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Emerson JS, Gruenewald SM, Gomes L, Lin MW, Swaminathan S. The conundrum of neuropsychiatric systemic lupus erythematosus: Current and novel approaches to diagnosis. Front Neurol 2023; 14:1111769. [PMID: 37025200 PMCID: PMC10070984 DOI: 10.3389/fneur.2023.1111769] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/07/2023] [Indexed: 04/08/2023] Open
Abstract
Recognising neuropsychiatric involvement by systemic lupus erythematosus (SLE) is of growing importance, however many barriers to this exist at multiple levels of our currently available diagnostic algorithms that may ultimately delay its diagnosis and subsequent treatment. The heterogeneous and non-specific clinical syndromes, serological and cerebrospinal fluid (CSF) markers and neuroimaging findings that often do not mirror disease activity, highlight important research gaps in the diagnosis of neuropsychiatric SLE (NPSLE). Formal neuropsychological assessments or the more accessible screening metrics may also help improve objective recognition of cognitive or mood disorders. Novel serum and CSF markers, including autoantibodies, cytokines and chemokines have also shown increasing utility as part of diagnosis and monitoring, as well as in distinguishing NPSLE from SLE patients without SLE-related neuropsychiatric manifestations. Novel neuroimaging studies also expand upon our existing strategy by quantifying parameters that indicate microarchitectural integrity or provide an assessment of neuronal function. Some of these novel markers have shown associations with specific neuropsychiatric syndromes, suggesting that future research move away from considering NPSLE as a single entity but rather into its individually recognized neuropsychiatric manifestations. Nevertheless, it is likely that a composite panel of these investigations will be needed to better address the gaps impeding recognition of neuropsychiatric involvement by SLE.
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Affiliation(s)
- Jonathan S. Emerson
- Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Centre for Immunology and Allergy Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia
- *Correspondence: Jonathan S. Emerson,
| | - Simon M. Gruenewald
- Department of Nuclear Medicine, PET and Ultrasound, Westmead Hospital, Sydney, NSW, Australia
| | - Lavier Gomes
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Radiology, Westmead Hospital, Sydney, NSW, Australia
| | - Ming-Wei Lin
- Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sanjay Swaminathan
- Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Clinical Immunology, Blacktown Hospital, Sydney, NSW, Australia
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
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Manca E. Autoantibodies in Neuropsychiatric Systemic Lupus Erythematosus (NPSLE): Can They Be Used as Biomarkers for the Differential Diagnosis of This Disease? Clin Rev Allergy Immunol 2022; 63:194-209. [PMID: 34115263 PMCID: PMC9464150 DOI: 10.1007/s12016-021-08865-2] [Citation(s) in RCA: 8] [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] [Accepted: 05/24/2021] [Indexed: 01/13/2023]
Abstract
Systemic lupus erythematosus is a complex immunological disease where both environmental factors and genetic predisposition lead to the dysregulation of important immune mechanisms. Eventually, the combination of these factors leads to the production of self-reactive antibodies that can target any organ or tissue of the human body. Autoantibodies can form immune complexes responsible for both the organ damage and the most severe complications. Involvement of the central nervous system defines a subcategory of the disease, generally known with the denomination of neuropsychiatric systemic lupus erythematosus. Neuropsychiatric symptoms can range from relatively mild manifestations, such as headache, to more severe complications, such as psychosis. The evaluation of the presence of the autoantibodies in the serum of these patients is the most helpful diagnostic tool for the assessment of the disease. The scientific progresses achieved in the last decades helped researchers and physicians to discover some of autoepitopes targeted by the autoantibodies, although the majority of them have not been identified yet. Additionally, the central nervous system is full of epitopes that cannot be found elsewhere in the human body, for this reason, autoantibodies that selectively target these epitopes might be used for the differential diagnosis between patients with and without the neuropsychiatric symptoms. In this review, the most relevant data is reported with regard to mechanisms implicated in the production of autoantibodies and the most important autoantibodies found among patients with systemic lupus erythematosus with and without the neuropsychiatric manifestations.
