and clinically apparent renal disease. However, among 34 patients who had renal biopsies antibodies to nRNP, Sm, and/or SS-A were seen in all 8 patients with membranous glomerulonephritis. Low-titre antibodies (less than 1:4) were seen in 3 out of 7 patients with diffuse proliferative glomerulonephritis. Longitudinal studies in 4 patients who had serial biopsies indicated that the association between serological and histological findings was maintained for prolonged periods. In 2 patients whose biopsy pattern changed, antibodies to nRNP, Sm, and SS-A antedated the development of membranous nephritis.