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Unal D, Cam V, Emreol HE, Özen S. Diagnosis and Management of Pediatric Neuropsychiatric Systemic Lupus Erythematosus: An Update. Paediatr Drugs 2024; 26:381-395. [PMID: 38805115 DOI: 10.1007/s40272-024-00632-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/29/2024]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is a potentially serious and life-threatening complication of SLE. The presentation and severity of neuropsychiatric involvement in SLE may show considerable variability. The disease can affect the neural tissue directly or may be associated with vascular involvement, mainly associated with anti-phospholipid (aPL) antibodies. A direct causal link with SLE may sometimes be challenging since there are many confounding factors and the symptoms may be non-specific. Despite its remarkable sensitivity in detecting hemorrhagic and ischemic stroke, transverse myelitis and ischemic infarction, magnetic resonance imaging (MRI) lacks the spatial resolution required to identify microvascular involvement. When standard MRI fails to detect a suspicious lesion, it is advisable to use advanced imaging modalities such as positron emission tomography (PET), single photon emission computed tomography (SPECT) or quantitative MRI, if available. Even with these advanced modalities, the specificity of neuroimaging in NPSLE remains inadequate (60-82% for MRI). Neuropsychiatric syndromes, such as cerebrovascular events, seizures and cognitive impairments appear to be associated with serum aPL antibodies. Some studies have shown that anti-ribosomal P antibodies have a low sensitivity for NPSLE and a limited contribution to the differentiation of different clinical entities. Treatment has two main goals: symptomatic relief and treatment of the disease itself. Commonly used immunosuppressants for NPSLE include cyclophosphamide (CYC), azathioprine (AZA), and mycophenolate mofetil (MMF). According to EULAR's current recommendation, strong immunosuppressants such as CYC and rituximab (RTX) should be preferred. Biologics have also been used in NPSLE. Fingolimod, eculizumab, and JAK inhibitors are potential drugs in the pipeline. Developing targeted therapies will be possible by a better understanding of the pathological mechanisms.
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Affiliation(s)
- Dilara Unal
- Department of Pediatric Rheumatology, Hacettepe University Medical Faculty, Sihhiye Campus, 06100, Ankara, Turkey
| | - Veysel Cam
- Department of Pediatric Rheumatology, Hacettepe University Medical Faculty, Sihhiye Campus, 06100, Ankara, Turkey
| | - Hulya Ercan Emreol
- Department of Pediatric Rheumatology, Hacettepe University Medical Faculty, Sihhiye Campus, 06100, Ankara, Turkey
| | - Seza Özen
- Department of Pediatric Rheumatology, Hacettepe University Medical Faculty, Sihhiye Campus, 06100, Ankara, Turkey.
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Berndorfler BD, Warwick JM, Doruyter AGG. Role of F-18 FDG PET-CT in neuropsychiatric systemic lupus erythematosus. Compr Psychiatry 2024; 132:152480. [PMID: 38555700 DOI: 10.1016/j.comppsych.2024.152480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/18/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Neuropsychiatric systemic lupus erythematosus (NPSLE) is a major contributor to morbidity and mortality in systemic lupus erythematosus (SLE) patients. To date no single clinical, laboratory or imaging test has proven accurate for NPSLE diagnosis which is a testament to the intricate and multifactorial pathophysiological mechanisms suspected to exist. Functional imaging with FDG PET-CT has shown promise in NPSLE diagnosis, detecting abnormalities prior to changes evident on anatomical imaging. Research indicates that NPSLE may be more aggressive in people of African descent with higher mortality rates, making rapid and correct diagnosis even more important in the African context. METHODS In this narrative review, we provide a thorough appraisal of the current literature on the role of FDG PET-CT in NPSLE. Large, well-known databases were searched using appropriate search terms. Manual searches of references of retrieved literature were also included. FINDINGS A total of 73 article abstracts were assessed, yielding 26 papers that were directly relevant to the topic of FDG PET-CT in NPSLE. Results suggest that FDG PET-CT is a sensitive imaging test for NPSLE diagnosis and may play a role in assessing treatment response. It is complementary to routine anatomical imaging, particularly in diffuse manifestations of the disease. Newer quantitative analyses are commonly used for interpretation and can detect even subtle abnormalities, missed on visual inspection. Findings of group-wise analyses of FDG PET-CT scans in NPSLE patients are important in furthering our understanding of the complicated pathophysiological mechanisms involved. Limitations of FDG PET-CT include its lack of specificity, high cost and poor access. CONCLUSION FDG PET-CT is a sensitive test for NPSLE diagnosis but is hampered by lack of specificity. It is a valuable tool for clinicians managing SLE patients, particularly when anatomical imaging is negative. Its exact application will depend on the local context and clinical scenario.
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Affiliation(s)
- Bianca D Berndorfler
- Nuclear Medicine Division, Department of Medical Imaging and Clinical Oncology, Stellenbosch University, Cape Town, South Africa.
| | - James M Warwick
- Nuclear Medicine Division, Department of Medical Imaging and Clinical Oncology, Stellenbosch University, Cape Town, South Africa
| | - Alex G G Doruyter
- Nuclear Medicine Division, Department of Medical Imaging and Clinical Oncology, Stellenbosch University, Cape Town, South Africa; NuMeRI Node for Infection Imaging, Central Analytical Facilities, Stellenbosch University, Cape Town, South Africa
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Rodrigo S, Costi S, Ellul P, Aubart M, Boddaert N, Auvin S, Elmaleh M, Ntorkou A, Bader-Meunier B, Lebon V, Melki I, Chiron C. Brain 18 F-FDG PET reveals cortico-subcortical hypermetabolic dysfunction in juvenile neuropsychiatric systemic lupus erythematosus. EJNMMI Res 2024; 14:34. [PMID: 38564068 PMCID: PMC10987444 DOI: 10.1186/s13550-024-01088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/02/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND In juvenile systemic lupus erythematosus (j-SLE) with neuropsychiatric (NP) symptoms, there is a lack of diagnostic biomarkers. Thus, we study whether PET-FDG may identify any metabolic dysfunction in j-NPSLE. METHODS A total of 19 18FDG-PET exams were consecutively performed using PET-MRI system in 11 non-sedated patients presenting with j-NPSLE (11-18y) for less than 18 months (m) and without any significant lesion at MRI. Psychiatric symptoms were scored from 0 (none) to 3 (severe) at PET time. PET images were visually analyzed and voxel-based analyses of cerebral glucose metabolism were performed using statistical parametric mapping (spm) with an age-matched control group, at threshold set > 50 voxels using both p < 0.001 uncorrected (unc.) and p < 0.05 corrected family wise error (FWE). RESULTS Patients exhibited mainly psychiatric symptoms, with diffuse inflammatory j-NPSLE. First PET (n = 11) was performed at a mean of 15y of age, second/third PET (n = 7/n = 1) 6 to 19 m later. PET individual analysis detected focal bilateral anomalies in 13/19 exams visually but 19/19 using spm (unc.), mostly hypermetabolic areas (18/19). A total of 15% of hypermetabolic areas identified by spm had been missed visually. PET group analysis (n = 19) did not identify any hypometabolic area, but a large bilateral cortico-subcortical hypermetabolic pattern including, by statistical decreasing order (unc.), thalamus, subthalamic brainstem, cerebellum (vermis and cortex), basal ganglia, visual, temporal and frontal cortices. Mostly the subcortical hypermetabolism survived to FWE analysis, being most intense and extensive (51% of total volume) in thalamus and subthalamus brainstem. Hypermetabolism was strictly subcortical in the most severe NP subgroup (n = 8, scores 2-3) whereas it also extended to cerebral cortex, mostly visual, in the less severe subgroup (n = 11, scores 0-1), but difference was not significant. Longitudinal visual analysis was inconclusive due to clinical heterogeneity. CONCLUSIONS j-NPSLE patients showed a robust bilateral cortico-subcortical hypermetabolic network, focused subcortically, particularly in thalamus, proportionally to psychiatric features severity. Further studies with larger, but homogeneous, cohorts are needed to determine the sensitivity and specificity of this dysfunctional pattern as a potential biomarker in diffuse inflammatory j-NPSLE with normal brain MRI.
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Affiliation(s)
- Sebastian Rodrigo
- CEA, SHFJ (Frederic Joliot Hospital), Orsay, France
- Biomedical Multimodal Imaging (BioMaps) Laboratory, CEA, INSERM, CNRS, and Paris-Saclay University, Orsay, France
| | - Stefania Costi
- Pediatric Rheumatology Unit, ASST-PINI-CTO (Regional Health Care and Social Agency Gaetano Pini), Milan, Italy
| | - Pierre Ellul
- Child and Adolescent Psychiatry, APHP, Robert Debré Hospital, Paris-Cité University, Paris, France
- Immunology-Immunopathology-Immunotherapy (i3) Laboratory, INSERM UMR-S 959 and Sorbonne University, Paris, France
| | - Melodie Aubart
- Pediatric Neurology, APHP, Hospital Necker for Sick Children, Paris-Cité University, Paris, France
- INSERM U1163, Imagine Institute, Paris, France
| | - Nathalie Boddaert
- INSERM U1163, Imagine Institute, Paris, France
- Pediatric Radiology, APHP, Hospital Necker for Sick Children, Paris-Cité University, Paris, France
| | - Stephane Auvin
- Pediatric Neurology, APHP, Robert Debré Hospital, Paris-Cité University, Institut Universitaire de France (IUF), Paris, France
| | - Monique Elmaleh
- Pediatric Radiology, APHP, Robert Debré Hospital, Paris-Cité University, Paris, France
- INSERM U1141 Neurodiderot and Neurospin Institute, Paris, France
| | - Alexandra Ntorkou
- Pediatric Radiology, APHP, Robert Debré Hospital, Paris-Cité University, Paris, France
| | - Brigitte Bader-Meunier
- INSERM U1163, Imagine Institute, Paris, France
- Pediatric Immunology and Rhumatology, APHP, Hospital Necker for Sick Children, Paris, France
| | - Vincent Lebon
- CEA, SHFJ (Frederic Joliot Hospital), Orsay, France
- Biomedical Multimodal Imaging (BioMaps) Laboratory, CEA, INSERM, CNRS, and Paris-Saclay University, Orsay, France
| | - Isabelle Melki
- INSERM U1163, Imagine Institute, Paris, France
- Robert Debré Hospital, General Pediatrics, Infectious Disease and Internal Medicine Department, Reference center for Rheumatic, APHP, AutoImmune and Systemic diseases in children (RAISE), Paris, France
- Paediatrics, Rheumatology and Paediatric Internal Medicine, Children's Hospital, Bordeaux, France
| | - Catherine Chiron
- CEA, SHFJ (Frederic Joliot Hospital), Orsay, France.
- Pediatric Neurology, APHP, Hospital Necker for Sick Children, Paris-Cité University, Paris, France.
- INSERM U1141 Neurodiderot and Neurospin Institute, Paris, France.
- Service Hospitalier Frederic Joliot (INSERM U1141), 4 Place du General Leclerc, Orsay, 91400, France.
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Nikolaidou A, Beis I, Dragoumi P, Zafeiriou D. Neuropsychiatric manifestations associated with Juvenile Systemic Lupus Erythematosus: An overview focusing on early diagnosis. Brain Dev 2024; 46:125-134. [PMID: 38061949 DOI: 10.1016/j.braindev.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 02/17/2024]
Abstract
Juvenile systemic lupus erythematosus (jSLE) is a chronic multisystem inflammatory disease that manifests before the age of 16 years, following a remitting - relapsing course. The clinical presentation in children is multifaceted, most commonly including constitutional, hematological, cutaneous, renal, and neuropsychiatric symptoms. Neuropsychiatric manifestations range widely, affecting approximately 14-95 % of jSLE patients. They are associated with high morbidity and mortality, particularly at a younger age. Headaches, seizures, cognitive dysfunction, and mood disorders are the most frequent neuropsychiatric manifestations. The pathophysiological mechanism is quite complex and has not yet been fully investigated, with autoantibodies being the focus of research. The diagnosis of neuropsychiatric jSLE remains challenging and exclusionary. In this article we review the clinical neuropsychiatric manifestations associated with jSLE with the aim that early diagnosis and prompt treatment is achieved in children and adolescents with the disease.
