1
|
McCombe JA. Neurologic Manifestations of Rheumatologic Disorders. Continuum (Minneap Minn) 2024; 30:1189-1225. [PMID: 39088293 DOI: 10.1212/con.0000000000001459] [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: 08/03/2024]
Abstract
OBJECTIVE This article provides an overview of the neurologic manifestations of sarcoidosis and select rheumatologic disorders. An approach to the assessment and differential diagnosis of characteristic clinical presentations, including meningitis and vasculitis, is also reviewed. A review of treatment options is included as well as discussion of distinct areas of overlap, including rheumatologic disease in the setting of neuromyelitis spectrum disorder and demyelinating disease in the setting of tumor necrosis factor-α inhibitors. LATEST DEVELOPMENTS An increased understanding of the immune mechanisms involved in sarcoidosis and rheumatologic diseases has resulted in a greater diversity of therapeutic options for their treatment. Evidence directing the treatment of the central nervous system (CNS) manifestations of these same diseases is lacking, with a paucity of controlled trials. ESSENTIAL POINTS It is important to have a basic knowledge of the common CNS manifestations of rheumatologic diseases and sarcoidosis so that they can be recognized when encountered. In the context of many systemic inflammatory diseases, including systemic lupus erythematosus, IgG4-related disease, and sarcoidosis, CNS disease may be a presenting feature or occur without systemic manifestations of the disease, making familiarity with these diseases even more important.
Collapse
|
2
|
Palazzo L, Lindblom J, Cetrez N, Ala H, Parodis I. Determinants of neuropsychiatric flares in patients with systemic lupus erythematosus: results from five phase III trials of belimumab. Rheumatology (Oxford) 2024; 63:798-808. [PMID: 37228034 PMCID: PMC10907808 DOI: 10.1093/rheumatology/kead249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To identify determinants of neuropsychiatric (NP) flares in patients with SLE treated for active SLE yet no ongoing severe NPSLE with non-biologic standard therapy plus belimumab or placebo. METHODS We analysed data from five phase III trials (BLISS-52, BLISS-76, BLISS-NEA, BLISS-SC, EMBRACE; n = 3638) after exclusion of patients with baseline NP BILAG A. Factors associated with NPSLE flare, defined as a new NP BILAG A or B, were investigated using Cox regression. In a subgroup analysis, we studied patients with baseline NP BILAG E for determinants of de novo NPSLE flare. Organ damage was assessed using the SLICC/ACR Damage Index (SDI). RESULTS We documented 105 (2.9%) NPSLE flares. In multivariable analysis, male sex (HR = 2.37; 95% CI: 1.31, 4.28; P = 0.004), baseline NP BILAG B-D (HR = 5.91; 95% CI: 3.86, 9.06; P < 0.001), and increasing SDI scores (HR = 1.35; 95% CI: 1.21, 1.50; P < 0.001) were strongly associated with NPSLE flare. Belimumab use yielded no association at any dose or administration form. In analysis of SDI domains, NP damage was the strongest determinant of NPSLE flare (HR = 3.25; 95% CI: 2.72, 3.88; P < 0.001), holding true for cognitive impairment (HR = 14.29; 95% CI: 9.22, 22.14; P < 0.001), transverse myelitis (HR = 21.89; 95% CI: 5.40, 88.72; P < 0.001), and neuropathy (HR = 8.87; 95% CI: 5.59, 14.09; P < 0.001). Male sex was the strongest determinant of de novo NPSLE flare (HR = 3.26; 95% CI: 1.51, 7.04; P = 0.003). CONCLUSION Male sex, NPSLE history, and NP damage were strong determinants of impending NPSLE flare. No clear protection or predisposition was conferred from add-on belimumab.
Collapse
Affiliation(s)
- Leonardo Palazzo
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Julius Lindblom
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Nursen Cetrez
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Henri Ala
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| |
Collapse
|
3
|
Abstract
Systemic lupus erythematosus (SLE) is a severe multisystem autoimmune disease that can cause injury in almost every body system. While considered a classic example of autoimmunity, it is still relatively poorly understood. Treatment with immunosuppressive agents is challenging, as many agents are relatively non-specific, and the underlying disease is characterized by unpredictable flares and remissions. This State of The Art Review provides a comprehensive current summary of systemic lupus erythematosus based on recent literature. In basic and translational science, this summary includes the current state of genetics, epigenetics, differences by ancestry, and updates about the molecular and immunological pathogenesis of systemic lupus erythematosus. In clinical science, the summary includes updates in diagnosis and classification, clinical features and subphenotypes, and current guidelines and strategies for treatment. The paper also provides a comprehensive review of the large number of recent clinical trials in systemic lupus erythematosus. Current knowns and unknowns are presented, and potential directions for the future are suggested. Improved knowledge of immunological pathogenesis and the molecular differences that exist between patients should help to personalize treatment, minimize side effects, and achieve better outcomes in this difficult disease.