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Affiliation(s)
- Elias Manca
- Department of Biomedical Sciences, University of Cagliari, 09042, Monserrato, Cagliari, Italy.
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Relationship Between Vitamin D Status and Brain Perfusion in Neuropsychiatric Lupus. Nucl Med Mol Imaging 2022; 56:158-168. [DOI: 10.1007/s13139-022-00741-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/20/2022] [Accepted: 02/08/2022] [Indexed: 11/26/2022] Open
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Papachristos DA, Oon S, Hanly JG, Nikpour M. Management of inflammatory neurologic and psychiatric manifestations of systemic lupus erythematosus: A systematic review. Semin Arthritis Rheum 2020; 51:49-71. [PMID: 33360230 DOI: 10.1016/j.semarthrit.2020.12.004] [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: 09/26/2020] [Revised: 12/06/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The neurological and psychiatric manifestations of systemic lupus erythematosus (NPSLE) are a heterogeneous group of conditions with variable clinical presentation and significant morbidity and mortality. OBJECTIVES Our aim was to comprehensively assess and present the evidence for treatments used in the management of inflammatory NPSLE. METHODS Medline, Embase, CINHAL and Cochrane CENTRAL were searched from 1990 to end of March 2019 using key words that related to NPSLE and treatment. Included studies comprised clinical trials, observational studies or case series with ≥5 patients and sufficient data related to treatment and outcome in NPSLE patients. RESULTS There were 7222 studies identified in the search, of which 90 were included in the review. There was a notable paucity of clinical trials, with only two randomised controlled trials and one pilot study. Treatment categories included corticosteroids (14 studies), cyclophosphamide (18 studies), synthetic DMARDs (7 studies), biologic therapies (14 studies), therapeutic plasma exchange (6 studies), intravenous immunoglobulin (2 studies), autologous stem cell transplant (3 studies), other therapies (8 studies), combination therapies (6 studies), studies with grouped outcome data (5 studies) and observational studies with therapy-specific associations (7 studies). Corticosteroids are accepted as first line treatment in NPSLE and there is low-moderate evidence supporting their benefit. Moderate evidence, based on consistent data in numerous studies and some trial data, supports the use of cyclophosphamide in the treatment of NPSLE. Limited data support some synthetic DMARDs such as mycophenolate, azathioprine and intrathecal methotrexate. In refractory disease, low-moderate evidence supports rituximab therapy and limited evidence supports benefit following autologous stem cell transplant. Regarding adjuvant treatments, limited evidence favours addition of plasma exchange, intravenous immunoglobulin and hydroxychloroquine. There exists very limited data for other therapies. CONCLUSION There are multiple therapeutic options for the management of inflammatory NPSLE including systemic, biologic and interventional therapies; however, currently there is a paucity of high-quality trial data to guide firm recommendations. In order to better understand the optimal treatment of NPSLE and its different subtypes, further well-designed clinical trials are needed.
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Affiliation(s)
- D A Papachristos
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - S Oon
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, The Royal Melbourne Hospital, Australia
| | - J G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, NS, Canada
| | - M Nikpour
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Australia.