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Affiliation(s)
- Anna Nikolaidou
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Beis
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
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Padilha IG, Nehme A, de Boysson H, Létourneau-Guillon L. Imaging of Vasculitis Associated with Systemic Disease. Neuroimaging Clin N Am 2024; 34:81-92. [PMID: 37951707 DOI: 10.1016/j.nic.2023.07.010] [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] [Indexed: 11/14/2023]
Abstract
Vasculitides are characterized by inflammation of the vessel wall, with their categorization relying on clinical and paraclinical manifestations, vessel type, size, distribution, histological attributes, and associated conditions. This review delves into the salient neuroimaging hallmarks of central nervous system vasculitis associated with the most prevalent systemic diseases and highlightings potential pitfalls and diagnostic confounders.
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Affiliation(s)
- Igor Gomes Padilha
- Division of Neuroradiology, Diagnósticos da América SA - DASA, São Paulo, São Paulo, Brazil; Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, São Paulo, Brazil; Division of Neuroradiology, United Health Group, São Paulo, São Paulo, Brazil; Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Ahmad Nehme
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France
| | - Hubert de Boysson
- Normandie University, Caen, France; Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Laurent Létourneau-Guillon
- Radiology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada; Imaging and Engineering Axis, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.
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Danieli MG, Brunetto S, Gammeri L, Palmeri D, Claudi I, Shoenfeld Y, Gangemi S. Machine learning application in autoimmune diseases: State of art and future prospectives. Autoimmun Rev 2024; 23:103496. [PMID: 38081493 DOI: 10.1016/j.autrev.2023.103496] [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] [Received: 11/12/2023] [Accepted: 11/29/2023] [Indexed: 04/30/2024]
Abstract
Autoimmune diseases are a group of disorders resulting from an alteration of immune tolerance, characterized by the formation of autoantibodies and the consequent development of heterogeneous clinical manifestations. Diagnosing autoimmune diseases is often complicated, and the available prognostic tools are limited. Machine learning allows us to analyze large amounts of data and carry out complex calculations quickly and with minimal effort. In this work, we examine the literature focusing on the use of machine learning in the field of the main systemic (systemic lupus erythematosus and rheumatoid arthritis) and organ-specific autoimmune diseases (type 1 diabetes mellitus, autoimmune thyroid, gastrointestinal, and skin diseases). From our analysis, interesting applications of machine learning emerged for developing algorithms useful in the early diagnosis of disease or prognostic models (risk of complications, therapeutic response). Subsequent studies and the creation of increasingly rich databases to be supplied to the algorithms will eventually guide the clinician in the diagnosis, allowing intervention when the pathology is still in an early stage and immediately directing towards a correct therapeutic approach.
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Affiliation(s)
- Maria Giovanna Danieli
- SOS Immunologia delle Malattie Rare e dei Trapianti. AOU delle Marche & Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, via Tronto 10/A, 60126 Torrette di Ancona, Italy; Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Silvia Brunetto
- Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Luca Gammeri
- Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Davide Palmeri
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy
| | - Ilaria Claudi
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, and Reichman University Herzliya, Israel.
| | - Sebastiano Gangemi
- Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy.
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Wang Q, Yao Q, Yuan S, Shen Y, Feng Y, Liu L, Zhu Y, Zhao Y, Cui J, Qin J, Tian J, Zhao R, Liu L, Zhou Y, Liu X. Recurrent Cerebral Infarction Due to Moyamoya Disease Complicated With Systemic Lupus Erythematosus: A Case Report and Literature Review. Neurologist 2024; 29:4-13. [PMID: 37582681 DOI: 10.1097/nrl.0000000000000517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
INTRODUCTION We report a rare case of moyamoya disease caused by an RNF213 mutation, complicated with systemic lupus erythematosus. CASE REPORT A 32-year-old woman experienced 4 cerebral ischemia stroke events within 6 months. The main symptom was left limb weakness with blurred vision in the right eye. Results of digital subtraction angiography conducted at another hospital were consistent with moyamoya disease. On genetic testing, we found that the patient carried 2 mutations in the moyamoya disease-related gene RNF213 (p.R4810K, p.T1727M). On the basis of the laboratory immunologic indicators, such as positive antibodies and abnormal immunoglobulin levels and imaging examinations, the patient was finally diagnosed as moyamoya disease complicated with systemic lupus erythematosus. She was treated with aspirin, butylphthalide, urinary kallidinogenase, and sodium methylprednisolone. CONCLUSIONS This was a 32-year-old young patient diagnosed with moyamoya disease carrying RNF213 gene mutation and accompanied by lupus with cerebral ischemic event as the first occurrence. The patient's condition was complex; therefore, comprehensive analysis and in-depth consideration were needed to avoid a missed diagnosis and misdiagnosis. When the primary disease cannot be identified, genetic testing can help to clarify the diagnosis of moyamoya disease.
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Affiliation(s)
- Qisong Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Cocco C, Manca E, Corda G, Angioni MM, Noli B, Congia M, Loy F, Isola M, Chessa E, Floris A, Lorefice L, Saba L, Mathieu A, Ferri GL, Cauli A, Piga M. Brain-reactive autoantibodies in neuropsychiatric systemic lupus erythematosus. Front Immunol 2023; 14:1157149. [PMID: 37383228 PMCID: PMC10294074 DOI: 10.3389/fimmu.2023.1157149] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/19/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction The pathogenesis of neuropsychiatric systemic lupus erythematosus (NPSLE) is widely unknown, and the role of autoantibodies is still undetermined. Methods To identify brain-reactive autoantibodies possibly related to NPSLE, immunofluorescence (IF) and transmission electron microscopy (TEM) on rat and human brains were performed. ELISA was used to reveal the presence of known circulating autoantibodies, while western blot (WB) was applied to characterize potential unknown autoantigen(s). Results We enrolled 209 subjects, including patients affected by SLE (n=69), NPSLE (n=36), Multiple Sclerosis (MS, n=22), and 82 age- and gender-matched healthy donors (HD). Autoantibody reactivity by IF was observed in almost the entire rat brain (cortex, hippocampus, and cerebellum) using sera from NPSLE and SLE patients and was virtually negative in MS and HD. NPSLE showed higher prevalence (OR 2.4; p = 0.047), intensity, and titer of brain-reactive autoantibodies than SLE patients. Most of the patient sera with brain-reactive autoantibodies (75%) also stained human brains. Double staining experiments on rat brains mixing patients' sera with antibodies directed against neuronal (NeuN) or glial markers showed autoantibody reactivity restricted to NeuN-containing neurons. Using TEM, the targets of brain-reactive autoantibodies were located in the nuclei and, to a lesser extent, in the cytoplasm and mitochondria. Given the high degree of colocalization between NeuN and brain-reactive autoantibodies, we assumed NeuN was a possible autoantigen. However, WB analysis with HEK293T cell lysates expressing or not expressing the gene encoding for NeuN protein (RIBFOX3) showed that patients' sera carrying brain-reactive autoantibodies did not recognize the NeuN corresponding band size. Among the panel of NPSLE-associated autoantibodies (e.g., anti-NR2, anti-P-ribosomal protein, antiphospholipid) investigated by ELISA assay, only the anti-β2-glycoprotein-I (aβ2GPI) IgG was exclusively found in those sera containing brain-reactive autoantibodies. Conclusion In conclusion, SLE and NPSLE patients possess brain-reactive autoantibodies but with higher frequency and titers found in NPSLE patients. Although many target antigens of brain-reactive autoantibodies are still undetermined, they likely include β2GPI.
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Affiliation(s)
- Cristina Cocco
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Elias Manca
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Giulia Corda
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Maria Maddalena Angioni
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Barbara Noli
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Mattia Congia
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
| | - Francesco Loy
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Michela Isola
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | | | - Alberto Floris
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Center, Binaghi Hospital, ATS Sardegna, ASSL Cagliari, Cagliari, Italy
| | - Luca Saba
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
- Radiology Department, University Clinic, AOU Cagliari, Cagliari, Italy
| | - Alessandro Mathieu
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Gian Luca Ferri
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Alberto Cauli
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Matteo Piga
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
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Salomonsson T, Rumetshofer T, Jönsen A, Bengtsson AA, Zervides KA, Nilsson P, Knutsson M, Wirestam R, Lätt J, Knutsson L, Sundgren PC. Abnormal cerebral hemodynamics and blood-brain barrier permeability detected with perfusion MRI in systemic lupus erythematosus patients. Neuroimage Clin 2023; 38:103390. [PMID: 37003131 PMCID: PMC10102558 DOI: 10.1016/j.nicl.2023.103390] [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] [Received: 01/18/2023] [Revised: 03/24/2023] [Accepted: 03/25/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE Dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) has previously shown alterations in cerebral perfusion in patients with systemic lupus erythematosus (SLE). However, the results have been inconsistent, in particular regarding neuropsychiatric (NP) SLE. Thus, we investigated perfusion-based measures in different brain regions in SLE patients with and without NP involvement, and additionally, in white matter hyperintensities (WMHs), the most common MRI pathology in SLE patients. MATERIALS AND METHODS We included 3 T MRI images (conventional and DSC) from 64 female SLE patients and 19 healthy controls (HC). Three different NPSLE attribution models were used: the Systemic Lupus International Collaborating Clinics (SLICC) A model (13 patients), the SLICC B model (19 patients), and the American College of Rheumatology (ACR) case definitions for NPSLE (38 patients). Normalized cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were calculated in 26 manually drawn regions of interest and compared between SLE patients and HC, and between NPSLE and non-NPSLE patients. Additionally, normalized CBF, CBV and MTT, as well as absolute values of the blood-brain barrier leakage parameter (K2) were investigated in WMHs compared to normal appearing white matter (NAWM) in the SLE patients. RESULTS After correction for multiple comparisons, the most prevalent finding was a bilateral significant decrease in MTT in SLE patients compared to HC in the hypothalamus, putamen, right posterior thalamus and right anterior insula. Significant decreases in SLE compared to HC were also found for CBF in the pons, and for CBV in the bilateral putamen and posterior thalamus. Significant increases were found for CBF in the posterior corpus callosum and for CBV in the anterior corpus callosum. Similar patterns were found for both NPSLE and non-NPSLE patients for all attributional models compared to HC. However, no significant perfusion differences were revealed between NPSLE and non-NPSLE patients regardless of attribution model. The WMHs in SLE patients showed a significant increase in all perfusion-based metrics (CBF, CBV, MTT and K2) compared to NAWM. CONCLUSION Our study revealed perfusion differences in several brain regions in SLE patients compared to HC, independently of NP involvement. Furthermore, increased K2 in WMHs compared to NAWM may indicate blood-brain barrier dysfunction in SLE patients. We conclude that our results show a robust cerebral perfusion, independent from the different NP attribution models, and provide insight into potential BBB dysfunction and altered vascular properties of WMHs in female SLE patients. Despite SLE being most prevalent in females, a generalization of our conclusions should be avoided, and future studies including all sexes are needed.
