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Pudukodu HS, Goldschen L, Bhattacharyya S, Valle A, Arabelovic S, Shah S, Retzel K, Feldman CH, Amonoo HL. Lupus on the Mind: A Case of Psychosis in Uncontrolled Systemic Lupus Erythematosus. Harv Rev Psychiatry 2024; 32:173-182. [PMID: 39265136 DOI: 10.1097/hrp.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2024]
Affiliation(s)
- Harish S Pudukodu
- From Harvard Medical School (Drs. Pudukodu, Goldschen, Bhattacharyya, Valle, Arabelovic, Shah, Retzel, Feldman, and Amonoo); Department of Psychiatry, Brigham and Women's Hospital (Drs. Pudukodu, Goldschen, and Amonoo); Department of Neurology, Brigham and Women's Hospital (Dr. Bhattacharyya); Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital (Drs. Valle, Arabelovic, Shah, Retzel, and Feldman); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (Dr. Amonoo), Boston, MA
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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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Fazio N, Raiss M, Shah R, Vagal V, Moore M, Chacko M. Diagnostic Challenges in Neuro-Psychiatric Systemic Lupus Erythematosus: A Case of a Patient With Psychosis Secondary to Lupus Cerebritis in the Setting of a Steroid Taper. Cureus 2024; 16:e64484. [PMID: 39139303 PMCID: PMC11319798 DOI: 10.7759/cureus.64484] [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] [Accepted: 07/12/2024] [Indexed: 08/15/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune condition whereby autoantibodies target systemic tissues, causing manifestations of inflammation and tissue damage. Neurologic inflammation in SLE can cause an array of neuropsychiatric (NP) symptoms, including headaches, depression, seizures, demyelinating conditions, mania, and psychosis. Patients treated for SLE are often on anti-inflammatory regimens, including high-dose steroids, which can independently precipitate psychosis. Steroid-induced psychosis (SIP) and lupus cerebritis (LC) are two distinct conditions that patients with SLE may have but often have overlapping presentations, which present a challenge for clinicians. Accurately differentiating between SIP and LC in an emergency setting is crucial for directing appropriate management and preventing potential complications. A clear timeline of the history of symptoms can help narrow down the cause. Diagnostic tools, mainly MRI patterns, can further clarify and indicate the presence of LC. We present a case of a 19-year-old African American female with a history of one steroid-induced psychotic episode five months prior in the setting of SLE who developed subsequent psychosis while on a steroid taper. MRI imaging elucidated a diagnosis of LC rather than a second SIP episode. There are few, if any, case reports that describe a patient with past SIP with a subsequent flare of cerebritis with psychotic symptoms. Strategic approaches to differentiating SIP from LC in the setting of SLE can lead to improved patient outcomes, follow-up care, and an overall understanding of the neuropsychiatric complexities of SLE.
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Affiliation(s)
| | - Monica Raiss
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Ronak Shah
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Vaibhav Vagal
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Maxwell Moore
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Mason Chacko
- Psychiatry, Stony Brook University, Stony Brook, USA
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Syed A, Shaik S, Afshan R, Karam A, Hafeez W, Almansour S. Neuropsychiatric Systemic Lupus Erythematosus (NPSLE): A Case Report and an Overview of the Diagnosis, Treatment Modalities, and Prognosis. Cureus 2024; 16:e65593. [PMID: 39192937 PMCID: PMC11349387 DOI: 10.7759/cureus.65593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2024] [Indexed: 08/29/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory, multisystem autoimmune disease with a broad spectrum of clinical presentations. Neuropsychiatric systemic lupus erythematosus (NPSLE) refers to neurological and psychiatric symptoms involving the central and peripheral nervous systems. A 23-year-old African American female with a history of undifferentiated connective tissue disease on hydroxychloroquine and poor medication adherence presented to the emergency department with an altered mental status and generalized headache. In addition, she had a fever, associated tachycardia (104 BPM), and hypotension (90/63 mmHg). She was given fluids and started on broad-spectrum antibiotics and antivirals, suspecting bacterial or viral meningitis. However, a broad infectious workup, including cerebral spinal fluid (CSF) culture, was unrevealing. Given the lack of improvement of antibiotics, an immunological workup for SLE was initiated, which showed low CH50, C3, and C4; anti-nucleic acid antibody (ANA) was 1:1280, anti-double-stranded (anti-DS) DNA antibody not detected, and fluorescent ANA was positive. For severe NPSLE, rituximab is the most commonly utilized immunosuppressant; it was not utilized in this case due to the patient's insurance. The patient was placed on methylprednisolone and cyclophosphamide (CYC) infusion per ACR guidelines. Due to the toxic effects of CYC on the gonads, we offered ovarian preservation; however, the patient opted to refuse. The patient's mental status started to improve after three days of pulse steroids. The patient was advised to follow up with rheumatology for CYC therapy and a gradual taper of her steroids. NPSLE is a diagnosis of exclusion primarily based on expert opinion due to the absence of a gold standard diagnostic procedure. Disease-specific therapy, symptomatic therapy, nonpharmacological approaches, and correction of aggravating variables are all used to treat individuals with NPSLE. This paper aims to contribute to the existing literature on NPSLE, with the intention to educate and strive for early detection and treatment. We hereby present an interesting case of SLE in a 23-year-old female who would not have responded to one treatment. Instead, she needed multidisciplinary management, along with poor compliance.