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Sahebari M, Rezaieyazdi Z, Khodashahi M, Abbasi B, Ayatollahi F. Brain Single Photon Emission Computed Tomography Scan (SPECT) and functional MRI in Systemic Lupus Erythematosus Patients with Cognitive Dysfunction: A Systematic Review. ASIA OCEANIA JOURNAL OF NUCLEAR MEDICINE & BIOLOGY 2018; 6:97-107. [PMID: 29998142 PMCID: PMC6038975 DOI: 10.22038/aojnmb.2018.26381.1184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives Systemic lupus erythematosus (SLE) is an autoimmune disease with a wide range of clinical manifestations. Cognitive dysfunction is one of the manifestations that could present prior to the emergence of any other neuropsychiatric involvements in SLE. Cognitive dysfunction is a subtle condition occurring with a high frequency. However, there is no data on the correlation of cognitive dysfunction with central nervous system (CNS) imaging findings, in particular single-photon emission computed tomography scan (SPECT) and functional MRI. We decided to perform a systematic review of brain SPECT and fMRI in SLE patients with cognitive dysfunction. Methods PubMed, Scopus, and Google Scholar databases were searched until April 2017 with the following keywords: "SLE OR systemic lupus erythematous OR lupus" AND "functional MRI OR functional magnetic resonance imaging OR fMRI OR SPECT or SCAN". A total of 1,767articles were found. Two rheumatologists reviewed the articles and finally 14 articles were selected for the final systematic review. Results The fMRI and SPECT imaging techniques could provide valuable information regarding the SLE patients with cognitive dysfunction at the early stages of the disease. Conclusion Brain SPECT scan and fMRI are used as functional imaging tools in SLE. Both of these diagnostic modalities are sensitive in reflecting the subtle brain damages in SLE patients with cognitive dysfunction. Brain fMRI and SPECT scan could be significantly beneficial in the diagnosis and initial management of cognitive dysfunction in SLE. Nevertheless, prospective studies could be useful in confirming the application of these diagnostic modalities in the clinical setting.
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Affiliation(s)
- Maryam Sahebari
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Rezaieyazdi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mandana Khodashahi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fazlollah Ayatollahi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Frantellizzi V, Morreale M, Pontico M, Francia A, Drudi FM, Farcomeni A, Liberatore M. 99m Tc-HMPAO brain SPECT in the monitoring of cerebral vasculitis therapy. Rev Esp Med Nucl Imagen Mol 2018. [DOI: 10.1016/j.remnie.2017.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Frantellizzi V, Morreale M, Pontico M, Francia A, Drudi FM, Farcomeni A, Liberatore M. 99mTc-HMPAO brain SPECT in the monitoring of cerebral vasculitis therapy. Rev Esp Med Nucl Imagen Mol 2018; 37:211-217. [PMID: 29605630 DOI: 10.1016/j.remn.2017.10.009] [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] [Received: 06/14/2017] [Revised: 09/21/2017] [Accepted: 10/02/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The central nervous system (CNS) may be involved in a variety of inflammatory diseases of the blood vessels, generally known as vasculitis. The clinical diagnosis of such involvement in early stages is difficult, since a mild cognitive impairment can be the only symptom. It was hypothesized that brain-perfusion SPECT would be able to reveal CNS involvement and to monitor the course of the disease. The purpose of this study was assess if and when an improvement of cerebral perfusion can be registered by SPECT during the follow-up of these diseases. MATERIAL AND METHODS Eighteen patients affected by Systemic Lupus Erythematosus (SLE), 22 by undifferentiated vasculitis (UV), 5 by Behcet's disease (BD) and 5 by primary Sjogren's Syndrome (pSS) were enrolled in this prospective study. A 99mTc-HMPAO brain perfusion SPECT was performed before the treatment and was repeated during the follow-up at different time intervals. Image analysis was performed on 10 cerebral areas using a specific software. RESULTS In the SLE patients, no significant improvement of brain perfusion was found. On the contrary, in the UV the cerebral uptake of the tracer significantly improved from the twenty-fourth month (18/22 patients). Patients with BD showed an improvement of scintigraphic findings (5/5 patients), while a similar result was obtained only in 2 of the patients with pSS. CONCLUSIONS In conclusion, brain SPECT seems to be able to monitor the disease in UV, indicating the moment when an improvement of the cerebral perfusion is achieved. In SLE patients this scintigraphic technique did not show a significant improvement in CNS perfusion.