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Affiliation(s)
- T Salomonsson
- Department of Clinical Sciences/Radiology, Lund University, Lund, Sweden
| | - T Rumetshofer
- Department of Clinical Sciences/Radiology, Lund University, Lund, Sweden; Department of Clinical Sciences/Division of Logopedics, Phoniatrics and Audiology, Lund University, Lund, Sweden
| | - A Jönsen
- Department of Clinical Sciences Lund/Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - A A Bengtsson
- Department of Clinical Sciences Lund/Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - K A Zervides
- Department of Clinical Sciences Lund/Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - P Nilsson
- Department of Clinical Sciences Lund/Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - M Knutsson
- Department of Clinical Sciences/Radiology, Lund University, Lund, Sweden
| | - R Wirestam
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - J Lätt
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - L Knutsson
- Department of Medical Radiation Physics, Lund University, Lund, Sweden; Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States; F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, United States
| | - P C Sundgren
- Department of Clinical Sciences/Radiology, Lund University, Lund, Sweden; Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden; Lund University Bioimaging Center, Lund University, Lund, Sweden.
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Microstructural Changes in the Corpus Callosum in Systemic Lupus Erythematous. Cells 2023; 12:cells12030355. [PMID: 36766697 PMCID: PMC9913100 DOI: 10.3390/cells12030355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 01/20/2023] Open
Abstract
Central nervous system (CNS) involvement in childhood-onset systemic lupus erythematosus (cSLE) occurs in more than 50% of patients. Structural magnetic resonance imaging (MRI) has identified global cerebral atrophy, as well as the involvement of the corpus callosum and hippocampus, which is associated with cognitive impairment. In this cross-sectional study we included 71 cSLE (mean age 24.7 years (SD 4.6) patients and a disease duration of 11.8 years (SD 4.8) and two control groups: (1) 49 adult-onset SLE (aSLE) patients (mean age of 33.2 (SD 3.7) with a similar disease duration and (2) 58 healthy control patients (mean age of 29.9 years (DP 4.1)) of a similar age. All of the individuals were evaluated on the day of the MRI scan (Phillips 3T scanner). We reviewed medical charts to obtain the clinical and immunological features and treatment history of the SLE patients. Segmentation of the corpus callosum was performed through an automated segmentation method. Patients with cSLE had a similar mid-sagittal area of the corpus callosum in comparison to the aSLE patients. When compared to the control groups, cSLE and aSLE had a significant reduction in the mid-sagittal area in the posterior region of the corpus callosum. We observed significantly lower FA values and significantly higher MD, RD, and AD values in the total area of the corpus callosum and in the parcels B, C, D, and E in cSLE patients when compared to the aSLE patients. Low complement, the presence of anticardiolipin antibodies, and cognitive impairment were associated with microstructural changes. In conclusion, we observed greater microstructural changes in the corpus callosum in adults with cSLE when compared to those with aSLE. Longitudinal studies are necessary to follow these changes, however they may explain the worse cognitive function and disability observed in adults with cSLE when compared to aSLE.
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11
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Khan MI, Qureshi H, Akhtar S, Bae SJ, Hassan F. Prevalence of neuropsychiatric disorders in patients with systemic lupus erythematosus in Pakistan: A systematic review and meta-analysis. Front Psychiatry 2023; 14:1098734. [PMID: 36816415 PMCID: PMC9931908 DOI: 10.3389/fpsyt.2023.1098734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION By conducting a systematic review and meta-analysis, we investigated the prevalence of neuropsychiatric (NP) symptoms among systemic lupus erythematosus (SLE) patients in Pakistan. METHODS In this review work, three electronic databases (Web of Science, MEDLINE, and Google Scholar) and local databases were screened for 20 years from 1 January 2002 to 30 September 2022, to identify the articles evaluating the prevalence of NP symptoms in SLE patients in Pakistan. We performed a random-effects meta-analysis to estimate the prevalence of NPSLE. Statistical heterogeneity was measured by the I2 index, and subgroup meta-analyses were used to access the statistical heterogeneity. Furthermore, meta-regression models were used to examine the associations between prevalence estimates and study characteristics of interest. Three independent authors reviewed existing studies, extracted data, and rated the qualities of selected studies. This review was registered on PROSPERO (Registration no. CRD42022361798). RESULTS Thirteen studies met the inclusion criteria out of the 322 studies with a total of 2,003 SLE patients for this systematic review and meta-analysis. The prevalence of NP disorders in SLE patients was estimated to be 30.42% (95% CI:18.26-44.11%), with cognitive dysfunction being the most common (31.51%; 95% CI:1.28-76.27%), followed by headache (10.22%; 95% CI: 0.00-33.43%), seizures (5.96%; 95% CI: 3.80-8.53%), psychosis (3.64%; 95% CI: 2.38-5.13%), and neuropathy is the least common (0.86%; 95% CI: 0.00-2.74%). The heterogeneity between studies was significant (p < 0.01). The pooled prevalence of NP disorders among SLE patients was found highest in Punjab (41.21%) and lowest in Sindh (17.60%). CONCLUSION Findings from this study revealed that SLE patients have a high prevalence of NP disorders. The most common symptoms were cognitive dysfunctions, headaches, seizures, psychosis, and neuropathy. Clinicians can manage these potentially deadly and disabling diseases more effectively if they understand the incidence of each NP symptom in SLE patients. NP symptoms among SLE patients are at their peak in Pakistan; policymakers should devise preventive strategies to curb the disease. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record. php?RecordID=361798, identifier CRD42022361798.
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Affiliation(s)
- Muhammad Imran Khan
- Department of Industrial Engineering, Hanyang University, Seoul, Republic of Korea
| | - Humera Qureshi
- Department of Industrial Engineering, Hanyang University, Seoul, Republic of Korea
| | - Sohail Akhtar
- Department of Mathematics and Statistics, The University of Haripur, Haripur, Pakistan
| | - Suk Joo Bae
- Department of Industrial Engineering, Hanyang University, Seoul, Republic of Korea
| | - Fazal Hassan
- Department of Mathematics and Statistics, The University of Haripur, Haripur, Pakistan
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12
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Odin VI, Yurkina EA, Yurkin AK, Toporkov MM, Shvartsman GI, Pervova EM. Neurological Aspects of Systemic Lupus Erythematosus in Individuals with Late Ontogenetic Debut. ADVANCES IN GERONTOLOGY 2022. [DOI: 10.1134/s2079057022040129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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13
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Jianing W, Jingyi X, Pingting Y. Neuropsychiatric lupus erythematosus: Focusing on autoantibodies. J Autoimmun 2022; 132:102892. [PMID: 36030137 DOI: 10.1016/j.jaut.2022.102892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
Patients with systemic lupus erythematosus (SLE) frequently suffer from nervous system complications, termed neuropsychiatric lupus erythematosus (NPLE). NPLE accounts for the poor prognosis of SLE. Correct attribution of NP events to SLE is the primary principle in managing NPLE. The vascular injuries and neuroinflammation are the fundamental neuropathologic changes in NPLE. Specific autoantibody-mediated central nerve system (CNS) damages distinguish NPLE from other CNS disorders. Though the central antibodies in NPLE are generally thought to be raised from the periphery immune system, they may be produced in the meninges and choroid plexus. On this basis, abnormal activation of microglia and disease-associated microglia (DAM) should be the common mechanisms of NPLE and other CNS disturbances. Improved understanding of both characteristic and sharing features of NPLE might yield further options for managing this disease.
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Affiliation(s)
- Wang Jianing
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| | - Xu Jingyi
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| | - Yang Pingting
- Department of Rheumatology and Immunology, The First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
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14
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Su L, Zhuo Z, Duan Y, Huang J, Qiu X, Li M, Liu Y, Zeng X. Structural and Functional Characterization of Gray Matter Alterations in Female Patients With Neuropsychiatric Systemic Lupus. Front Neurosci 2022; 16:839194. [PMID: 35585919 PMCID: PMC9108669 DOI: 10.3389/fnins.2022.839194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate morphological and functional alterations within gray matter (GM) in female patients with neuropsychiatric systemic lupus (NPSLE) and to explore their clinical significance. Methods 54 female patients with SLE (30 NPSLE and 24 non-NPSLE) and 32 matched healthy controls were recruited. All subjects received a quantitative MRI scan (FLAIR, 3DT1, resting-state functional MRI). GM volume (GMV), fractional amplitude of low-frequency fluctuation (fALFF), regional homogeneity (ReHo), and degree of centrality (DC) were obtained. Between-group comparison, clinical correlation, and discrimination of NPSLE from non-NPSLE were achieved by voxel-based analysis, cerebellar seed-based functional connectivity analysis, regression analysis, and support vector machine (SVM), respectively. Results Patients with NPSLE showed overt subcortical GM atrophy without significantly abnormal brain functions in the same region compared with controls. The dysfunction within the left superior temporal gyri (L-STG) was found precede the GM volumetric loss. The function of the nodes in default mode network (DMN) and salience network (SN) were weakened in NPSLE patients compared to controls. The function of the cerebellar posterior lobes was significantly activated in non-NPSLE patients but attenuated along with GM atrophy and presented higher connectivity with L-STG and DMN in NPSLE patients, while the variation of the functional activities in the sensorimotor network (SMN) was the opposite. These structural and functional alterations were mainly correlated with disease burden and anti-phospholipid antibodies (aPLs) (r ranges from -1.53 to 1.29). The ReHos in the bilateral cerebellar posterior lobes showed high discriminative power in identifying patients with NPSLE with accuracy of 87%. Conclusion Patients with NPSLE exhibit both structural and functional alterations in the GM of the brain, which especially involved the deep GM, the cognitive, and sensorimotor regions, reflecting a reorganization to compensate for the disease damage to the brain which was attenuated along with pathologic burden and cerebral vascular risk factors. The GM within the left temporal lobe may be one of the direct targets of lupus-related inflammatory attack. The function of the cerebellar posterior lobes might play an essential role in compensating for cortical functional disturbances and may contribute to identifying patients with suspected NPSLE in clinical practice.
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Affiliation(s)
- Li Su
- Department of Rheumatology and Clinical Immunology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Education, Beijing, China
| | - Zhizheng Zhuo
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Huang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaolu Qiu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Education, Beijing, China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Education, Beijing, China
- *Correspondence: Xiaofeng Zeng,
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15
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Langensee L, Mårtensson J, Jönsen A, Zervides K, Bengtsson A, Nystedt J, Cannerfelt B, Nilsson P, Mannfolk P, Lätt J, Rumetshofer T, Sundgren PC. Cognitive performance in systemic lupus erythematosus patients: a cross-sectional and longitudinal study. BMC Rheumatol 2022; 6:22. [PMID: 35440096 PMCID: PMC9019974 DOI: 10.1186/s41927-022-00253-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/16/2022] [Indexed: 12/02/2022] Open
Abstract
Background Previous research has provided evidence for cognitive dysfunction as a common symptom of systemic lupus erythematosus (SLE). In light of this, the primary goal of this study was to investigate how cognitive impairment in this patient group develops over time. In addition, the present dataset contributes to delineating the specific abilities that are impaired in SLE patients as well as answering the question whether the disease affects the cognition of SLE patients with neuropsychiatric manifestations (NPSLE) and without (non-NPSLE) in distinct ways. Methods 91 female participants (33 NPSLE, 29 non-NPSLE, 29 healthy controls (HC)) underwent standardized neurocognitive testing. A total of ten different cognitive abilities were assessed, among others executive function, memory, and attention. Some of the participants (30 NPSLE patients, 22 non-NPSLE, 13 HC) were tested twice (mean time between testing sessions: 50 months) to enable longitudinal tracking of cognitive abilities. Analyses of Variance (ANOVA) were conducted to determine whether cognitive performance differed cross-sectionally between the groups. Linear mixed effects models were fit to investigate performance differences between the groups over time. Results Cross-sectional analysis at follow-up demonstrated that the cognitive performance of both NPSLE and non-NPSLE was significantly lower than that of HC for the motor speed and the psychomotor speed domain. Additionally, NPSLE patients performed significantly weaker than HC in the complex attention domain. At the same time, the cross-sectional data did not yield any support for performance differences between NPSLE and non-NPSLE patients. Weak positive correlations between disease duration and psychomotor speed, motor speed and reaction time emerged. A temporal progression of cognitive dysfunction in SLE patients was not confirmed. Conclusions Cognitive performance is affected in both non-NPSLE and NPSLE patients. However, a linear decline in performance over time could not be verified. More in-depth longitudinal assessments of cognition in SLE patients are needed to establish how cognitive abilities in this patient population develop over time. Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00253-3.