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Affiliation(s)
- Ameena Syed
- Department of Internal Medicine, Orlando Health Physician Associates, Orlando, USA
| | - Sajid Shaik
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, USA
| | - Roshan Afshan
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Sinai Grace Hospital, Detroit, USA
| | - Andrew Karam
- Department of Emergency Medicine, Ascension Providence Hospital, Detroit, USA
| | - Wasif Hafeez
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Sinai Grace Hospital, Detroit, USA
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5
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Patel V. The Challenge of Neuropsychiatric Systemic Lupus Erythematosus: From Symptoms to Therapeutic Strategies. Diagnostics (Basel) 2024; 14:1186. [PMID: 38893713 PMCID: PMC11172037 DOI: 10.3390/diagnostics14111186] [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: 04/30/2024] [Revised: 05/31/2024] [Accepted: 06/02/2024] [Indexed: 06/21/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune condition that can seriously impair multiple organs including the nervous system, causing neuropsychiatric SLE (NPSLE), which encompasses a broad range of symptoms. Pathogenesis is not completely understood but is thought to involve inflammatory and vascular pathways. This comprehensive review discusses the complex nature and heterogeneity of NPSLE and the challenges in diagnosis and treatment that result from it. Diagnosis often requires a multidisciplinary approach with multiple assessments, including laboratory testing, imaging, and neuropsychological evaluations. Current treatments focus on managing symptoms through immunosuppressive and anti-thrombotic therapies tailored to the inflammatory or vascular nature of the specific NPSLE manifestations. This paper emphasizes the necessity for interdisciplinary approaches and further research to enhance diagnostic accuracy and treatment effectiveness. It also highlights the importance of understanding the underlying mechanisms of NPSLE to develop more targeted therapies, citing the need for high-quality studies and novel treatment agents.
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Affiliation(s)
- Veena Patel
- Department of Medicine, Division of Rheumatology, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA
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Salas JR, Farrell A, Potts C, Robinson P. Longitudinally Extensive Transverse Myelitis in a Patient With Systemic Lupus Erythematosus, Recent Influenza Infection, and Nutritional Deficiencies in the Setting of Chronic Alcohol Use. Cureus 2024; 16:e61601. [PMID: 38962621 PMCID: PMC11221627 DOI: 10.7759/cureus.61601] [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] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
Longitudinally extensive transverse myelitis (LETM) is traditionally classified as an inflammatory disorder of the spinal cord spanning three or more vertebral segments. The differential diagnosis for TM is vast and can include infectious, nutritional, and can even be idiopathic in some reported cases. However, autoimmune etiologies such as systemic lupus erythematosus (SLE) can rarely present with neurological manifestations such as LETM. In this case report, we present a 33-year-old female with a prior history of SLE who developed an LETM in the setting of possible provoking factors such as nutritional deficiencies and a recent viral illness. In this case report, we highlight her clinical course, recovery, and working differential diagnosis after laboratory testing and neurological imaging. Finally, we discuss the different treatments that ultimately lead to her successful recovery after her prolonged clinical course.