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Affiliation(s)
- V Frantellizzi
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, "Sapienza" University of Rome, Roma, Italia; PhD Program: Angio-Cardio-Thoracic Pathophisiology and Imaging, "Sapienza" University of Rome, Roma, Italia.
| | - M Morreale
- Department of Neurology and Psychiatry, "Sapienza" University of Rome, Roma, Italia
| | - M Pontico
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, "Sapienza" University of Rome, Roma, Italia
| | - A Francia
- Department of Neurology and Psychiatry, "Sapienza" University of Rome, Roma, Italia
| | - F M Drudi
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, "Sapienza" University of Rome, Roma, Italia
| | - A Farcomeni
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Roma, Italia
| | - M Liberatore
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, "Sapienza" University of Rome, Roma, Italia
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Mauro L, Manuela M, Valentina M, Sara C, Chondrogiannis S, Maria DF, Christos A, Liana C, Ada F, Maffione AM, Marzola MC, Rubello D. Role of Brain Perfusion SPECT with 99mTc HMPAO in the Assessment of Response to Drug Therapy in Patients with Autoimmune Vasculitis: A Prospective Study. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:135-42. [PMID: 25973400 PMCID: PMC4426516 DOI: 10.4103/1947-2714.156008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The diagnosis of vasculitis in the brain remains a quite difficult achievement. To the best of our knowledge, there is no imaging method reported in literature which is capable of reaching to a diagnosis of vasculitis with very high sensitivity. AIM The aim of this study was to determine whether perfusion brain single photon emission computed tomography (SPECT) can be usefully employed in monitoring the treatment of vasculitis, allowing treating only potentially responder patients and avoiding the side effects on patients who do not respond. MATERIALS AND METHODS Twenty patients (two males and 18 females) suffering from systemic lupus erythematosus (SLE; n = 5), Behcet's disease (BD; n = 5), undifferentiated vasculitis (UV; n = 5), and Sjogren's syndrome (SS; n = 5) were included in the study. All patients underwent a wide neurological anamnestic investigation, a complete objective neurological examination and SPECT of the brain with 99mTc-hexamethyl-propylene-aminoxime (HMPAO). The brain SPECT was then repeated after appropriate medical treatment. The neurological and neuropsychiatric follow-up was performed at 6 months after the start of the treatment. RESULTS Overall, the differences between the scintigraphic results obtained after and before the medical treatment indicated a statistically significant increase of the cerebral perfusion (CP). In 19 out of 200 regions of interest (ROI) studied, the difference between pre- and post treatment percentages had negative sign, indicating a worsening of CP. This latter event has occurred six times (five in the same patients) in the UV, 10 times (eight in the same patients) in the SLE, never in BD, and three times (two in the same patient) in the SS. CONCLUSION The reported results seem to indicate the possibility of identifying, by the means of a brain SPECT, responder and nonresponder (unchanged or worsened CP) patients, affected by autoimmune vasculitis, to the therapy.
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Affiliation(s)
- Liberatore Mauro
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, University of Rome “Sapienza”, Rome, Italy
| | - Morreale Manuela
- Department of Medical and Surgical Sciences and Biotechnologies, Section of Neurology, Neuropsychology Outpatients Service, University of Rome “Sapienza”, Rome, Italy
| | - Megna Valentina
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, University of Rome “Sapienza”, Rome, Italy
| | - Collorone Sara
- Department of Neurology and Psychiatry, University of Rome “Sapienza”, Rome, Italy
| | | | - Drudi Francesco Maria
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, University of Rome “Sapienza”, Rome, Italy
| | - Anagnostou Christos
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, University of Rome “Sapienza”, Rome, Italy
| | - Civitelli Liana
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, University of Rome “Sapienza”, Rome, Italy
| | - Francia Ada
- Department of Neurology and Psychiatry, University of Rome “Sapienza”, Rome, Italy
| | | | | | - Domenico Rubello
- Department of Nuclear Medicine, Santa Maria della Misericordia Hospital, Rovigo, Italy
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Lee IH, Ryu YU. Physical therapy combined with corticosteroid intervention for systemic lupus erythematosus with central nervous system involvement: a case report. J Phys Ther Sci 2014; 26:1839-41. [PMID: 25435712 PMCID: PMC4242967 DOI: 10.1589/jpts.26.1839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 05/21/2014] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Systemic lupus erythematosus (SLE) is a chronic, immune-mediated disease, affecting 0.1% of the general population. To date, few studies have investigated the efficacy of physical therapy for SLE patients with CNS involvement. The aim of this study was to report whether the combined use of corticosteroids and physical therapy, consisting of reflex inhibition and functional training, was beneficial to functional recovery. [Subjects and Methods] A 22-year-old male SLE patient with CNS involvement requested physical therapy due to strong spasticity of the trunk and limbs in a bedridden state. Corticosteroid intervention and physical therapy were undertaken for 16 days. [Result] After 16 days of the interventions, the patient demonstrated stabilized and alleviated neurological symptoms and an improved functional level. [Conclusion] The present case indicates that physical therapy combined with corticosteroids might be a possible treatment and rehabilitation method to effectively recover motor function for SLE patients who have strong spasticity due to CNS involvement.