Collapse
Affiliation(s)
- Eric F Morand
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
- Department of Rheumatology, Monash Health, Melbourne, VIC, Australia
| | | | | | | |
Collapse
|
4
|
Clarke AE, Hanly JG, Urowitz MB, St Pierre Y, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey-Goldman R, Manzi S, Jönsen A, Alarcón GS, Van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Farewell V. Assessing the Costs of Neuropsychiatric Disease in the Systemic Lupus International Collaborating Clinics Cohort Using Multistate Modeling. Arthritis Care Res (Hoboken) 2023; 75:1859-1870. [PMID: 36691838 PMCID: PMC10363569 DOI: 10.1002/acr.25090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/19/2022] [Accepted: 01/19/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To estimate direct and indirect costs associated with neuropsychiatric (NP) events in the Systemic Lupus International Collaborating Clinics inception cohort. METHODS NP events were documented annually using American College of Rheumatology definitions for NP events and attributed to systemic lupus erythematosus (SLE) or non-SLE causes. Patients were stratified into 1 of 3 NP states (no, resolved, or new/ongoing NP event). Change in NP status was characterized by interstate transition rates using multistate modeling. Annual direct costs and indirect costs were based on health care use and impaired productivity over the preceding year. Annual costs associated with NP states and NP events were calculated by averaging all observations in each state and adjusted through random-effects regressions. Five- and 10-year costs for NP states were predicted by multiplying adjusted annual costs per state by expected state duration, forecasted using multistate modeling. RESULTS A total of 1,697 patients (49% White race/ethnicity) were followed for a mean of 9.6 years. NP events (n = 1,971) occurred in 956 patients, 32% attributed to SLE. For SLE and non-SLE NP events, predicted annual, 5-, and 10-year direct costs and indirect costs were higher in new/ongoing versus no events. Direct costs were 1.5-fold higher and indirect costs 1.3-fold higher in new/ongoing versus no events. Indirect costs exceeded direct costs 3.0 to 5.2 fold. Among frequent SLE NP events, new/ongoing seizure disorder and cerebrovascular disease accounted for the largest increases in annual direct costs. For non-SLE NP events, new/ongoing polyneuropathy accounted for the largest increase in annual direct costs, and new/ongoing headache and mood disorder for the largest increases in indirect costs. CONCLUSION Patients with new/ongoing SLE or non-SLE NP events incurred higher direct and indirect costs.
Collapse
Affiliation(s)
| | - John G Hanly
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Murray B Urowitz
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Yvan St Pierre
- McGill University Health Center, Montreal, Quebec, Canada
| | | | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases and Hanyang University, Seoul, Republic of Korea
| | | | | | | | | | | | | | | | - Paul R Fortin
- CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Dafna D Gladman
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- The University of Manchester and Central Manchester University Hospitals National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen M Ginzler
- State University of New York Downstate Health Sciences University, Brooklyn
| | | | | | - Susan Manzi
- Alleghany Health Network, Pittsburgh, Pennsylvania
| | | | | | | | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - S Sam Lim
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Soren Jacobsen
- Rigshospitalet and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Anca Askanase
- Hospital for Joint Diseases and New York University Seligman Center for Advanced Therapeutics, New York, New York
| | | |
Collapse
|
5
|
Central nervous system involvement in systemic lupus erythematosus: Data from the Spanish Society of Rheumatology Lupus Register (RELESSER). Semin Arthritis Rheum 2023; 58:152121. [PMID: 36375359 DOI: 10.1016/j.semarthrit.2022.152121] [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: 06/14/2022] [Revised: 09/15/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To analyze the prevalence, incidence, survival and contribution on mortality of major central nervous system (CNS) involvement in systemic lupus erythematosus (SLE). METHODS Patients fulfilling the SLE 1997 ACR classification criteria from the multicentre, retrospective RELESSER-TRANS (Spanish Society of Rheumatology Lupus Register) were included. Prevalence, incidence and survival rates of major CNS neuropsychiatric (NP)-SLE as a group and the individual NP manifestations cerebrovascular disease (CVD), seizure, psychosis, organic brain syndrome and transverse myelitis were calculated. Furthermore, the contribution of these manifestations on mortality was analysed in Cox regression models adjusted for confounders. RESULTS A total of 3591 SLE patients were included. Of them, 412 (11.5%) developed a total of 522 major CNS NP-SLE manifestations. 61 patients (12%) with major CNS NP-SLE died. The annual mortality rate for patients with and without ever major CNS NP-SLE was 10.8% vs 3.8%, respectively. Individually, CVD (14%) and organic brain syndrome (15.5%) showed the highest mortality rates. The 10% mortality rate for patients with and without ever major CNS NP-SLE was reached after 12.3 vs 22.8 years, respectively. CVD (9.8 years) and organic brain syndrome (7.1 years) reached the 10% mortality rate earlier than other major CNS NP-SLE manifestations. Major CNS NP-SLE (HR 1.85, 1.29-2.67) and more specifically CVD (HR 2.17, 1.41-3.33) and organic brain syndrome (HR 2.11, 1.19-3.74) accounted as independent prognostic factors for poor survival. CONCLUSION The presentation of major CNS NP-SLE during the disease course contributes to a higher mortality, which may differ depending on the individual NP manifestation. CVD and organic brain syndrome are associated with the highest mortality rates.