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Affiliation(s)
- Jesus R Salas
- Neurology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Anna Farrell
- Internal Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Casey Potts
- Neurology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Peter Robinson
- Neurology, The Ohio State University Wexner Medical Center, Columbus, USA
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Labouret M, Trebossen V, Ntorkou A, Bartoli S, Aubart M, Auvin S, Bader-Meunier B, Baudouin V, Corseri O, Dingulu G, Ducrocq C, Dumaine C, Elmaleh M, Fabien N, Faye A, Hau I, Hentgen V, Kwon T, Meinzer U, Ouldali N, Parmentier C, Pouletty M, Renaldo F, Savioz I, Benoist JF, Le Roux E, Ellul P, Melki I. Juvenile neuropsychiatric systemic lupus erythematosus: A specific clinical phenotype and proposal of a probability score. Lupus 2024; 33:328-339. [PMID: 38315109 DOI: 10.1177/09612033241229022] [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: 02/07/2024]
Abstract
OBJECTIVE Juvenile systemic lupus erythematosus (j-SLE) is a rare chronic auto-immune disease involving several organs. Neuropsychiatric (NP) SLE (NPSLE) is frequent in j-SLE and associated with increased morbidity/mortality. Although NPSLE classification criteria exist, attributing NP features to j-SLE remains a major challenge. The study objective is to thoroughly describe j-NPSLE patients and assist in their diagnosis. METHODS This is a 4-year retrospective monocentric study of j-SLE patients. NP events were attributed to j-SLE using standardised diagnostic criteria and multidisciplinary paediatric clinical expertise. Clinical features, brain magnetic resonance imaging (MRI)s and samples analysis including cerebrospinal fluid were assessed. A risk of j-NPSLE score was developed based on multivariable logistic regression analysis. RESULTS Of 39 patients included, 44% were identified as having j-NPSLE. J-NPSLE diagnosis was established at the onset of j-SLE in 59% of patients. In addition to frequent kidney involvement (76%) and chilblains (65%), all j-NPSLE patients displayed psychiatric features: cognitive symptoms (82%), hallucinations (76%), depressed mood (35%), acute confused state (18%) and catatonia (12%). Neurological involvement was often mild and nonspecific, with headache (53%) in about half of the patients. The main features reported on brain MRI were nonspecific T2/FLAIR white matter hyperintensities (65%), and cerebral atrophy (88%). Upon immunosuppressive treatment, clinical improvement of NP features was observed in all j-NPSLE patients. The score developed to attribute j-NPSLE probability, guide further investigations and appropriate treatments is based on hallucinations, memory, sleep and renal involvement (Sensitivity: 0.95 Specificity: 0.85). Cerebrospinal fluid (CSF) neopterin assessment increases the score sensitivity and specificity. CONCLUSION Physicians should carefully and systematically assess the presence of NP features at diagnosis and early stages of j-SLE. For j-NPSLE patients with predominant psychiatric features, a multidisciplinary collaboration, including psychiatrists, is essential for the diagnosis, management and follow-up.