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Affiliation(s)
- In-Hee Lee
- Department of Physical Medicine and Rehabilitation, Keimyung University, Dongsan Hospital, Republic of Korea
| | - Young Uk Ryu
- Department of Physical Therapy, Collage of Medical Science, Catholic University of Daegu, Republic of Korea
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Luijten RK, Fritsch-Stork RD, Bijlsma JW, Derksen RH. The use of glucocorticoids in Systemic Lupus Erythematosus. After 60years still more an art than science. Autoimmun Rev 2013; 12:617-28. [DOI: 10.1016/j.autrev.2012.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/02/2012] [Indexed: 01/18/2023]
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GIOVACCHINI GIAMPIERO, MOSCA MARTA, MANCA GIANPIERO, DELLA PORTA MAURO, NERI CLAUDIA, BOMBARDIERI STEFANO, CIARMIELLO ANDREA, STRAUSS HWILLIAM, MARIANI GIULIANO, VOLTERRANI DUCCIO. Cerebral Blood Flow in Depressed Patients with Systemic Lupus Erythematosus. J Rheumatol 2010; 37:1844-51. [DOI: 10.3899/jrheum.100121] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To characterize the neural circuitry involved in depression associated with systemic lupus erythematosus (SLE), we used single photon emission computed tomography (SPECT) to study regional cerebral blood flow (CBF) in patients with SLE.Methods.SPECT with 99mTc-ethylcysteinate dimer was performed in 30 depressed women patients with SLE, in 14 women patients with SLE and without history of neuropsychiatric disorders, and in 25 healthy women controls. Magnetic resonance imaging was done for all subjects for diagnostic purposes. Analysis of CBF patterns was performed using statistical parametric mapping. Statistical significance was taken at uncorrected p < 0.001 at cluster level.Results.There were no significant differences between depressed and nondepressed patients with SLE for any rheumatologic variable. In comparison to healthy controls, depressed patients with SLE had significantly reduced CBF in bilateral frontal and temporal cortex; global maximum was located in the left precentral gyrus. There were no significant CBF differences between nondepressed patients with SLE and controls. Compared to nondepressed patients with SLE, depressed patients with SLE had significantly lower CBF in 2 clusters that had their local maxima in the right precentral gyrus and in the left superior temporal gyrus. The duration of SLE correlated with decreased perfusion in the left middle and superior frontal gyrus.Conclusion.Depressed patients with SLE have CBF reductions in discrete temporal and frontal regions that may account for depressive symptoms.
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Gasparovic CM, Roldan CA, Sibbitt WL, Qualls CR, Mullins PG, Sharrar JM, Yamamoto JJ, Bockholt HJ. Elevated cerebral blood flow and volume in systemic lupus measured by dynamic susceptibility contrast magnetic resonance imaging. J Rheumatol 2010; 37:1834-43. [PMID: 20551095 DOI: 10.3899/jrheum.091276] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Studies that have examined abnormalities in cerebral blood flow (CBF) in patients with systemic lupus erythematosus (SLE) reported CBF relative to a region assumed to be normal in the brain. We examined the absolute differences in both regional CBF and cerebral blood volume (CBV) between patients with SLE and healthy controls. METHODS CBF and CBV were measured with dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI), a technique that provides an alternative to radionuclide perfusion studies and permits quantitative anatomic, CBF, and CBV imaging in a single scanning session. CBF and CBV were measured in lesions and in normal-appearing tissue in the major cerebral and subcortical brain regions. Unlike most perfusion studies in SLE, CBF and CBV values were not normalized to a region of the brain assumed to be healthy. RESULTS CBF and CBV within MRI-visible lesions were markedly reduced relative to surrounding normal-appearing white matter. CBF and CBV in normal-appearing tissue were both higher in SLE patient groups, with or without lesions, relative to the control group. CONCLUSION DSC MRI, without normalization to a region presumed to be healthy, revealed that CBF and CBV in normal-appearing tissue in patients with SLE was higher than CBF and CBV in controls. Since this finding was made in subgroups of patients with and without lesions, the higher CBF and CBV appear to precede lesion pathology.