Collapse
|
6
|
Renaudineau Y, Muller S, Hedrich CM, Chauveau D, Bellière J, De Almeida S, Damoiseaux J, Scherlinger M, Guery JC, Sailler L, Bost C. Immunological and translational key challenges in systemic lupus erythematosus: A symposium update. J Transl Autoimmun 2023; 6:100199. [PMID: 37065621 PMCID: PMC10090709 DOI: 10.1016/j.jtauto.2023.100199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
The first LBMR-Tim (Toulouse Referral Medical Laboratory of Immunology) symposium convened on December 16, 2022 in Toulouse, France to address challenging questions in systemic lupus erythematosus (SLE). Special focus was put on (i) the role played by genes, sex, TLR7, and platelets on SLE pathophysiology; (ii) autoantibodies, urinary proteins, and thrombocytopenia contribution at the time of diagnosis and during follow-up; (iii) neuropsychiatric involvement, vaccine response in the COVID-19 era, and lupus nephritis management at the clinical frontline; and (iv) therapeutic perspectives in patients with lupus nephritis and the unexpected adventure of the Lupuzor/P140 peptide. The multidisciplinary panel of experts further supports the concept that a global approach including basic sciences, translational research, clinical expertise, and therapeutic development have to be prioritized in order to better understand and then improve the management of this complex syndrome.
Collapse
|
7
|
Pinto B, Suresh SC, Ramyasri K, Narayan G, Susan D, Manuel S, Wodeyar A, Shivanna A, Janardana R, Chanakya K, Charles BS, Nanjundaswamy SK, Desai AM, Nadig R, Shobha V. Neuropsychiatric manifestations are associated with increased mortality in Indian patients with lupus: A single centre retrospective observational study. Lupus 2022; 31:1563-1571. [PMID: 36134692 DOI: 10.1177/09612033221127898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the prevalence of different NPSLE manifestations in our cohort and to compare clinical and immunological features and outcomes including mortality of patients with NPSLE and SLE controls without NP involvement. METHODS This was a retrospective study in a tertiary care referral centre. All patients of SLE seen in the last 10 years and fulfilling the SLICC criteria with neuropsychiatric manifestations as per the ACR definitions were included. Patients of SLE without NP involvement were sequentially assigned as controls in a ratio of 1:2. RESULTS Of the 769 patients diagnosed with SLE from Jan 2011 to December 2020, 128 (16.6%) had NPSLE manifestations as per the ACR definitions. The commonest NPSLE manifestation was seizures (6.5%) followed by cerebrovascular accident (3.9%). NPSLE manifestation occurred at the first presentation of SLE in 99/128 (77.3%) patients and 58 (45.3%) patients had more than one NPSLE manifestation. Lupus anticoagulant and anticardiolipin antibody were tested in 120 patients and were positive in 16 (13.3%) and 12 (10%), respectively. No difference was found in anti-ribosomal p, lupus anticoagulant and anticardiolipin antibodies between the cases and controls. Twenty-one (16.4%) deaths occurred in patients with NPSLE (median follow-up of 40 months) as compared to 13 (5%) in controls (median follow-up of 32 months) (p = <0.001). The cumulative survival of patients with NPSLE was lower as compared to controls (p < 0.001). Relapse of NPSLE was seen in 11(8.6%) patients and was associated with mortality (p = 0.017). CONCLUSIONS Seizures and cerebrovascular accidents are the commonest NPSLE syndromes in our patients. The presence of NPSLE was associated with high mortality in Indian patients with lupus.
Collapse
Affiliation(s)
- Benzeeta Pinto
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Sumatha C Suresh
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Kodali Ramyasri
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Girish Narayan
- Emergency Medicine, St John's Medical College, Bengaluru, India
| | - Deepa Susan
- Radiodiagnosis, St John's Medical College, Bengaluru, India
| | - Sandra Manuel
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Aishwarya Wodeyar
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Archana Shivanna
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Ramya Janardana
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - Kodishala Chanakya
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | - B Sheba Charles
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | | | - Anu M Desai
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| | | | - Vineeta Shobha
- Departments of Clinical Immunology and Rheumatology, St John's Medical College, Bengaluru, India
| |
Collapse
|