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Affiliation(s)
- Mathilde Labouret
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Sorbonne Université, Paris, France
| | - Vincent Trebossen
- Department of Child and Adolescent Psychiatry, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
| | - Alexandra Ntorkou
- Department of Paediatric Radiology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Sophie Bartoli
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Mélodie Aubart
- Paediatric Neurology Department, Necker-Enfants Malades Hospital, University of Paris-Cité, AP-HP, Paris, France
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, French Institute of Health and Medical Research U1163, Imagine Institute, University of Paris-Cité, Paris, France
| | - Stéphane Auvin
- Department of Paediatric Neurology, Center for Rare Epilepsies & Epilepsy Unit, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Université Paris Cité, INSERM NeuroDiderot, Paris, France
- Institut Universitaire de France (IUF), Paris, France
| | - Brigitte Bader-Meunier
- Department of Paediatric Haematology-Immunology And Rheumatology, Necker-Enfants-Malades University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Laboratory of Immunogenetics of Paediatric Autoimmune Diseases, Imagine Institute, INSERM UMR 1163, Université Paris Cité, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Olivier Corseri
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Glory Dingulu
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Camille Ducrocq
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Cécile Dumaine
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Monique Elmaleh
- Department of Paediatric Radiology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Nicole Fabien
- Immunology Department, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Albert Faye
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
- UMR1123 Inserm, Université Paris Cité, Paris, France
| | - Isabelle Hau
- Department of General Paediatrics, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Véronique Hentgen
- Department of General Paediatrics, French Reference centre for Autoinflammatory diseases and amyloidosis (CEREMAIA), Versailles Hospital, Le Chesnay, France
| | - Théresa Kwon
- Department of Paediatric Nephrology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Ulrich Meinzer
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
- Center for Research on Inflammation, INSERM, Université Paris Cité, Paris, France
- Biology and Genetics of Bacterial Cell Wall Unit, Pasteur Institute, Paris, France
| | - Naim Ouldali
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
| | - Cyrielle Parmentier
- Department of Paediatric Nephrology, Armand-Trousseau Childrens' Hospital, AP-HP, Paris, France
| | - Marie Pouletty
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Florence Renaldo
- Department of Paediatric Neurology, Center for Neurogenetic Diseases, Armand-Trousseau Childrens' Hospital, AP-HP, Paris, France
| | - Isabelle Savioz
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Jean-François Benoist
- Metabolic Biochemistry Laboratory, Reference Centre for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, AP-HP, Paris, France
- Université Paris Saclay, UFR Pharmacie, France
| | - Enora Le Roux
- UMR1123 Inserm, Université Paris Cité, Paris, France
- Unité d'Épidémiologie Clinique, Inserm, CIC 1426, Robert Debré Mother-Child University Hospital, Nord-Université Paris Cité, AP-HP, Paris, France
| | - Pierre Ellul
- Department of Child and Adolescent Psychiatry, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Immunology-Immunopathology-Immunotherapy (i3), Sorbonne Université, Paris, France
| | - Isabelle Melki
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Department of Paediatric Haematology-Immunology And Rheumatology, Necker-Enfants-Malades University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Imagine Institute, Laboratory of Neurogenetics and Neuroinflammation, INSERM UMR 1163, Université Paris Cité, Paris, France
- Paediatrics, Rheumatology and Paediatric Internal Medicine, Children's Hospital, Bordeaux, France
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Geng W, Zhang S, Cao J, Hong X, Duan Y, Jiang Y, Wei J. Predictive factors of psychiatric syndrome in patients with systemic lupus erythematosus. Front Immunol 2024; 15:1323209. [PMID: 38585267 PMCID: PMC10996363 DOI: 10.3389/fimmu.2024.1323209] [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: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Early detection of neuropsychiatric systemic lupus erythematosus (NPSLE) remains a challenge in clinical settings. Previous studies have found different autoantibodies as markers for NPSLE. This study aimed to describe the distribution of psychiatric syndromes in a group of patients with systemic lupus erythematosus (SLE) and to investigate the association between psychiatric syndromes and specific autoantibodies. Methods This retrospective study was conducted at a single medical center in China. We reviewed medical records of hospitalized patients with SLE who were consulted by psychiatrists due to potential mental disorders. Results of serum autoantibodies and general laboratory tests were collected. The correlation between clinical variables was examined. Binary logistic regression analyses were used to determine factors related to NPSLE and different psychiatric diagnoses. Results Among the 171 psychiatric manifestations in 160 patients, 141 (82.4%) were attributed to SLE. Acute confusional state (ACS) had the highest prevalence (57.4%). Anti-cardiolipin (ACL) antibody (X2 = 142.261, p < 0.001) and anti-β2 glycoprotein I (-β2GP1) antibody (X2 = 139.818, p < 0.001) varied significantly between groups, with the highest positive rate found in patients with mood disorders (27.3% and 18.2%). SLE disease activity index - 2000 (SLEDAI-2K) score excluding item ACS and item psychosis was a predictor of NPSLE (OR 1.172 [95% CI 1.105 - 1.243]). Conclusions Disease activity reflected by SLEDAI-2K score is a predictor for NPSLE. Antiphospholipid antibodies are associated with mood disorders in SLE. Further separate investigation of neuropsychiatric disorders is needed in order to better comprehend NPSLE's pathological mechanism.