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Affiliation(s)
- Charles M Gasparovic
- Department of Psychology, Divisions of Cardiology and Rheumatology, University of New Mexico, 1101 Yale Blvd. NE, Albuquerque, NM 87106, USA.
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Zandman-Goddard G, Chapman J, Shoenfeld Y. Autoantibodies Involved in Neuropsychiatric SLE and Antiphospholipid Syndrome. Semin Arthritis Rheum 2007; 36:297-315. [PMID: 17258299 DOI: 10.1016/j.semarthrit.2006.11.003] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 10/23/2006] [Accepted: 11/23/2006] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought (1) to identify and (2) to define the association of all reported antibodies (Abs) with neuropsychiatric lupus (NPSLE), (3) to search for possible mechanisms that are involved in NPSLE, and (4) to determine whether we can recognize a panel of Abs associated with specific neuropsychiatric (NP) manifestations. METHODS A MEDLINE search (1975 to 2005) was performed utilizing the following terms: neuropsychiatric lupus, antiphospholipid syndrome, or central nervous system systemic lupus erythematosus matched with the term antibodies. RESULTS Twenty Abs (11 brain-specific and 9 systemic) were described in NPSLE patients. These include Abs that target brain-specific antigens (neuronal, ganglioside, synaptosomes, glia, methyl-d-aspartate receptors, lymphocytotoxic) and systemic antigens (nuclear, cytoplasmic, phospholipid, endothelial cells). Cognitive impairment, psychosis, and depression were associated with many Abs. Elevated titers of anticardiolipin Abs (aCL) were reported most often and found in patients with cognitive impairment, psychosis, depression, seizures, chorea, and migraine. No specificity was encountered among brain-specific or systemic Abs for any single NP manifestation. No studies evaluated a specific NP manifestation with the full panel of 20 Abs. A panel of brain-specific and systemic Abs may be helpful in establishing the diagnosis of NPSLE. Postulated mechanisms in experimental models included vascular occlusion and injury by pathogenic Abs in a disrupted blood brain barrier. CONCLUSIONS NPSLE is associated with brain-specific and systemic Abs. Cognitive impairment, psychosis, and depression were associated with many Abs, including aCL Abs. Possible mechanisms include vascular occlusion and injury by pathogenic Abs in a disrupted blood brain barrier.
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Affiliation(s)
- Gisele Zandman-Goddard
- Lecturer of Internal Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel; Head of the Department of Medicine C, Wolfson Medical Center, Holon, Israel
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Santoro TJ, Tomita M, Larson SJ. The potential impact of sickness-motivated behavior on the expression of neuropsychiatric disturbances in systemic lupus erythematosus. Med Hypotheses 2007; 69:502-7. [PMID: 17399911 DOI: 10.1016/j.mehy.2007.01.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Accepted: 01/09/2007] [Indexed: 11/18/2022]
Abstract
Activation of the peripheral immune system is often accompanied by changes in cognition, ingestive behavior, sleep pattern, and sexual drive; collectively referred to as sickness behavior. Mounting evidence suggests that sickness behavior may be a purposeful attempt on the part of an organism to conserve energy and thereby facilitate recuperation. Illnesses characterized by chronic, uncontrolled immune reactivity such as systemic lupus erythematosus are also frequently associated with impaired emotionality and cognition; which, unlike sickness behavior, are conventionally thought to emanate from fixed structural lesions of the brain. Clinical observations, however, indicate that the neuropsychiatric disturbances in lupus may wax and wane in intensity and suggest the hypothesis that sickness-motivated behavior may significantly influence the neuropsychiatric manifestations of systemic lupus erythematosus and, perhaps, those of other autoimmune diseases associated with neuroinflammation. The hypothesis that patients with systemic lupus erythematosus undergo a reorganization of their motivational priorities, which influences cognitive performance and emotional output, may be examined using validated behavior paradigms in autoimmune MRL-MpJ-Tnfrsf6(lpr) (MRL-lpr/lpr) mice that spontaneously develop a lupus-like illness accompanied by disturbances in cognition and emotionality. Confirming that sickness-motivated behavior contributes to the aberrations in cognition and emotionality exhibited by an experimental model of systemic lupus erythematosus might have important therapeutic and prognostic implications by invoking the possibility that similar motivational effects may be influencing cognitive and/or emotional output in patients with neuropsychiatric lupus.