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Affiliation(s)
- L Langensee
- Department of Clinical Sciences Lund, Logopedics, Phoniatrics and Audiology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - J Mårtensson
- Department of Clinical Sciences Lund, Logopedics, Phoniatrics and Audiology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - A Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - K Zervides
- Department of Clinical Sciences Lund, Rheumatology, Faculty of Medicine, Lund University, 22185, Lund, Sweden.,Department of Clinical Sciences Lund, Neurology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - A Bengtsson
- Department of Clinical Sciences Lund, Rheumatology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - J Nystedt
- Department of Clinical Sciences Lund, Radiology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - B Cannerfelt
- Department of Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden
| | - P Nilsson
- Department of Clinical Sciences Lund, Neurology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - P Mannfolk
- Department of Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden
| | - J Lätt
- Department of Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden
| | - T Rumetshofer
- Department of Clinical Sciences Lund, Logopedics, Phoniatrics and Audiology, Faculty of Medicine, Lund University, 22185, Lund, Sweden
| | - P C Sundgren
- Department of Clinical Sciences Lund, Radiology, Faculty of Medicine, Lund University, 22185, Lund, Sweden. .,Department of Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden. .,Lund University BioImaging Center (LBIC), Lund University, 22185, Lund, Sweden.
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16
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Yuan Y, Quan T, Song Y, Guan J, Zhou T, Wu R. Noise-immune Extreme Ensemble Learning for Early Diagnosis of Neuropsychiatric Systemic Lupus Erythematosus. IEEE J Biomed Health Inform 2022; 26:3495-3506. [PMID: 35380977 DOI: 10.1109/jbhi.2022.3164937] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Early diagnosis is currently the most effective way of saving the life of patients with neuropsychiatric systemic lupus erythematosus (NPSLE). However, it is rather difficult to detect this terrible disease at the early stage, due to the subtle and elusive symptomatic signals. Recent studies show that the 1H-MRS (proton magnetic resonance spectroscopy) imaging technique can capture more information reflecting the early appearance of this disease than conventional magnetic resonance imaging techniques. 1H-MRS data, however, also presents more noises that can bring serious diagnosis bias. We hence proposed a noise-immune extreme ensemble learning technique for effectively leveraging 1H-MRS data for advancing the early diagnosis of NPSLE. Our main results are that 1) by developing generalized maximum correntropy criterion in the kernel extreme learning setting, many types of non-Gaussian noises can be distinguished, and 2) weighted recursive feature elimination, using maximal information coefficient to weight feature's importance, helps to further alleviate the bad impact of noises on the diagnosis performance. The proposed method is assessed on a publicly available dataset with 97.5% accuracy, 95.8% sensitivity, and 99.9% specificity, which well demonstrates its efficacy.
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17
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Features of hyperintense white matter lesions and clinical relevance in systemic lupus erythematosus. Chin Med J (Engl) 2022; 135:962-970. [PMID: 35730373 PMCID: PMC9276293 DOI: 10.1097/cm9.0000000000002074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Luo X, Piao S, Li H, Li Y, Xia W, Bao Y, Liu X, Geng D, Wu H, Yang L. Multi-lesion radiomics model for discrimination of relapsing-remitting multiple sclerosis and neuropsychiatric systemic lupus erythematosus. Eur Radiol 2022; 32:5700-5710. [PMID: 35243524 DOI: 10.1007/s00330-022-08653-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/18/2022] [Accepted: 02/06/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To develop an MRI-based multi-lesion radiomics model for discrimination of relapsing-remitting multiple sclerosis (RRMS) and its mimicker neuropsychiatric systemic lupus erythematosus (NPSLE). METHODS A total of 112 patients with RRMS (n = 63) or NPSLE (n = 49) were assigned to training and test sets with a ratio of 3:1. All lesions across the whole brain were manually segmented on T2-weighted fluid-attenuated inversion recovery images. For each single lesion, 371 radiomics features were extracted and trained using machine learning algorithms, producing Radiomics Index for Lesion (RIL) for each lesion and a single-lesion radiomics model. Then, for each subject, single lesions were assigned to one of two disease courts based on their distance to decision threshold, and a Radiomics Index for Subject (RIS) was calculated as the mean RIL value of lesions on the higher-weighted court. Accordingly, a subject-level discrimination model was constructed and compared with performances of two radiologists. RESULTS The subject-based discrimination model satisfactorily differentiated RRMS and NPSLE in both training (AUC = 0.967, accuracy = 0.892, sensitivity = 0.917, and specificity = 0.872) and test sets (AUC = 0.962, accuracy = 0.931, sensitivity = 1.000, and specificity = 0.875), significantly better than the single-lesion radiomics method (training: p < 0.001; test: p = 0.001) Besides, the discrimination model significantly outperformed the senior radiologist in the training set (training: p = 0.018; test: p = 0.077) and the junior radiologist in both the training and test sets (training: p = 0.008; test: p = 0.023). CONCLUSIONS The multi-lesion radiomics model could effectively discriminate between RRMS and NPSLE, providing a supplementary tool for accurate differential diagnosis of the two diseases. KEY POINTS • Radiomic features of brain lesions in RRMS and NPSLE were different. • The multi-lesion radiomics model constructed using a merging strategy was comprehensively superior to the single-lesion-based model for discrimination of RRMS and NPSLE. • The RRMS-NPSLE discrimination model showed a significantly better performance or a trend toward significance than the radiologists.
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Affiliation(s)
- Xiao Luo
- Academy for Engineering and Technology, Fudan University, 220 Handan Road, Shanghai, 200433, China
| | - Sirong Piao
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Haiqing Li
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Yuxin Li
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Wei Xia
- Academy for Engineering and Technology, Fudan University, 220 Handan Road, Shanghai, 200433, China
| | - Yifang Bao
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Xueling Liu
- Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Daoying Geng
- Academy for Engineering and Technology, Fudan University, 220 Handan Road, Shanghai, 200433, China.,Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Hao Wu
- Department of Dermatology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China.
| | - Liqin Yang
- Academy for Engineering and Technology, Fudan University, 220 Handan Road, Shanghai, 200433, China. .,Department of Radiology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China. .,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China.
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19
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Inglese F, Kim M, Steup-Beekman GM, Huizinga TWJ, van Buchem MA, de Bresser J, Kim DS, Ronen I. MRI-Based Classification of Neuropsychiatric Systemic Lupus Erythematosus Patients With Self-Supervised Contrastive Learning. Front Neurosci 2022; 16:695888. [PMID: 35250439 PMCID: PMC8889016 DOI: 10.3389/fnins.2022.695888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction/PurposeSystemic lupus erythematosus (SLE) is a chronic auto-immune disease with a broad spectrum of clinical presentations, including heterogeneous neuropsychiatric (NP) syndromes. Structural brain abnormalities are commonly found in SLE and NPSLE, but their role in diagnosis is limited, and their usefulness in distinguishing between NPSLE patients and patients in which the NP symptoms are not primarily attributed to SLE (non-NPSLE) is non-existent. Self-supervised contrastive learning algorithms proved to be useful in classification tasks in rare diseases with limited number of datasets. Our aim was to apply self-supervised contrastive learning on T1-weighted images acquired from a well-defined cohort of SLE patients, aiming to distinguish between NPSLE and non-NPSLE patients.Subjects and MethodsWe used 3T MRI T1-weighted images of 163 patients. The training set comprised 68 non-NPSLE and 34 NPSLE patients. We applied random geometric transformations between iterations to augment our data sets. The ML pipeline consisted of convolutional base encoder and linear projector. To test the classification task, the projector was removed and one linear layer was measured. Validation of the method consisted of 6 repeated random sub-samplings, each using a random selection of a small group of patients of both subtypes.ResultsIn the 6 trials, between 79% and 83% of the patients were correctly classified as NPSLE or non-NPSLE. For a qualitative evaluation of spatial distribution of the common features found in both groups, Gradient-weighted Class Activation Maps (Grad-CAM) were examined. Thresholded Grad-CAM maps show areas of common features identified for the NPSLE cohort, while no such communality was found for the non-NPSLE group.Discussion/ConclusionThe self-supervised contrastive learning model was effective in capturing common brain MRI features from a limited but well-defined cohort of SLE patients with NP symptoms. The interpretation of the Grad-CAM results is not straightforward, but indicates involvement of the lateral and third ventricles, periventricular white matter and basal cisterns. We believe that the common features found in the NPSLE population in this study indicate a combination of tissue loss, local atrophy and to some extent that of periventricular white matter lesions, which are commonly found in NPSLE patients and appear hypointense on T1-weighted images.
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Affiliation(s)
- Francesca Inglese
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Minseon Kim
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | | | - Tom W. J. Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark A. van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Dae-Shik Kim
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Itamar Ronen,
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20
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Tan G, Huang B, Cui Z, Dou H, Zheng S, Zhou T. A noise-immune reinforcement learning method for early diagnosis of neuropsychiatric systemic lupus erythematosus. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2022; 19:2219-2239. [PMID: 35240783 DOI: 10.3934/mbe.2022104] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The neuropsychiatric systemic lupus erythematosus (NPSLE), a severe disease that can damage the heart, liver, kidney, and other vital organs, often involves the central nervous system and even leads to death. Magnetic resonance spectroscopy (MRS) is a brain functional imaging technology that can detect the concentration of metabolites in organs and tissues non-invasively. However, the performance of early diagnosis of NPSLE through conventional MRS analysis is still unsatisfactory. In this paper, we propose a novel method based on genetic algorithm (GA) and multi-agent reinforcement learning (MARL) to improve the performance of the NPSLE diagnosis model. Firstly, the proton magnetic resonance spectroscopy (1H-MRS) data from 23 NPSLE patients and 16 age-matched healthy controls (HC) were standardized before training. Secondly, we adopt MARL by assigning an agent to each feature to select the optimal feature subset. Thirdly, the parameter of SVM is optimized by GA. Our experiment shows that the SVM classifier optimized by feature selection and parameter optimization achieves 94.9% accuracy, 91.3% sensitivity, 100% specificity and 0.87 cross-validation score, which is the best score compared with other state-of-the-art machine learning algorithms. Furthermore, our method is even better than other dimension reduction ones, such as SVM based on principal component analysis (PCA) and variational autoencoder (VAE). By analyzing the metabolites obtained by MRS, we believe that this method can provide a reliable classification result for doctors and can be effectively used for the early diagnosis of this disease.