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Affiliation(s)
- Wenqi Geng
- Department of Psychological Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jinya Cao
- Department of Psychological Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xia Hong
- Department of Psychological Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yanping Duan
- Department of Psychological Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yinan Jiang
- Department of Psychological Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Wei
- Department of Psychological Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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Xue H, Liu S, Zeng L, Fan W. Causal effect of systemic lupus erythematosus on psychiatric disorders: A two-sample Mendelian randomization study. J Affect Disord 2024; 347:422-428. [PMID: 38008292 DOI: 10.1016/j.jad.2023.11.033] [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: 08/23/2023] [Revised: 10/19/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND This study aims to investigate the association between systemic lupus erythematosus (SLE) and the risk of seven psychiatric disorders through the application of Mendelian randomization (MR) analysis due to previous observational studies that have suggested a potential link between SLE and psychiatric disorders. METHODS We collected genetic instruments for SLE from a genome-wide association study (GWAS) involving 23,210 individuals. Seven psychiatric traits were enrolled from the recent largest GWAS, including major depression disorder (MDD), generalized anxiety disorder (GAD), schizophrenia (SCZ), bipolar disorder (BID), autism spectrum disorder (ASD), attention deficit/hyperactivity disorder (ADHD), and insomnia. Summary statistics for psychiatric disorders were obtained from different GWAS meta-analysis studies. The inverse variance weighted (IVW) method was used as the main MR analysis. RESULTS The IVW method indicated that SLE is associated with a higher risk of GAD (OR = 1.072, 95 % CI [1.017-1.129], P = 0.008) and SCZ (OR = 3.242, 95 % CI [1.578-6.660], P = 0.007). However, no evidence was found for the causal associations between SLE and other psychiatric disorders. Further analyses found no evidence of pleiotropy and heterogeneity. CONCLUSIONS This two-sample MR analysis provides evidence that genetically predicted SLE may increase the risk of GAD and SCZ in a European population. Future studies are needed to elucidate and investigate the mechanisms underlying these causal relationships. Considering the existence of racial genomic heterogeneity, our findings must be viewed with caution.
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Affiliation(s)
- Hua Xue
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China.
| | - Shuangjuan Liu
- Department of Neurology, Qionglai People's Hospital, Chengdu, Sichuan, China
| | - Li Zeng
- Department of Respiratory, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Wenhui Fan
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China.
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10
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Justiz-Vaillant AA, Gopaul D, Soodeen S, Arozarena-Fundora R, Barbosa OA, Unakal C, Thompson R, Pandit B, Umakanthan S, Akpaka PE. Neuropsychiatric Systemic Lupus Erythematosus: Molecules Involved in Its Imunopathogenesis, Clinical Features, and Treatment. Molecules 2024; 29:747. [PMID: 38398500 PMCID: PMC10892692 DOI: 10.3390/molecules29040747] [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: 10/20/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/25/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is an idiopathic chronic autoimmune disease that can affect any organ in the body, including the neurological system. Multiple factors, such as environmental (infections), genetic (many HLA alleles including DR2 and DR3, and genes including C4), and immunological influences on self-antigens, such as nuclear antigens, lead to the formation of multiple autoantibodies that cause deleterious damage to bodily tissues and organs. The production of autoantibodies, such as anti-dsDNA, anti-SS(A), anti-SS(B), anti-Smith, and anti-neuronal DNA are characteristic features of this disease. This autoimmune disease results from a failure of the mechanisms responsible for maintaining self-tolerance in T cells, B cells, or both. Immune complexes, circulating antibodies, cytokines, and autoreactive T lymphocytes are responsible for tissue injury in this autoimmune disease. The diagnosis of SLE is a rheumatological challenge despite the availability of clinical criteria. NPSLE was previously referred to as lupus cerebritis or lupus sclerosis. However, these terms are no longer recommended because there is no definitive pathological cause for the neuropsychiatric manifestations of SLE. Currently, the treatment options are primarily based on symptomatic presentations. These include the use of antipsychotics, antidepressants, and anxiolytic medications for the treatment of psychiatric and mood disorders. Antiepileptic drugs to treat seizures, and immunosuppressants (e.g., corticosteroids, azathioprine, and mycophenolate mofetil), are directed against inflammatory responses along with non-pharmacological interventions.