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Affiliation(s)
- Thomas J Santoro
- Department of Graduate Medical Education, University of Illinois College of Medicine at Peoria, One Illini Drive, Box 1649, Peoria, IL 61605, United States.
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Abstract
The diagnosis of neuropsychiatric systemic lupus erythematosus (NPSLE) is complex not only on account of the heterogeneous nature of neurological presentation but also because of the difficulty of differentiating lupus-related pathology from other neuropsychiatric diseases. Magnetic resonance imaging (MRI) remains the gold standard for the non-invasive assessment of NPSLE but there are problems, both with sensitivity and specificity. Both T(2) quantitation and the use of gadolinium have shown promise in differentiating acute from chronic lesions. Nonetheless, the lack of sensitivity of conventional MRI has led to the exploration of other MR-based techniques. Magnetic resonance spectroscopy (MRS) allows the measurement of brain metabolites, whereas diffusion weighted imaging and diffusion tensor imaging allow assessment of white matter structure and integrity. MRS studies in NPSLE have consistently shown a reduction in N-acetyl aspartate (a neuronal marker). Diffusion weighted imaging has had only limited application in lupus and the results to date have shown abnormal diffusivity in lupus patients consistent with inflammation and loss of white matter structure. These techniques remain research tools at this early stage. Positron emission tomography (PET) and single photon emission computed tomography (SPECT) have also been explored as functional imaging tools in lupus and both appear to be more sensitive in detecting subtle brain changes in NPSLE but there are issues with specificity which deter their use in the clinical setting.
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Affiliation(s)
- Pamela L Peterson
- St George's Hospital Medical School, Sir Joseph Hotung Centre for Musculoskeletal Disorders, Blackshaw Road, Tooting, London SW17 0QT, UK.
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Unger L, Kayser M, Enderlein M, Manger K, Nüsslein H. Glucocorticoidtherapie bei Kollagenosen. Z Rheumatol 2005; 64:162-9. [PMID: 15868333 DOI: 10.1007/s00393-005-0721-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Abstract
Glucocorticoids are irreplaceable for the treatment of connective tissue diseases due to their strong and rapid anti-inflammatory and immuno-modulatory effects. Its use and their dosage depend on the activity of the disease and organ manifestations. There is no alternative to high doses, often even as intravenous pulse therapy, in life-threatening situations with imminent organ failure. Despite an additional immuno- suppressive medication, glucocorticosteroids are mandatory for long-term treatment in most cases. In special situations like high age, gravity or comorbidities like renal failure or hepatosis, glucocorticosteroids are the option with the least possible potential for complications. In the future, new corticosteroids and steroid sparing immuno-suppressants like biologics will be able to reduce the spectrum and the severity of corticoid-induced side effects. Modern state-of-the-art therapeutic regimens for patients with connective tissue diseases should not only be able to sufficiently control the disease activity but also include the prophylaxis of associated comorbidities like arteriosclerosis, osteoporosis or infections.
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Affiliation(s)
- L Unger
- I. Medizinische Klinik, Städtisches Klinikum Dresden-Friedrichstadt, Friedrichstrasse 41, 01067 Dresden, Germany.
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