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Affiliation(s)
- Guanru Tan
- Department of Computer Science, Shantou University, Shantou 515063, China
| | - Boyu Huang
- Department of Computer Science, Shantou University, Shantou 515063, China
| | - Zhihan Cui
- Department of Computer Science, Shantou University, Shantou 515063, China
| | - Haowen Dou
- Department of Computer Science, Shantou University, Shantou 515063, China
| | - Shiqiang Zheng
- Department of Computer Science, Shantou University, Shantou 515063, China
| | - Teng Zhou
- Department of Computer Science, Shantou University, Shantou 515063, China
- Key Laboratory of Intelligent Manufacturing Technology, Shantou University, Ministry of Education, Shantou 515063, China
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21
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Ota Y, Srinivasan A, Capizzano AA, Bapuraj JR, Kim J, Kurokawa R, Baba A, Moritani T. Central Nervous System Systemic Lupus Erythematosus: Pathophysiologic, Clinical, and Imaging Features. Radiographics 2022; 42:212-232. [PMID: 34990324 DOI: 10.1148/rg.210045] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by multiple immunologic abnormalities and has the potential to involve the central nervous system (CNS). The prevalence of SLE seems to be growing, possibly because of earlier diagnosis and improved survival; however, the associated mortality is still high. The mortality is associated with disease-related risk factors such as lupus disease activity, young age, and organ damage or with antiphospholipid syndrome (APS). Neuropsychiatric SLE (NPSLE), which is caused by SLE-related CNS involvement, comprises a broad range of neurologic and psychiatric manifestations with varying severity, which can make this disease indistinguishable from other conditions that are unrelated to SLE. No unifying pathophysiology has been found in the etiology of NPSLE, suggesting that this condition has multiple contributors such as various immune effectors and the brain-intrinsic neuroimmune interfaces that are breached by the immune effectors. The postulated neuroimmune interfaces include the blood-brain barrier, blood-cerebrospinal fluid barrier, meningeal barrier, and glymphatic system. On the basis of the immunologic, pathologic, and imaging features of NPSLE, the underlying pathophysiology can be classified as vasculitis and vasculopathy, APS, demyelinating syndrome, or autoimmune antibody-mediated encephalitis. Each pathophysiology has different imaging characteristics, although the imaging and pathophysiologic features may overlap. Moreover, there are complications due to the immunocompromised status caused by SLE per se or by SLE treatment. Radiologists and clinicians should become familiar with the underlying mechanisms, radiologic findings, and complications of NPSLE, as this information may aid in the diagnosis and treatment of NPSLE. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Yoshiaki Ota
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Ashok Srinivasan
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Aristides A Capizzano
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Jayapalli R Bapuraj
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - John Kim
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Ryo Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Akira Baba
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Toshio Moritani
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
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22
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Cerebral Microstructure Analysis by Diffusion-Based MRI in Systemic Lupus Erythematosus: Lessons Learned and Research Directions. Brain Sci 2021; 12:brainsci12010070. [PMID: 35053811 PMCID: PMC8773633 DOI: 10.3390/brainsci12010070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/29/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022] Open
Abstract
Diffusion-based magnetic resonance imaging (MRI) studies, namely diffusion-weighted imaging (DWI) and diffusion-tensor imaging (DTI), have been performed in the context of systemic lupus erythematosus (SLE), either with or without neuropsychiatric (NP) involvement, to deepen cerebral microstructure alterations. These techniques permit the measurement of the variations in random movement of water molecules in tissues, enabling their microarchitecture analysis. While DWI is recommended as part of the initial MRI assessment of SLE patients suspected for NP involvement, DTI is not routinely part of the instrumental evaluation for clinical purposes, and it has been mainly used for research. DWI and DTI studies revealed less restricted movement of water molecules inside cerebral white matter (WM), expression of a global loss of WM density, occurring in the context of SLE, prevalently, but not exclusively, in case of NP involvement. More advanced studies have combined DTI with other quantitative MRI techniques, to further characterize disease pathogenesis, while brain connectomes analysis revealed structural WM network disruption. In this narrative review, the authors provide a summary of the evidence regarding cerebral microstructure analysis by DWI and DTI studies in SLE, focusing on lessons learned and future research perspectives.
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23
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Inglese F, Jaarsma-Coes MG, Steup-Beekman GM, Monahan R, Huizinga T, van Buchem MA, Ronen I, de Bresser J. Neuropsychiatric systemic lupus erythematosus is associated with a distinct type and shape of cerebral white matter hyperintensities. Rheumatology (Oxford) 2021; 61:2663-2671. [PMID: 34730801 PMCID: PMC9157072 DOI: 10.1093/rheumatology/keab823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/27/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives Advanced white matter hyperintensity (WMH) markers on brain MRI may help reveal underlying mechanisms and aid in the diagnosis of different phenotypes of SLE patients experiencing neuropsychiatric (NP) manifestations. Methods In this prospective cohort study, we included a clinically well-defined cohort of 155 patients consisting of 38 patients with NPSLE (26 inflammatory and 12 ischaemic phenotype) and 117 non-NPSLE patients. Differences in 3 T MRI WMH markers (volume, type and shape) were compared between patients with NPSLE and non-NPSLE and between patients with inflammatory and ischaemic NPSLE by linear and logistic regression analyses corrected for age, sex and intracranial volume. Results Compared with non-NPSLE [92% female; mean age 42 (13) years], patients with NPSLE [87% female; mean age 40 (14) years] showed a higher total WMH volume [B (95%-CI)]: 0.46 (0.0 7 ↔ 0.86); P = 0.021], a higher periventricular/confluent WMH volume [0.46 (0.0 6 ↔ 0.86); P = 0.024], a higher occurrence of periventricular with deep WMH type [0.32 (0.1 3 ↔ 0.77); P = 0.011], a higher number of deep WMH lesions [3.06 (1.2 1 ↔ 4.90); P = 0.001] and a more complex WMH shape [convexity: ‒0.07 (‒0.12 ↔ ‒0.02); P = 0.011, concavity index: 0.05 (0.0 1 ↔ 0.08); P = 0.007]. WMH shape was more complex in inflammatory NPSLE patients [89% female; mean age 39 (15) years] compared with patients with the ischaemic phenotype [83% female; mean age 41 (11) years] [concavity index: 0.08 (0.0 1 ↔ 0.15); P = 0.034]. Conclusion We demonstrated that patients with NPSLE showed a higher periventricular/confluent WMH volume and more complex shape of WMH compared with non-NPSLE patients. This finding was particularly significant in inflammatory NPLSE patients, suggesting different or more severe underlying pathophysiological abnormalities.
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Affiliation(s)
- Francesca Inglese
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Rory Monahan
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
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24
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Nikolopoulos D, Kitsos D, Papathanasiou M, Chondrogianni M, Theodorou A, Garantziotis P, Pieta A, Doskas T, Bertsias G, Voumvourakis K, Boumpas DT, Fanouriakis A. Demyelination with autoimmune features: a distinct clinical entity? Results from a longitudinal cohort. Rheumatology (Oxford) 2021; 60:4166-4174. [PMID: 33404657 DOI: 10.1093/rheumatology/keaa902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/23/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE CNS demyelinating syndromes occurring in the context of SLE may represent a manifestation of neuropsychiatric lupus, or an overlap of SLE and multiple sclerosis (MS). We evaluated prospectively patients presenting with demyelinating syndrome for clinical and serological evidence of SLE and characterized the evolution of their clinical syndrome to a defined disease. METHODS Patients with CNS demyelinating syndromes not fulfilling the criteria for MS were evaluated in a rheumatology unit for features of SLE and followed longitudinally (enrolment period 2016-20). Clinical, laboratory and neuroimaging data were recorded at every visit, following multidisciplinary evaluation. At end of follow-up, patients were assessed for their final neurological and rheumatological diagnosis, and classified accordingly. RESULTS A total of 79 patients were included in the study [91.1% female, mean (s.d.) age at first demyelinating episode 38.4 (10.3) years, median (interquartile range) observation period 39 (57) months]. At last follow-up, 38 patients (48.1%) had evolved into MS. Of the remaining patients, 7 (17.1%) had SLE, while 34 (82.9%) had features of systemic autoimmunity without fulfilling classification criteria for SLE. The most common rheumatological features of these patients were inflammatory arthritis (73.5%), acute cutaneous lupus (47.1%) and positive ANA (72.1%). Importantly, these patients were less likely to have elevated IgG index (odds ratio 0.11, 95% CI 0.04, 0.32) and positive oligoclonal bands (odds ratio 0.21, 95% CI 0.08, 0.55). CONCLUSION A significant number of patients with demyelination do not fulfill criteria for either MS or SLE at follow-up. These patients exhibit lupus-like autoimmune features and may represent a distinct entity, 'demyelination with autoimmune features'.
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Affiliation(s)
- Dionysis Nikolopoulos
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens
| | - Dimitris Kitsos
- 2nd Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Matilda Papathanasiou
- 2nd Department of Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Maria Chondrogianni
- 2nd Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Aikaterini Theodorou
- 2nd Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Panagiotis Garantziotis
- Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens
| | - Antigone Pieta
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School
| | | | - George Bertsias
- Department of Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Heraklion, Greece
| | - Konstantinos Voumvourakis
- 2nd Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School.,Department of Rheumatology, 'Asklepieion' General Hospital, Voula, Athens, Greece
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25
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Neuroimaging findings in rheumatologic disorders. J Neurol Sci 2021; 427:117531. [PMID: 34130065 DOI: 10.1016/j.jns.2021.117531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/12/2021] [Accepted: 06/02/2021] [Indexed: 01/06/2023]
Abstract
Patients with rheumatological diseases may present with neurological manifestations of peripheral and/or central nervous system (CNS). Symptoms may be related to underlying rheumatological disease or CNS effects of immune-modulating drugs. Early diagnosis and therapy may help prevent serious complications. Magnetic resonance imaging (MRI), given its excellent soft tissue details, is the preferred imaging modality when evaluating patients with rheumatological disease and suspected CNS involvement. We present a review of the neuroimaging manifestations of various rheumatic diseases with emphasis on the imaging findings on MRI.
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26
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Kumar P, Kumar A, Thakur V, Sharma CB, Thomas A, Chatterjee S. Acute psychosis as the presenting manifestation of lupus. J Family Med Prim Care 2021; 10:1050-1053. [PMID: 34041122 PMCID: PMC8138362 DOI: 10.4103/jfmpc.jfmpc_1475_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/17/2020] [Accepted: 10/20/2020] [Indexed: 01/14/2023] Open
Abstract
Neuropsychiatric manifestations like cognitive dysfunction, peripheral neuropathy, stroke headache, seizures in systemic lupus erythematosus (SLE) are quite common. However, psychosis as the sole presenting manifestation of SLE is rarely encountered clinically. If lupus is not kept as differential among patients with acute psychosis, delay in diagnosis and subsequent mismanagement are likely to happen. Here, we present a case of a young female presenting with acute psychosis as the predominant symptom and was further evaluated and diagnosed as a case of SLE. The patient was managed with immunosuppressive agents and carried an excellent outcome.
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Affiliation(s)
- Piyush Kumar
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Abhishek Kumar
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Vikram Thakur
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Chandra B Sharma
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Aneesha Thomas
- Department of Neurology, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
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27
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Chen L, Sun J, Wang Q, Hu L, Zhang Y, Ma H, Jia X, Yang X. Altered Temporal Dynamics of Brain Activity in Multiple-Frequency Bands in Non-Neuropsychiatric Systemic Lupus Erythematosus Patients with Inactive Disease. Neuropsychiatr Dis Treat 2021; 17:1385-1395. [PMID: 33994788 PMCID: PMC8113012 DOI: 10.2147/ndt.s292302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/15/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE In this study, we seek to investigate dynamic changes of brain activity in non-neuropsychiatric systemic lupus erythematosus (non-NPSLE) patients with inactive disease. PATIENTS AND METHODS Thirty-one non-NPSLE patients with inactive disease and 20 matched healthy controls underwent the blood oxygenation level-dependent fMRI examination. Dynamic regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuations (fALFF) were used to analyze the brain activity in typical band (0.01-0.08 Hz), slow-4 (0.027-0.073 Hz) and slow-5 (0.01-0.027 Hz). Pearson's correlation analysis was performed to correlate dynamic regional homogeneity (dReHo) and dynamic fractional amplitude of low-frequency fluctuations (dfALFF) values for clusters of voxels where significant group differences were found with clinical variables in non-NPSLE patients with inactive disease. RESULTS In typical band, non-NPSLE patients showed increased dReHo in left middle occipital gyrus (MOG) compared to healthy controls. Meanwhile, patients showed decreased dfALFF in right superior frontal gyrus (SFG) and bilateral middle frontal gyrus (MFG) in typical band. In slow-4, increased dReHo in left MOG was found in non-NPSLE patients. In slow-5, non-NPSLE patients showed increased dReHo in left MOG, left calcarine fissure and surrounding cortex, right precentral gyrus (PreCG) and left postcentral gyrus (PoCG). Meanwhile, non-NPSLE patients showed decreased dfALFF in left SFG, right MFG, and right PreCG in slow-5. Moreover, the glucocorticoid dose showed significantly negative correlations with dReHo values in right PreCG in slow-5, left PoCG in slow-5, and left MOG in typical band. CONCLUSION dReHo and dfALFF abnormalities in different frequency bands may be the key characteristics in the pathogenesis mechanism of non-NPSLE.