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Affiliation(s)
- Angel A. Justiz-Vaillant
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
| | - Darren Gopaul
- Port of Spain General Hospital, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago;
| | - Sachin Soodeen
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
| | - Rodolfo Arozarena-Fundora
- Eric Williams Medical Sciences Complex, North Central Regional Health Authority, Champs Fleurs, San Juan 00000, Trinidad and Tobago; (R.A.-F.); (O.A.B.)
- Department of Clinical and Surgical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine 00000, Trinidad and Tobago
| | - Odette Arozarena Barbosa
- Eric Williams Medical Sciences Complex, North Central Regional Health Authority, Champs Fleurs, San Juan 00000, Trinidad and Tobago; (R.A.-F.); (O.A.B.)
| | - Chandrashehkar Unakal
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
| | - Reinand Thompson
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
| | - Bijay Pandit
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
| | - Srikanth Umakanthan
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
| | - Patrick E. Akpaka
- Department of Para-Clinical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine 00000, Trinidad and Tobago; (S.S.); (C.U.); (R.T.); (B.P.); (P.E.A.)
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11
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Kassim FM, Wordefo DK, Berhanu M, Megersa SW, Tessema SA. Psychiatric manifestations of systemic lupus erythematosus: A brief review with two case-reports. SAGE Open Med Case Rep 2024; 12:2050313X241229010. [PMID: 38313038 PMCID: PMC10838031 DOI: 10.1177/2050313x241229010] [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: 08/30/2023] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
Neuropsychiatric systemic lupus erythematosus is a severe neurological and psychiatric manifestation following systemic lupus erythematosus. Neuropsychiatric systemic lupus erythematosus is a global concern with limited data on its impact on quality of life in Africa. Furthermore, there is a lack of published research on neuropsychiatric systemic lupus erythematosus in Ethiopia. In this article, we present two case reports of Ethiopian patients with systemic lupus erythematosus and neuropsychiatric systemic lupus erythematosus, highlighting the challenges of diagnosing neuropsychiatric systemic lupus erythematosus worldwide. Although the patients were treated with alternative pharmacological agents based on available medications, interdisciplinary collaboration between psychologists, psychiatrists, neurologists, and internists is necessary to decrease the burden of systemic lupus erythematosus patients with neuropsychiatric manifestations. Overall, symptomatic therapy for neuropsychiatric systemic lupus erythematosus in developing countries is a good approach until future evidence-based pharmacotherapy is developed.
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Affiliation(s)
- Faiz Mohammed Kassim
- Department of Psychiatry, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Dureti Kassim Wordefo
- Department of Psychiatry, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mahlet Berhanu
- Department of Psychiatry, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Surafel Worku Megersa
- Department of Psychiatry, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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12
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Li N, Liu X, Wu P, Liu J, Chen P, Zeng J. Three cases of systemic lupus erythematosus presenting with ischemic stroke as the initial symptom: Case reports and literature review. Immun Inflamm Dis 2024; 12:e1183. [PMID: 38332684 PMCID: PMC10853674 DOI: 10.1002/iid3.1183] [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: 08/25/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Ischemic stroke constitutes a grave complication within the context of systemic lupus erythematosus (SLE), typically manifesting several years postdiagnosis of SLE. Incidents where ischemic stroke precedes and acts as an initial symptom of SLE are comparatively rare in its early stages, and such presentations are frequently misdiagnosed as ischemic cerebrovascular diseases, posing significant diagnostic challenges. CASE REPORTS This article presents three cases of young females in whom ischemic stroke emerged as the initial manifestation of SLE. It incorporates a review of 17 case reports published over the past two decades, focusing on patients with SLE where ischemic stroke was a primary symptom. This discussion encompasses the clinical presentation, outcomes, and therapeutic approaches for these patients. CONCLUSION In young patients, particularly females presenting with ischemic stroke and especially in cases accompanied by hematologic or multisystemic involvement, there should be heightened vigilance for SLE-induced ischemic stroke. Early diagnosis and treatment significantly enhance patients' quality of life and survival rates.
