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Fitriah M, Rahmawati LD, Wulanda IA, Susianti H, Tambunan BA. The Discrepancy of ANA and Compartment Bead Patterns Suggestive of a Neuropsychiatry Systemic Lupus Erythematosus (NPSLE). Case Rep Psychiatry 2023; 2023:5260208. [PMID: 37928319 PMCID: PMC10622596 DOI: 10.1155/2023/5260208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 11/07/2023] Open
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) exhibits neurological and psychiatric manifestations in systemic lupus erythematosus (SLE) patients, which NPSLE diagnosis can be challenging for rheumatologists. An Indonesian female, 44 years old, complained of two times seizures with 10-min duration, which during seizures were stiff, eyes rolled up, foaming at the mouth, wet the bed, and fainting afterward. The patient also has a history of SLE and received cyclophosphamide therapy 5 years ago. Her clinical condition showed facial and lingual palsy, with central type on the right. Antinuclear antibody indirect immunofluorescence (ANA IF) positive using cytobead ANA with a homogenous pattern and cytoplasmic speckled titer 1/80. Confirmation beads showed positive of dsDNA only. ANA profile showed positive antinucleosome, antihistone, and AMA-M2, and also increased anticardiolipin antibody that supports the diagnosis of NPSLE. The difference in the pattern of ANA IF with confirmation beads suggests the presence of other autoantibodies in NPSLE.
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Affiliation(s)
- Munawaroh Fitriah
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga—Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Lita Diah Rahmawati
- Department of Internal Medicine, Faculty of Medicine, Universitas University—Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Indah Adhita Wulanda
- Department of Clinical Pathology, Faculty of Medicine, Brawijaya University—Dr Saiful Anwar General Hospital, Malang, Indonesia
| | - Hani Susianti
- Department of Clinical Pathology, Faculty of Medicine, Brawijaya University—Dr Saiful Anwar General Hospital, Malang, Indonesia
| | - Betty Agustina Tambunan
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga—Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Tomalla V, Schmeisser MJ, Weinmann-Menke J. Mouse models, antibodies, and neuroimaging: Current knowledge and future perspectives in neuropsychiatric systemic lupus erythematosus (NPSLE). Front Psychiatry 2023; 14:1078607. [PMID: 36970286 PMCID: PMC10031066 DOI: 10.3389/fpsyt.2023.1078607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
As a chronic autoimmune disease systemic lupus erythematosus (SLE) can also affect the central and the peripheral nervous system causing symptoms which are summed up as neuropsychiatric systemic lupus erythematosus (NPSLE). These symptoms are heterogenous including cognitive impairment, seizures, and fatigue, leading to morbidity or even mortality. At present, little is known about the pathophysiological processes involved in NPSLE. This review focuses on the current knowledge of the pathogenesis of NPSLE gained from the investigation of animal models, autoantibodies, and neuroimaging techniques. The antibodies investigated the most are anti-ribosomal P protein antibodies (Anti-rib P) and anti-N-Methyl-D-Aspartic Acid Receptor 2 antibodies (Anti-NR2), which represent a subpopulation of anti-dsDNA autoantibodies. Experimental data demonstrates that Anti-rib P and Anti-NR2 cause different neurological pathologies when applied intravenously (i.v.), intrathecally or intracerebrally in mice. Moreover, the investigation of lupus-prone mice, such as the MRL/MpJ-Faslpr/lpr strain (MRL/lpr) and the New Zealand black/New Zealand white mice (NZB × NZW F1) showed that circulating systemic antibodies cause different neuropsychiatric symptoms compared to intrathecally produced antibodies. Furthermore, neuroimaging techniques including magnetic resonance imaging (MRI) and positron emission tomography (PET) are commonly used tools to investigate structural and functional abnormalities in NPSLE patients. Current research suggests that the pathogenesis of NPSLE is heterogenous, complex and not yet fully understood. However, it demonstrates that further investigation is needed to develop individual therapy in NPSLE.