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Affiliation(s)
- Liheng Chen
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310009, People’s Republic of China
| | - Jiawei Sun
- School of Information and Electronics Technology, Jiamusi University, Jiamusi, People’s Republic of China
- Integrated Medical Research School, Jiamusi University, Jiamusi, People’s Republic of China
| | - Qiaohong Wang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310009, People’s Republic of China
| | - Lingzhen Hu
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310009, People’s Republic of China
| | - Yi Zhang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310009, People’s Republic of China
| | - Huibin Ma
- School of Information and Electronics Technology, Jiamusi University, Jiamusi, People’s Republic of China
- Integrated Medical Research School, Jiamusi University, Jiamusi, People’s Republic of China
| | - Xize Jia
- Institute of Psychological Sciences, Hangzhou Normal University, Hangzhou, People’s Republic of China
- Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, People’s Republic of China
| | - Xuyan Yang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310009, People’s Republic of China
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28
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Inglese F, Kant IMJ, Monahan RC, Steup-Beekman GM, Huizinga TWJ, van Buchem MA, Magro-Checa C, Ronen I, de Bresser J. Different phenotypes of neuropsychiatric systemic lupus erythematosus are related to a distinct pattern of structural changes on brain MRI. Eur Radiol 2021; 31:8208-8217. [PMID: 33929569 PMCID: PMC8523434 DOI: 10.1007/s00330-021-07970-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 12/14/2022]
Abstract
Objectives The underlying structural brain correlates of neuropsychiatric involvement in systemic lupus erythematosus (NPSLE) remain unclear, thus hindering correct diagnosis. We compared brain tissue volumes between a clinically well-defined cohort of patients with NPSLE and SLE patients with neuropsychiatric syndromes not attributed to SLE (non-NPSLE). Within the NPSLE patients, we also examined differences between patients with two distinct disease phenotypes: ischemic and inflammatory. Methods In this prospective (May 2007 to April 2015) cohort study, we included 38 NPSLE patients (26 inflammatory and 12 ischemic) and 117 non-NPSLE patients. All patients underwent a 3-T brain MRI scan that was used to automatically determine white matter, grey matter, white matter hyperintensities (WMH) and total brain volumes. Group differences in brain tissue volumes were studied with linear regression analyses corrected for age, gender, and total intracranial volume and expressed as B values and 95% confidence intervals. Results NPSLE patients showed higher WMH volume compared to non-NPSLE patients (p = 0.004). NPSLE inflammatory patients showed lower total brain (p = 0.014) and white matter volumes (p = 0.020), and higher WMH volume (p = 0.002) compared to non-NPSLE patients. Additionally, NPSLE inflammatory patients showed lower white matter (p = 0.020) and total brain volumes (p = 0.038) compared to NPSLE ischemic patients. Conclusion We showed that different phenotypes of NPSLE were related to distinct patterns of underlying structural brain MRI changes. Especially the inflammatory phenotype of NPSLE was associated with the most pronounced brain volume changes, which might facilitate the diagnostic process in SLE patients with neuropsychiatric symptoms. Key Points • Neuropsychiatric systemic lupus erythematosus (NPSLE) patients showed a higher WMH volume compared to SLE patients with neuropsychiatric syndromes not attributed to SLE (non-NPSLE). • NPSLE patients with inflammatory phenotype showed a lower total brain and white matter volume, and a higher volume of white matter hyperintensities, compared to non-NPSLE patients. • NPSLE patients with inflammatory phenotype showed lower white matter and total brain volumes compared to NPSLE patients with ischemic phenotype. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07970-2.
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Affiliation(s)
- Francesca Inglese
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.
| | - Ilse M J Kant
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Cesar Magro-Checa
- Department of Rheumatology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419, PC, Heerlen, The Netherlands
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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29
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Bulk M, van Harten T, Kenkhuis B, Inglese F, Hegeman I, van Duinen S, Ercan E, Magro-Checa C, Goeman J, Mawrin C, van Buchem M, Steup-Beekman G, Huizinga T, van der Weerd L, Ronen I. Quantitative susceptibility mapping in the thalamus and basal ganglia of systemic lupus erythematosus patients with neuropsychiatric complaints. Neuroimage Clin 2021; 30:102637. [PMID: 33812303 PMCID: PMC8053812 DOI: 10.1016/j.nicl.2021.102637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
Systemic lupus erythematosus (SLE) is an auto-immune disease characterized by multi-organ involvement. Although uncommon, central nervous system involvement in SLE, termed neuropsychiatric SLE (NPSLE), is not an exception. Current knowledge on underlying pathogenic mechanisms is incomplete, however, neuroinflammation is thought to play a critical role. Evidence from neurodegenerative diseases and multiple sclerosis suggests that neuroinflammation is correlated with brain iron accumulation, making quantitative susceptibility mapping (QSM) a potential hallmark for neuroinflammation in vivo. This study assessed susceptibility values of the thalamus and basal ganglia in (NP)SLE patients and further investigated the in vivo findings with histological analyses of postmortem brain tissue derived from SLE patients. We used a 3T MRI scanner to acquire single-echo T2*-weighted images of 44 SLE patients and 20 age-matched healthy controls. Of the 44 patients with SLE, all had neuropsychiatric complaints, of which 29 were classified as non-NPSLE and 15 as NPSLE (seven as inflammatory NPSLE and eight as ischemic NPSLE). Mean susceptibility values of the thalamus, caudate nucleus, putamen, and globus pallidus were calculated. Formalin-fixed paraffin-embedded post-mortem brain tissue including the putamen and globus pallidus of three additional SLE patients was obtained and stained for iron, microglia and astrocytes. Susceptibility values of SLE patients and age-matched controls showed that iron levels in the thalamus and basal ganglia were not changed due to the disease. No subgroup of SLE showed higher susceptibility values. No correlation was found with disease activity or damage due to SLE. Histological examination of the post-mortem brain showed no increased iron accumulation. Our results suggest that neuroinflammation in NPSLE does not necessarily go hand in hand with iron accumulation, and that the inflammatory pathomechanism in SLE may differ from the one observed in neurodegenerative diseases and in multiple sclerosis.
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Affiliation(s)
- Marjolein Bulk
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thijs van Harten
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Boyd Kenkhuis
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Francesca Inglese
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingrid Hegeman
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sjoerd van Duinen
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ece Ercan
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands; Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jelle Goeman
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian Mawrin
- Department of Neuropathology, Otto-von-Guericke University, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany
| | - Mark van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerda Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Louise van der Weerd
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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30
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Nikolopoulos D, Fanouriakis A, Bertsias G. Treatment of neuropsychiatric systemic lupus erythematosus: clinical challenges and future perspectives. Expert Rev Clin Immunol 2021; 17:317-330. [PMID: 33682602 DOI: 10.1080/1744666x.2021.1899810] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Neuropsychiatric (NP) involvement represents an emerging frontier in systemic lupus erythematosus (SLE), posing significant challenges due to its clinical diversity and obscure pathophysiology. The authors herein discuss selected aspects in the management of NPSLE based on existing literature and our experience, aiming to facilitate routine medical care.Areas covered: Research related to diagnosis, neuroimaging, treatment and outcome is discussed, focusing on data published in PubMed during the last 5 years. Selected translational studies of clinical relevance are included.Expert opinion: Identification of NPSLE patients who may benefit from appropriate treatment can be facilitated by attribution algorithms. Immunosuppressants are typically indicated in recurrent seizures, optic neuritis, myelopathy, psychosis and peripheral nerve disease, although a low threshold is recommended for cerebrovascular disease and other NP manifestations, especially when SLE is active. With the exception of stroke with positive antiphospholipid antibodies, anti-coagulation is rarely indicated in other syndromes. Refractory NPSLE can be treated with rituximab, whereas the role of other biologics remains unknown. Advances in the fields of biomarkers, neuroimaging for brain structural, perfusion or functional abnormalities, and design of novel compounds targeting not only systemic autoimmunity but also inflammatory and regenerative pathways within the nervous system, hold promise for optimizing NPSLE management.
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Affiliation(s)
- Dionysis Nikolopoulos
- 4th Department of Internal Medicine, Joint Rheumatology Program, National and Kapodistrian University of Athens, Athens, Greece.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | | | - George Bertsias
- Department of Rheumatology, Clinical Immunology, University of Crete Medical School and University Hospital of Heraklion, Heraklion, Greece.,Laboratory of Rheumatology, Autoimmunity and Inflammation, Infections & Immunity Division, Institute of Molecular Biology and Biotechnology (FORTH), Heraklion, Greece
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Abstract
Neuropsychiatric lupus (NPSLE) comprises a disparate collection of syndromes affecting the central and peripheral nervous systems. Progress in the attribution of neuropsychiatric syndromes to SLE-related mechanisms and development of targeted treatment strategies has been impeded by a lack of objective imaging biomarkers that reflect specific neuropsychiatric syndromes and/or pathologic mechanisms. The present review addresses recent publications of neuroimaging techniques in NPSLE.
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Govoni M, Hanly JG. The management of neuropsychiatric lupus in the 21st century: still so many unmet needs? Rheumatology (Oxford) 2021; 59:v52-v62. [PMID: 33280014 PMCID: PMC7719041 DOI: 10.1093/rheumatology/keaa404] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/03/2020] [Indexed: 02/06/2023] Open
Abstract
Neuropsychiatric (NP) events occur in the majority of patients with SLE and predominantly affect the CNS in addition to the peripheral and autonomic systems. Approximately 30% of all NP events are attributable to SLE (NPSLE) and present most frequently around the time of SLE onset. NPSLE is associated with increased morbidity and mortality and the proposed pathogenesis includes both ischaemic and neuroinflammatory mechanisms. Following diagnosis and causal attribution, the treatment of NPSLE is tailored to the type of NP event, the predominant putative pathogenic pathway and the activity and severity of the clinical event. There is a dearth of controlled clinical trials to guide management, but therapeutic options include symptomatic, antithrombotic and immunosuppressive agents that are supported by observational cohort studies. Our objective was to review what is currently known about NPSLE and to identify deficiencies in diagnostic biomarkers, novel therapies and clinical trials for this manifestation of SLE.
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Affiliation(s)
- Marcello Govoni
- Rheumatology Unit, S. Anna Hospital - Ferrara (loc. Cona), Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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Valdez-López M, Aguirre-Aguilar E, Valdés-Ferrer SI, Martínez-Carrillo FM, Arauz A, Barrera-Vargas A, Merayo-Chalico J. Posterior reversible encephalopathy syndrome: A neuropsychiatric manifestation of systemic lupus erythematosus. Autoimmun Rev 2020; 20:102739. [PMID: 33326853 DOI: 10.1016/j.autrev.2020.102739] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 08/18/2020] [Indexed: 12/29/2022]
Abstract
Posterior Reversible Encephalopathy Syndrome (PRES) is an acute neurological syndrome clinically characterized by seizures, altered mental status, headache, and visual disturbances. It is caused by a variety of abnormalities in the endothelial function that ultimately result in vasogenic edema in the circulation of the central nervous system. This is reflected by the neuroimaging findings, that most often show reversible parieto-occipital edema. An important proportion of patients with PRES present with Systemic Lupus Erythematosus (SLE), and its complications, as their sole risk factors. This review describes the relationship between these two clinical entities and explains the pathophysiological models that have been proposed to describe the development of PRES. We explain how SLE can cause alterations in every pathway implicated in the development of PRES. Given the relatively high frequency and the distinct clinical course, PRES in the setting of SLE might be best described as a distinct neuropsychiatric syndrome associated with SLE.