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Affiliation(s)
- Na Li
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Xiaoxia Liu
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Pengjia Wu
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Jun Liu
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Pengyu Chen
- Radiology DepartmentThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Jiashun Zeng
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
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13
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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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14
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Castellazzi M, Candeloro R, Pugliatti M, Govoni M, Silvagni E, Bortoluzzi A. Cerebrospinal Fluid Analysis in Rheumatological Diseases with Neuropsychiatric Complications and Manifestations: A Narrative Review. Diagnostics (Basel) 2024; 14:242. [PMID: 38337758 PMCID: PMC10854855 DOI: 10.3390/diagnostics14030242] [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: 12/27/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/12/2024] Open
Abstract
The analysis of cerebrospinal fluid (CSF) remains a valuable diagnostic tool in the evaluation of inflammatory and infectious conditions involving the brain, spinal cord, and meninges. Since many rheumatic inflammatory diseases can involve the central and peripheral nervous system, the aims of this narrative review were to summarize the latest evidence on the use of CSF analysis in the field of neuropsychiatric manifestations of rheumatic diseases. Routine CSF parameters were taken into consideration for this review: appearance; total protein and cellular content (pleocytosis); lactate and/or glucose; CSF/serum albumin quotient; intrathecal synthesis of IgG. Data regarding the role of CSF analysis in the clinical management of neuropsychiatric systemic lupus erythematosus, primary Sjogren's syndrome, rheumatoid arthritis, and Behçet's syndrome are presented. Although no disease-specific picture has been identified, CSF analysis remains a useful diagnostic tool to confirm the presence of a neuro-inflammatory state or, conversely, to exclude the concomitant presence of other inflammatory/infectious diseases affecting the CNS in the context of systemic rheumatologic conditions.
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Affiliation(s)
- Massimiliano Castellazzi
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (M.P.)
| | - Raffaella Candeloro
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (M.P.)
| | - Maura Pugliatti
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (M.P.)
| | - Marcello Govoni
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy; (M.G.); (E.S.); (A.B.)
| | - Ettore Silvagni
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy; (M.G.); (E.S.); (A.B.)
| | - Alessandra Bortoluzzi
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy; (M.G.); (E.S.); (A.B.)
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15
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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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16
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Zouari R, Saeid MZ, Marzouk M, Rachdi A, Ben Sassi S. Diffuse cerebral edema with leukoencephalopathy revealing systemic lupus erythematosus: A case report and review of literature. Lupus 2023; 32:1561-1571. [PMID: 37887528 DOI: 10.1177/09612033231207723] [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: 10/28/2023]
Abstract
Background: Systemic lupus erythematosus (SLE) is a common autoimmune disease with various symptoms involving multiple organs. Neuropsychological manifestations are various and generally serious. Leukoencephalopathy is particularly rare but life-threatening in patients with SLE. Results: Here, we describe the case of a young woman who developed a subacute onset intracranial hypertension, papillar edema on fundus examination, diffuse cerebral edema on brain CT scan, and diffuse leukoencephalopathy on brain magnetic resonance imaging (MRI). The immunological workup was positive for antinuclear antibodies, anti-DNA and anti-extractable nuclear antigens (ENA) antibodies. She was ultimately diagnosed with SLE and experienced significant improvement after treatment with high dose of corticosteroids, acetazolamide, and immunosuppressant. We additionally review the previously reported cases of SLE with diffuse cerebral edema and leukoencephalopathy with a focus on the possible pathophysiological mechanisms of such association. Conclusions: We highlight, through this case report and the literature review, the importance of considering SLE in patients with cerebral edema and diffuse leukoencephalopathy and treating it aggressively.