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Affiliation(s)
- Vanessa Tomalla
- Department of Internal Medicine, Division of Nephrology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael J. Schmeisser
- Institute of Anatomy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Focus Program Translational Neurosciences (FTN), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Julia Weinmann-Menke
- Department of Internal Medicine, Division of Nephrology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- *Correspondence: Julia Weinmann-Menke,
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Wang M, Wang Z, Zhang S, Wu Y, Zhang L, Zhao J, Wang Q, Tian X, Li M, Zeng X. Progress in the Pathogenesis and Treatment of Neuropsychiatric Systemic Lupus Erythematosus. J Clin Med 2022; 11:jcm11174955. [PMID: 36078885 PMCID: PMC9456588 DOI: 10.3390/jcm11174955] [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: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022] Open
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) has a broad spectrum of subtypes with diverse severities and prognoses. Ischemic and inflammatory mechanisms, including autoantibodies and cytokine-mediated pathological processes, are key components of the pathogenesis of NPSLE. Additional brain-intrinsic elements (such as the brain barrier and resident microglia) are also important facilitators of NPSLE. An improving understanding of NPSLE may provide further options for managing this disease. The attenuation of neuropsychiatric disease in mouse models demonstrates the potential for novel targeted therapies. Conventional therapeutic algorithms include symptomatic, anti-thrombotic, and immunosuppressive agents that are only supported by observational cohort studies, therefore performing controlled clinical trials to guide further management is essential and urgent. In this review, we aimed to present the latest pathogenetic mechanisms of NPSLE and discuss the progress in its management.
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Hanly JG, Li Q, Su L, Urowitz MB, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Clarke AE, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Steinsson K, Ramsey-Goldman R, Zoma AA, Manzi S, Nived O, Jonsen A, Khamashta MA, Alarcón GS, Svenungsson E, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Ramos-Casals M, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Theriault C, Farewell V. Peripheral Nervous System Disease in Systemic Lupus Erythematosus: Results From an International Inception Cohort Study. Arthritis Rheumatol 2020; 72:67-77. [PMID: 31390162 PMCID: PMC6935421 DOI: 10.1002/art.41070] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency, clinical characteristics, associations, and outcomes of different types of peripheral nervous system (PNS) disease in a multiethnic/multiracial, prospective inception cohort of systemic lupus erythematosus (SLE) patients. METHODS Patients were evaluated annually for 19 neuropsychiatric (NP) events including 7 types of PNS disease. SLE disease activity, organ damage, autoantibodies, and patient and physician assessment of outcome were measured. Time to event and linear regressions were used as appropriate. RESULTS Of 1,827 SLE patients, 88.8% were female, and 48.8% were white. The mean ± SD age was 35.1 ± 13.3 years, disease duration at enrollment was 5.6 ± 4.2 months, and follow-up was 7.6 ± 4.6 years. There were 161 PNS events in 139 (7.6%) of 1,827 patients. The predominant events were peripheral neuropathy (66 of 161 [41.0%]), mononeuropathy (44 of 161 [27.3%]), and cranial neuropathy (39 of 161 [24.2%]), and the majority were attributed to SLE. Multivariate Cox regressions suggested longer time to resolution in patients with a history of neuropathy, older age at SLE diagnosis, higher SLE Disease Activity Index 2000 scores, and for peripheral neuropathy versus other neuropathies. Neuropathy was associated with significantly lower Short Form 36 (SF-36) physical and mental component summary scores versus no NP events. According to physician assessment, the majority of neuropathies resolved or improved over time, which was associated with improvements in SF-36 summary scores for peripheral neuropathy and mononeuropathy. CONCLUSION PNS disease is an important component of total NPSLE and has a significant negative impact on health-related quality of life. The outcome is favorable for most patients, but our findings indicate that several factors are associated with longer time to resolution.
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Affiliation(s)
- John G Hanly
- Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Qiuju Li
- University of Cambridge, Cambridge, UK
| | - Li Su
- University of Cambridge, Cambridge, UK
| | - Murray B Urowitz
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Caroline Gordon
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | | | | | | | - Ann E Clarke
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Daniel J Wallace
- Cedars-Sinai and University of California, Los Angeles School of Medicine
| | | | | | | | - Paul R Fortin
- CHU de Québec and Université Laval, Québec City, Québec, Canada
| | - Dafna D Gladman
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Centre, and Manchester University NHS Foundation Trust, Manchester, UK
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - M A Dooley
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | - Susan Manzi
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | | | - Munther A Khamashta
- St. Thomas' Hospital and King's College London School of Medicine, London, UK
| | | | | | | | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - Manuel Ramos-Casals
- Institut d'Investigacions Biomèdiques August Pi i Sunyer and Hospital Clínic de Barcelona, Barcelona, Spain
| | - S Sam Lim
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Soren Jacobsen
- Rigshospitalet and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | | - Chris Theriault
- Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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Nalakonda G, Islam M, Chukwu VE, Soliman A, Munim R, Abukraa I. Psycho-rheumatic Integration in Systemic Lupus Erythematosus: An Insight into Antibodies Causing Neuropsychiatric Changes. Cureus 2018; 10:e3091. [PMID: 30324045 PMCID: PMC6171782 DOI: 10.7759/cureus.3091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The main purpose of this paper is to bring together all the antibodies and markers related to neurological and psychiatric manifestations in systemic lupus erythematosus and also the pharmacology that could help treat these symptoms. Existing research data regarding specific antibodies involved in the disease process and drugs that were being studied was collected and analyzed. After reviewing the studies published by various authors, symptoms were shown to be mainly caused by antibodies against N-methyl-D-aspartate receptor (NMDAR) antibodies, anti-endothelial, anti-ribosomal P, antiphospholipid antibodies, cytokines like interferons and chemokines. The monoclonal antibody rituximab has shown to be beneficial in some of the cases. Based on all the articles reviewed, the antibodies and cytokines showed the most effective evidence in causing the different manifestations of neuropsychiatric systemic lupus erythematosus (NPSLE), but studies regarding the drugs being effective against all the symptoms are inconclusive as there are very few studies. Further research to support the drug’s effectiveness in managing the symptoms is needed. More studies are needed regarding early diagnosis of NPSLE using the antibodies as biomarkers as it could help in preventing these manifestations.