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Affiliation(s)
- Martín Valdez-López
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Eduardo Aguirre-Aguilar
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Sergio Iván Valdés-Ferrer
- Departmento of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Francisco M Martínez-Carrillo
- Departmento of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suarez", Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico.
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Mansour HE, Habeeb RA, El-Azizi NO, Afeefy HH, Nassef MA, Abd Alkader AA, Afifi N. Electroencephalography in systemic lupus erythematosus patients with neuropsychiatric manifestations. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2020. [DOI: 10.1186/s43162-020-00012-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Neuropsychiatric manifestations are frequently reported in systemic lupus erythematosus (SLE) patients. This study was done to describe electroencephalographic (EEG) findings in SLE patients with neuropsychiatric manifestation (NPSLE).
Results
Among 60 SLE patients, there were 50 females (83.3%) and 10 males (16.7%). EEG abnormalities were reported in 12 patients out of 30 (40%) with NPSLE, while all patients with non-NPSLE (n = 30) had no EEG abnormalities; diffuse slowing (20%) was the most common abnormalities, followed by generalized epileptiform activity (13.3%), and lastly temporal epileptiform activity (6.7%). Seizure was the most reported neuropsychiatric disorder in 13 patients (43.3%); 8 of them had abnormal EEG (61.5%). Periventricular white matter lesion (23.3%) followed by infarction (13.3%) were the most common MRI brain findings among 53.3% of NPSLE group. Half of the cases with EEG abnormality had normal brain MRI. SLEDAI score and ACL IgM positivity were higher in the NPSLE group than the non-NPSLE group. EEG is not a sensitive or specific test for detecting NPSLE with sensitivity (37.5%) and specificity (57.1%).
Conclusion
Not all patients with NPSLE must have abnormal brain MRI or EEG. EEG is a useful assistant tool in the assessment of different manifestations of NPSLE, but it cannot be used as a screening test alone and must be supplemented by neuroimaging studies.
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Tsubouchi S, Hayashi H, Tahara K, Ishii K, Yasuda T, Yamamoto Y, Mizuuchi T, Mori H, Tago M, Kato E, Sawada T. Clinical presentation of a neuropsychiatric lupus patient with symmetrical basal ganglia lesions containing cytotoxic oedema cores surrounded by vasogenic oedema. Mod Rheumatol Case Rep 2020; 4:39-46. [PMID: 33086978 DOI: 10.1080/24725625.2019.1651955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Neuropsychiatric (NP) manifestations of systemic lupus erythematosus (SLE) are diverse, but involvement of basal ganglia is rare. We describe here a 28-year-old woman with NPSLE presenting aseptic meningitis accompanied by elevated interleukin-6 levels in the cerebrospinal fluid, who developed symmetrical basal ganglia lesions, containing a cytotoxic oedematous core, surrounded by vasogenic oedema upon magnetic resonance imaging. We were able to observe these lesions from a de novo appearance during the disease onset to its disappearance during immunosuppressive treatment. Reversibility upon immunosuppressive treatment indicated that autoimmune mediated mechanisms could contribute to the basal ganglia lesions in NPSLE.
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Affiliation(s)
- Syoko Tsubouchi
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Haeru Hayashi
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Koichiro Tahara
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Kayo Ishii
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takuya Yasuda
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yusuke Yamamoto
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takahiro Mizuuchi
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hiroaki Mori
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Mayu Tago
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Eri Kato
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Tetsuji Sawada
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
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Mavrogeni S, Koutsogeorgopoulou L, Dimitroulas T, Markousis-Mavrogenis G, Boki K, Katsifis G, Vartela V, Kallenberg CG, Kolovou G, Kitas G. Combined Brain/Heart Magnetic Resonance Imaging in Systemic Lupus Erythematosus. Curr Cardiol Rev 2020; 16:178-186. [PMID: 31368877 PMCID: PMC7536815 DOI: 10.2174/1573403x15666190801122105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 12/27/2022] Open
Abstract
Cardiovascular Disease (CVD) in Systemic Lupus Erythematosus (SLE) and Neuropsychiatric SLE (NPSLE) has an estimated prevalence of 50% and 40%, respectively and both constitute major causes of death among SLE patients. In this review, a combined brain/heart Magnetic Resonance Imaging (MRI) for SLE risk stratification has been proposed. The pathophysiologic background of NPSLE includes microangiopathy, macroscopic infarcts and accelerated atherosclerosis. Classic brain MRI findings demonstrate lesions suggestive of NPSLE in 50% of the NPSLE cases, while advanced MRI indices can detect pre-clinical lesions in the majority of them, but their clinical impact still remains unknown. Cardiac involvement in SLE includes myo-pericarditis, valvular disease/endocarditis, Heart Failure (HF), coronary macro-micro-vascular disease, vasculitis and pulmonary hypertension. Classic and advanced Cardiovascular Magnetic Resonance (CMR) indices allow function and tissue characterization for early diagnosis and treatment follow-up of CVD in SLE. Although currently, there are no clinical data supporting the combined use of brain/heart MRI in asymptomatic SLE, it may have a place in cases with clinical suspicion of brain/heart involvement, especially in patients at high risk for CVD/stroke such as SLE with antiphospholipid syndrome (SLE/APS), in whom concurrent cardiac and brain lesions have been identified. Furthermore, it may be of value in SLE with multi-organ involvement, NPSLE with concurrent cardiac involvement, and recent onset of arrhythmia and/or heart failure.
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Affiliation(s)
| | | | - Theodoros Dimitroulas
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | - Cees G Kallenberg
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - George Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester, M13 9PL, United Kingdom
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Schwartz N, Stock AD, Putterman C. Neuropsychiatric lupus: new mechanistic insights and future treatment directions. Nat Rev Rheumatol 2020; 15:137-152. [PMID: 30659245 DOI: 10.1038/s41584-018-0156-8] [Citation(s) in RCA: 207] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Patients with systemic lupus erythematosus (SLE) frequently show symptoms of central nervous system (CNS) involvement, termed neuropsychiatric SLE (NPSLE). The CNS manifestations of SLE are diverse and have a broad spectrum of severity and prognostic implications. Patients with NPSLE typically present with nonspecific symptoms, such as headache and cognitive impairment, but might also experience devastating features, such as memory loss, seizures and stroke. Some features of NPSLE, in particular those related to coagulopathy, have been characterized and an evidence-based treatment algorithm is available. The cognitive and affective manifestations of NPSLE, however, remain poorly understood. Various immune effectors have been evaluated as contributors to its pathogenesis, including brain-reactive autoantibodies, cytokines and cell-mediated inflammation. Additional brain-intrinsic elements (such as resident microglia, the blood-brain barrier and other neurovascular interfaces) are important facilitators of NPSLE. As yet, however, no unifying model has been found to underlie the pathogenesis of NPSLE, suggesting that this disease has multiple contributors and perhaps several distinct aetiologies. This heterogeneity presents a challenge for clinicians who have traditionally relied on empirical judgement in choosing treatment modalities for patients with NPSLE. Improved understanding of this manifestation of SLE might yield further options for managing this disease.
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Affiliation(s)
- Noa Schwartz
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Ariel D Stock
- Department of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Chaim Putterman
- Department of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY, USA. .,Division of Rheumatology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.
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Sodavarapu S, Rudrangi R, Hoffman J. Rare case of bilateral wrist and foot drop from SLE-related vasculitic polyneuropathy. BMJ Case Rep 2020; 13:13/1/e232890. [DOI: 10.1136/bcr-2019-232890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous, chronic, inflammatory, autoimmune disease characterised by multiorgan involvement and the production of multiple autoantibodies. Neurological manifestations in SLE patients are frequently reported—the prevalence is 37%–90%. We present a unique case where the patient presented with bilateral wrist and foot drop for 4 days, which later led to the diagnosis of SLE-related vasculitic polyneuropathy. During the course of treatment, the patient received prednisone, rituximab and hydroxychloroquine. At 6-month follow-up, patient had reported significant improvement in her weakness with increased mobility in upper and lower extremities. Prompt diagnosis and treatment are necessary in these cases to prevent disease progression and morbidity.
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39
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Kaplan C, Minc A, Basu N, Schrepf A. Inflammation and the Central Nervous System in Inflammatory Rheumatic Disease. Curr Rheumatol Rep 2019; 21:67. [PMID: 31807958 DOI: 10.1007/s11926-019-0870-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW To review how peripheral inflammation in rheumatic disease influences the central nervous system. We consider recent studies of rheumatic disease that employ functional and structural neuroimaging in the context of inflammation, as well as recent studies considering how immunosuppressive therapy is associated with changes in brain function and structure. RECENT FINDINGS The most compelling evidence thus far comes from studies of rheumatoid arthritis and indicates that higher levels of inflammation are associated with changes in cognitive, affective, and pain-processing brain regions, some of which may be rectified by anti-inflammatory treatment. Comorbid symptoms such as widespread pain and fatigue may also be associated with these changes. Inflammation may be associated with compensatory activation of brain regions to offset structural changes. This emerging line of evidence suggests that communication between the brain and immune system are an important and underappreciated aspect of inflammatory rheumatic disease.
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Affiliation(s)
- Chelsea Kaplan
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Health System, Domino's Farms, Lobby M, 24 Frank Lloyd Wright Dr., PO Box 385, Ann Arbor, MI, 48106, USA
| | | | - Neil Basu
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Andrew Schrepf
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Health System, Domino's Farms, Lobby M, 24 Frank Lloyd Wright Dr., PO Box 385, Ann Arbor, MI, 48106, USA.
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40
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Goutte J, Killian M, Antoine JC, Massoubre C, Fakra E, Cathébras P. [First-episode psychosis as primary manifestation of medical disease: An update]. Rev Med Interne 2019; 40:742-749. [PMID: 31421899 DOI: 10.1016/j.revmed.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/09/2019] [Accepted: 07/17/2019] [Indexed: 11/15/2022]
Abstract
A huge variety of medical diseases may potentially present with isolated psychotic symptoms, and disease-specific treatment or management is available for a significant part of them. The initial medical work-up of a first-episode psychosis (FEP) is of crucial importance. This literature review aimed to identify medical conditions potentially revealed by FEP, to list the warning signs of secondary psychosis, and to discuss a screening strategy. Underlying organic conditions may be drugs and medications, neurologic diseases, infections, inflammatory and/or autoimmune pathologies, and metabolic disorders whether of hereditary origin. Each patient presenting with a first-episode psychosis should be evaluated with a precise anamnesis, a careful clinical examination, and routine laboratory tests. Brain imaging and tests (depending on the context) should be performed in the presence of atypical clinical features or "red flags", leading to suspect an organic disease.
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Affiliation(s)
- J Goutte
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - M Killian
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - J C Antoine
- Service de neurologie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - C Massoubre
- Service de psychiatrie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - E Fakra
- Service de psychiatrie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - P Cathébras
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
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41
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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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42
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LI YACHI, CHANG DEHMING, LU CHUNCHI. Montreal Cognitive Assessment and Magnetic Resonance Imaging Identify Cognitive Impairment in Young Patients with Neuropsychiatric Systemic Lupus Erythematosus. J Rheumatol 2019; 46:653. [DOI: 10.3899/jrheum.181231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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43
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Mvambo N, Bhigjee AI, Mody GM. Clinical, neuroimaging and immunological phenotype of South African neuropsychiatric systemic lupus erythematosus patients. Lupus 2019; 28:685-694. [PMID: 31018814 DOI: 10.1177/0961203319843351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is an important cause of morbidity and mortality. We undertook this observational retrospective study of patients with NPSLE who had brain magnetic resonance imaging (MRI) to determine the indications for MRI and the correlation of clinical and laboratory findings with MRI. We identified 83 NPSLE patients (84.3% women) seen at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, between June 2003 and May 2017. The mean age at SLE diagnosis was 26.24 ± 12.81 years and the median interval to NPSLE was 11.0 (interquartile range, 4.0-39.0) months. The most common indications for MRI were seizures (45.8%), psychosis (18.1%) and cerebrovascular disease (18.1%). The MRI was abnormal in 68 (81.9%) with small-vessel disease in 65 (78.3%) and large-vessel disease in eight (9.6%). The small-vessel abnormalities were white-matter hyperintensities (WMH) (59.0%), atrophy (55.4%) and lacunae (4.6%). Our patients had high disease activity at NPSLE. Cerebrovascular disease was associated with an abnormal MRI ( p = 0.018) and large-vessel disease ( p = 0.014) on MRI. Our NPSLE patients were younger and had high disease activity, and seizures were more common compared with other studies. The most common MRI abnormalities were WMH and cortical atrophy, in agreement with other studies.
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Affiliation(s)
- N Mvambo
- 1 Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - A I Bhigjee
- 2 Department of Neurology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - G M Mody
- 1 Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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44
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Barraclough M, McKie S, Parker B, Jackson A, Pemberton P, Elliott R, Bruce IN. Altered cognitive function in systemic lupus erythematosus and associations with inflammation and functional and structural brain changes. Ann Rheum Dis 2019; 78:934-940. [PMID: 30979715 PMCID: PMC6585286 DOI: 10.1136/annrheumdis-2018-214677] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/15/2019] [Accepted: 03/02/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Cognitive dysfunction (CD) is common in systemic lupus erythematosus (SLE) but the cause remains unclear and treatment options are limited. We aimed to compare cognitive function in SLE and healthy controls (HCs) using both behavioural and neuroimaging techniques. METHODS Patients with SLE with stable disease and HCs were recruited. Clinical and psychological data were collected along with a blood sample for relevant biomarkers. Neurocognitive function was assessed using tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) and functional magnetic resonance imaging (fMRI) was used to examine brain responses to working memory (WM) and emotional processing (facial emotional recognition task, FERT) tasks. RESULTS Compared with HCs (n=30), patients with SLE (n=36) scored higher on measures of depression, fatigue and had higher hsCRP (p=0.013), IL-6 (p=0.003) and B lymphocyte stimulator (p<0.001). Patients with SLE had poorer performance on a task of sustained attention (p=0.002) and had altered brain responses, particularly in default mode network (DMN) regions and the caudate, during the WM task. Higher organ damage and higher VCAM-1 were associated with less attenuation of the DMN (p=0.005 and p=0.01, respectively) and lower BOLD signal in the caudate areas (p=0.005 and p=0.001, respectively). Increased IL-6 was also associated with lower BOLD signal in caudate areas (p=0.032). CONCLUSIONS Sustained attention was impaired in patients with SLE. Poor attenuation of the DMN may contribute to cognitive impairments in SLE and our data suggest that in addition to mood and fatigue inflammatory mechanisms and organ damage impact cognitive functioning in SLE. The multifaceted nature of CD in SLE means any therapeutic interventions should be individually tailored.
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Affiliation(s)
- Michelle Barraclough
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Shane McKie
- FBMH Platform Sciences, Enabling Technologies & Infrastructure, FBMH Research & Innovation, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Ben Parker
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Alan Jackson
- Wolfson Molecular Imaging Centre, Institute of Imaging and Bioinformatics, The University of Manchester, Manchester, UK
| | - Philip Pemberton
- Department of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rebecca Elliott
- Neuroscience and Psychiatry Unit, Division of Neuroscience and Experimental Psychology, The University of Manchester, Manchester, UK
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK .,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Nikolopoulos D, Fanouriakis A, Boumpas DT. Cerebrovascular Events in Systemic Lupus Erythematosus: Diagnosis and Management. Mediterr J Rheumatol 2019; 30:7-15. [PMID: 32185337 PMCID: PMC7045913 DOI: 10.31138/mjr.30.1.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 02/06/2023] Open
Abstract
Stroke is a major cause of morbidity, mortality and disability in systemic lupus erythematosus (SLE). Patients with SLE have a two-fold increase in the risk of stroke with younger patients (ie, less than 50 years of age) having an ever-higher risk (up to 10-fold). Although the prognosis of SLE has improved, mortality due to cerebrovascular events (CVE) remains unchanged. Cerebrovascular disease may be directly attributed to the disease per se, as a manifestation of neuropsychiatric SLE, or be the result of traditional cardiovascular risk factors accompanying the disease. Elucidation of the underlying mechanism(s) of CVE is essential as it may guide the type of therapy (ie, antithrombotic or anticoagulant therapy versus immunosuppressive). Strokes attributed to lupus usually occur early in the course of the disease and are often accompanied by evidence of activity in other organs; those related to antiphospholipid antibodies can occur at any time, in patients with either active or inactive SLE. In this review, we discuss the epidemiology, work-up, management and primary prevention of CVE in patients with lupus. In view of the effectiveness of thrombolysis, physicians need to educate lupus patients and their families for the early recognition of the signs of stroke and the need to seek prompt attention. To this end acronyms, such as FAST (Facial drooping, Arm weakness, Speech difficulties and Time to call emergency service) can be used as a mnemonic to help detect and enhance responsiveness to the needs of a person having a stroke.
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Affiliation(s)
- Dionysis Nikolopoulos
- Rheumatology and Clinical Immunology Unit, 4th Department of Medicine, "Attikon" University Hospital, Athens, Greece.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Medicine, "Attikon" University Hospital, Athens, Greece.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Medical School, University of Cyprus, Nicosia, Cyprus
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Fanouriakis A, Bertsias G, Govoni M. Editorial: Lupus and the Brain: Advances in Neuropsychiatric Systemic Lupus Erythematosus. Front Med (Lausanne) 2019; 6:52. [PMID: 30972337 PMCID: PMC6443841 DOI: 10.3389/fmed.2019.00052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 12/05/2022] Open
Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - Marcello Govoni
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliero-Universitaria Sant'Anna Ferrara, Ferrara, Italy
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Magro-Checa C, Kumar S, Ramiro S, Beaart-van de Voorde L, Eikenboom J, Ronen I, de Bresser J, van Buchem M, Huizinga T, Steup-Beekman G. Are serum autoantibodies associated with brain changes in systemic lupus erythematosus? MRI data from the Leiden NP-SLE cohort. Lupus 2019; 28:94-103. [PMID: 30526327 PMCID: PMC6304692 DOI: 10.1177/0961203318816819] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/09/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The effect of serum autoantibodies on the brain of systemic lupus erythematosus (SLE) patients remains unclear. We investigated whether serum autoantibodies, individually and assessed in groups, are associated with specific brain-MRI abnormalities or whether these structural changes are associated with other SLE-related or traditional cardiovascular disease risk factors. METHODS All patients underwent brain 3Tesla-MRI. White matter hyperintensities (WMHs), ischemic lesions, inflammatory-like lesions and cerebral atrophy were scored. Serum autoantibodies analyzed included lupus anticoagulant (LAC), anticardiolipine (aCL) IgG and IgM (first 3 also grouped into antiphospholipid autoantibodies (aPL)), anti-dsDNA, anti-SSA, anti-SSB, anti-RNP, and anti-Sm (the latter 5 grouped into SLE-related autoantibodies). Associations were assessed using logistic regression analysis adjusted for potential confounders. Furthermore, a sensitivity analysis including anti-Beta2 glycoprotein-1 antibodies (anti-β2GP1) in the aPL group was performed and the potential modification role of the neuropsychiatric clinical status in the model was assessed. RESULTS 325 patients (mean age 42 years (SD 14), 89% female) were included. The following MRI-brain abnormalities were found: WMHs (71%), lacunar infarcts (21%), gliosis (11%), micro-hemorrhages (5%), large hemorrhages (2%), inflammatory-like lesions (6%) and atrophy (14%). No associations were found between individual or total SLE-related autoantibodies and inflammatory-like lesions. A higher number of positive aPL was associated with lacunar infarcts (OR 1.37 (95%CI 1.02-1.99) and gliosis (OR 2.15 (1.37-3.37)). LAC was associated with lacunar infarcts in white matter (OR 3.38 (1.32-8.68)) and atrophy (OR 2.49 (1.01-6.15)), and aCL IgG with gliosis (OR 2.71 (1.05-7.02)). Among other variables, SLE patients with hypertension presented a higher chance for WMHs (OR 5.61 (2.52-12.48)) and lacunar infarcts in WM (OR 2.52 (1.10-5.74)) and basal ganglia (OR 8.34 (2.19-31.70)), while cumulative SLE-damage was correlated with lacunar infarcts in WM (OR 1.43 (1.07-1.90)), basal ganglia (OR 1.72 (1.18-2.51)) and cerebellum (OR 1.79 (1.33-2.41)). These associations were confirmed in the sensitivity analysis. CONCLUSIONS Brain abnormalities in SLE represent different underlying pathogenic mechanisms. aPL are associated with ischemic brain changes in SLE, while the presence of SLE-related serum autoantibodies is not related to inflammatory-like lesions. Hypertension and cumulative SLE-damage associate with ischemic MRI-brain changes in SLE, suggesting the importance of accelerated atherosclerosis in this process.
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Affiliation(s)
- C. Magro-Checa
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
- Department of Rheumatology, Zuyderland
Medical Center, Heerlen, the Netherlands
| | - S. Kumar
- Department of Neuroradiology,
National
Neuroscience Institute, Singapore
| | - S. Ramiro
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
- Department of Rheumatology, Zuyderland
Medical Center, Heerlen, the Netherlands
| | | | - J. Eikenboom
- Department of Thrombosis and Hemostasis,
Leiden University Medical Center, Leiden, the Netherlands
| | - I. Ronen
- CJ Gorter Center for High Field MRI,
Department of Radiology, Leiden University Medical Center, Leiden, the
Netherlands
| | - J de Bresser
- Department of Radiology, Leiden
University Medical Center, Leiden, The Netherlands
| | - M.A van Buchem
- Department of Radiology, Leiden
University Medical Center, Leiden, The Netherlands
| | - T.W. Huizinga
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
| | - G.M. Steup-Beekman
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
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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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Kelley BP, Corrigan JJ, Patel SC, Griffith BD. Neuropsychiatric Lupus with Antibody-Mediated Striatal Encephalitis. AJNR Am J Neuroradiol 2018; 39:2263-2269. [PMID: 30467216 DOI: 10.3174/ajnr.a5842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/25/2018] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus is a chronic autoimmune disease characterized by the production of autoantibodies resulting in tissue injury across multiple organs; up to 50% of patients develop neurologic involvement, collectively referred to as neuropsychiatric systemic lupus erythematosus. The cases in this clinical report will highlight a subtype of neuropsychiatric systemic lupus erythematosus demonstrating imaging findings of striatal inflammation responsive to plasmapheresis similar to those in the subset of N-methyl-D-aspartate receptor autoimmune encephalitis that involves the striatum. Although the cause for this striking imaging appearance is not definitely known, literature will be presented supporting the hypothesis that it is due to peripheral anti-double-stranded DNA antibodies entering the central nervous system to cross-react with N-methyl-D-aspartate receptor antigens.
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Affiliation(s)
- B P Kelley
- From the Department of Neuroradiology, Henry Ford Hospital, Detroit, Michigan.
| | - J J Corrigan
- From the Department of Neuroradiology, Henry Ford Hospital, Detroit, Michigan
| | - S C Patel
- From the Department of Neuroradiology, Henry Ford Hospital, Detroit, Michigan
| | - B D Griffith
- From the Department of Neuroradiology, Henry Ford Hospital, Detroit, Michigan
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50
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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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