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Affiliation(s)
- Gouthami Nalakonda
- Medical Student, Chalmeda Anandrao Institute of Medical Sciences, Karimnagar, IND
| | - Mimsa Islam
- Internal Medicine, Sir Salimullah Medical College, Dhaka, USA
| | | | | | - Rujina Munim
- Miscellaneous, Sylhet Mag Osmani Medical College and Hospital, Sylhet, BGD
| | - Inas Abukraa
- Faculty of Medicine, Tripoli University, Tripoli, LBY
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McGlasson S, Wiseman S, Wardlaw J, Dhaun N, Hunt DPJ. Neurological Disease in Lupus: Toward a Personalized Medicine Approach. Front Immunol 2018; 9:1146. [PMID: 29928273 PMCID: PMC5997834 DOI: 10.3389/fimmu.2018.01146] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/07/2018] [Indexed: 12/11/2022] Open
Abstract
The brain and nervous system are important targets for immune-mediated damage in systemic lupus erythematosus (SLE), resulting in a complex spectrum of neurological syndromes. Defining nervous system disease in lupus poses significant challenges. Among the difficulties to be addressed are a diversity of clinical manifestations and a lack of understanding of their mechanistic basis. However, despite these challenges, progress has been made in the identification of pathways which contribute to neurological disease in SLE. Understanding the molecular pathogenesis of neurological disease in lupus will inform both classification and approaches to clinical trials.
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Affiliation(s)
- Sarah McGlasson
- MRC Institute of Genetics and Molecular Medicine, Edinburgh, United Kingdom
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- The Anne Rowling Clinic, University of Edinburgh, Edinburgh, United Kingdom
| | - Stewart Wiseman
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna Wardlaw
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David P. J. Hunt
- MRC Institute of Genetics and Molecular Medicine, Edinburgh, United Kingdom
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- The Anne Rowling Clinic, University of Edinburgh, Edinburgh, United Kingdom
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Tay SH, Mak A. Diagnosing and attributing neuropsychiatric events to systemic lupus erythematosus: time to untie the Gordian knot? Rheumatology (Oxford) 2017; 56:i14-i23. [PMID: 27744358 DOI: 10.1093/rheumatology/kew338] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Indexed: 01/12/2023] Open
Abstract
Neurological and psychiatric syndromes, collectively referred to as NPSLE, occur frequently in SLE. The frequency of NPSLE varies from 21 to 95%; however, only 13-38% of neuropsychiatric (NP) events could be attributable to SLE in the NPSLE SLICC inception cohort. This variability in the frequency of NPSLE is attributable to the low specificity of the ACR case definitions for SLE-attributed NP syndromes, inclusion of minor NP events in the ACR nomenclature, difficulty in ascertainment of NP events and diverse experience of rheumatologists in the clinical assessment of NP events. Making the correct and early attribution of NP events to SLE is important to institute appropriate immunosuppressive treatment for favourable outcomes. Various attribution models using composite decision rules have been developed and used to ascribe NP events to SLE. This review will focus on the various clinical presentations, diagnostic work-up and attributions of the common NPSLE syndromes, including other NP events not included in the ACR nomenclature but which have come to attention in recent years.
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Affiliation(s)
- Sen Hee Tay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore.,Division of Rheumatology, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Anselm Mak
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore.,Division of Rheumatology, Department of Medicine, National University Hospital, National University Health System, Singapore
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Salcini C, Baştan B, Sunter G, Kahraman Koytak P, Yilmaz O, Tanridağ T, Us Ö, Uluç K. Brainstem Reflexes in Systemic Lupus Erythematosus Patients Without Clinical Neurological Manifestations. Noro Psikiyatr Ars 2017; 54:78-81. [PMID: 28566964 DOI: 10.5152/npa.2016.19301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/17/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We aimed to assess central and peripheral nervous system involvement in systemic lupus erythematosus (SLE) patients without any neurological signs and symptoms by performing electrophysiological investigations. METHODS Thirty-eight SLE patients and 35 healthy volunteers participated in this study. Peripheral nerve conduction and brainstem reflexes were evaluated by performing nerve conduction studies (NCSs) and blink reflex (BR) and masseter inhibitory reflex (MIR) recordings. RESULTS Eleven patients (29%) had an abnormality in at least 1 NCS parameter, and 1 (2.6%) patient was diagnosed with polyneuropathy. The number of patients with abnormal BR and MIR was 23 (60.5%) and 14 (37%), respectively. The contralateral R2 latency of BR and the silent period 1 (SP1) latency of MIR were significantly prolonged in the patients compared with the controls (p=0.015 and p<0.001, respectively). CONCLUSION This study showed that irrespective of peripheral nervous system involvement, brainstem reflexes could be affected in SLE patients even without clinical neurological findings. Brainstem reflex abnormalities suggested that the functional integrity of the inhibitory or excitatory interneurons in the lateral caudal pons and lateral medulla is disturbed in SLE patients.
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Affiliation(s)
- Celal Salcini
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey.,Department of Neurology, Üsküdar University, NPIstanbul Neuropsychiatry Hospital, İstanbul, Turkey
| | - Birgül Baştan
- Clinic of Neurology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Gülin Sunter
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| | | | - Orhan Yilmaz
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| | - Tülin Tanridağ
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| | - Önder Us
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| | - Kayıhan Uluç
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
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Alessi H, Dutra LA, Braga Neto P, Pedroso JL, Toso FF, Kayser C, Barsottini OGP. Neuropsychiatric Lupus in clinical practice. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:1021-1030. [DOI: 10.1590/0004-282x20160150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/11/2016] [Indexed: 12/20/2022]
Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple organs, characterized by the production of autoantibodies and the development of tissue injury. The etiology of SLE is partially known, involving multiple genetic and environmental factors. As many as 50% of patients with SLE have neurological involvement during the course of their disease. Neurological manifestations are associated with impaired quality of life, and high morbidity and mortality rates. Nineteen neuropsychiatric syndromes have been identified associated with SLE, and can be divided into central and peripheral manifestations. This article reviews major neuropsychiatric manifestations in patients with SLE and discusses their clinical features, radiological findings and treatment options.
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Affiliation(s)
| | | | - Pedro Braga Neto
- Universidade Estadual do Ceará, Brasil; Universidade Federal do Ceará, Brasil
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Kampylafka EI, Alexopoulos H, Dalakas MC, Tzioufas AG. Immunotherapies for Neurological Manifestations in the Context of Systemic Autoimmunity. Neurotherapeutics 2016; 13:163-78. [PMID: 26510559 PMCID: PMC4720664 DOI: 10.1007/s13311-015-0393-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Neurological involvement is relatively common in the majority of systemic autoimmune diseases and may lead to severe morbidity and mortality, if not promptly treated. Treatment options vary greatly, depending on the underlying systemic pathophysiology and the associated neurological symptoms. Selecting the appropriate therapeutic scheme is further complicated by the lack of definite therapeutic guidelines, the necessity to differentiate primary neurological syndromes from those related to the underlying systemic disease, and to sort out adverse neurological manifestations caused by immunosuppressants or the biological agents used to treat the primary disease. Immunotherapy is a sine qua non for treating most, if not all, neurological conditions presenting in the context of systemic autoimmunity. Specific agents include classical immune modulators such as corticosteroids, cyclophosphamide, intravenous immunoglobulin, and plasma exchange, as well as numerous biological therapies, for example anti-tumor necrosis factor agents and monoclonal antibodies that target various immune pathways such as B cells, cytokines, and co-stimulatory molecules. However, experience regarding the use of these agents in neurological complications of systemic diseases is mainly empirical or based on small uncontrolled studies and case series. The aim of this review is to present the state-of-the-art therapies applied in various neurological manifestations encountered in the context of systemic autoimmune diseases; evaluate all treatment options on the basis of existing guidelines; and compliment these data with our personal experience derived from a large number of patients.
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Affiliation(s)
- Eleni I Kampylafka
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Harry Alexopoulos
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Marinos C Dalakas
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Athanasios G Tzioufas
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece.
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