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Affiliation(s)
- Rania Zouari
- Department of neurology, Mongi Ben Hmida National Institute of Neurology of Tunis, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Mohamed Zakaria Saeid
- Department of neurology, Mongi Ben Hmida National Institute of Neurology of Tunis, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Mahmoud Marzouk
- Department of anesthesiology and reanimation, Mongi Ben Hmida National Institute of Neurology in Tunis, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Amine Rachdi
- Department of neurology, Mongi Ben Hmida National Institute of Neurology of Tunis, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Samia Ben Sassi
- Department of neurology, Mongi Ben Hmida National Institute of Neurology of Tunis, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
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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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18
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Kuchcinski G, Rumetshofer T, Zervides KA, Lopes R, Gautherot M, Pruvo JP, Bengtsson AA, Hansson O, Jönsen A, Sundgren PCM. MRI BrainAGE demonstrates increased brain aging in systemic lupus erythematosus patients. Front Aging Neurosci 2023; 15:1274061. [PMID: 37927336 PMCID: PMC10622955 DOI: 10.3389/fnagi.2023.1274061] [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: 08/07/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disease affecting multiple organs in the human body, including the central nervous system. Recently, an artificial intelligence method called BrainAGE (Brain Age Gap Estimation), defined as predicted age minus chronological age, has been developed to measure the deviation of brain aging from a healthy population using MRI. Our aim was to evaluate brain aging in SLE patients using a deep-learning BrainAGE model. Methods Seventy female patients with a clinical diagnosis of SLE and 24 healthy age-matched control females, were included in this post-hoc analysis of prospectively acquired data. All subjects had previously undergone a 3 T MRI acquisition, a neuropsychological evaluation and a measurement of neurofilament light protein in plasma (NfL). A BrainAGE model with a 3D convolutional neural network architecture, pre-trained on the 3D-T1 images of 1,295 healthy female subjects to predict their chronological age, was applied on the images of SLE patients and controls in order to compute the BrainAGE. SLE patients were divided into 2 groups according to the BrainAGE distribution (high vs. low BrainAGE). Results BrainAGE z-score was significantly higher in SLE patients than in controls (+0.6 [±1.1] vs. 0 [±1.0], p = 0.02). In SLE patients, high BrainAGE was associated with longer reaction times (p = 0.02), lower psychomotor speed (p = 0.001) and cognitive flexibility (p = 0.04), as well as with higher NfL after adjusting for age (p = 0.001). Conclusion Using a deep-learning BrainAGE model, we provide evidence of increased brain aging in SLE patients, which reflected neuronal damage and cognitive impairment.
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Affiliation(s)
- Grégory Kuchcinski
- Division of Diagnostic Radiology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
- Lund University BioImaging Centre, Lund University, Lund, Sweden
- Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Univ. Lille, Lille, France
| | - Theodor Rumetshofer
- Division of Diagnostic Radiology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
- Division of Logopedics, Phoniatrics and Audiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Kristoffer A. Zervides
- Division of Rheumatology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Renaud Lopes
- Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Univ. Lille, Lille, France
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Morgan Gautherot
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Jean-Pierre Pruvo
- Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Univ. Lille, Lille, France
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Anders A. Bengtsson
- Division of Rheumatology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Oskar Hansson
- Clinical Memory Research Unit, Lund University, Lund, Sweden
- Memory Clinic, Skåne University Hospital, Malmö, Sweden
| | - Andreas Jönsen
- Division of Rheumatology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Pia C. Maly Sundgren
- Division of Diagnostic Radiology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
- Lund University BioImaging Centre, Lund University, Lund, Sweden
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19
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Geng W, Zhang S, Cao J, Zhu B, Duan Y, Hong X, Wei J. Antipsychotics reduces mortality in patients with neuropsychiatric systemic lupus erythematosus: a retrospective study of psychiatric consultation cases. Front Psychiatry 2023; 14:1189940. [PMID: 37583844 PMCID: PMC10424435 DOI: 10.3389/fpsyt.2023.1189940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/17/2023] [Indexed: 08/17/2023] Open
Abstract
Objective This study aimed to identify the presence of psychiatric comorbidities as well as investigate the relationship between psychiatric interventions for mental symptoms and mortality in patients with systemic lupus erythematosus (SLE). Method We retrospectively evaluated the records of 160 inpatients with SLE who required psychiatric consultation for further therapeutic intervention from 2013 to 2020 in a tertiary general hospital. We collected clinical data, including diagnoses, medications, and mortality rate. We compared clinical characteristics among the diagnosis groups and correlations between variables. Results A total of 138 (86.3%) patients met the diagnostic criteria for at least one mental disorder, with the most common being delirium (54.4%). The average Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score significantly differed among the diagnosis groups (p = 0.003). The mortality rate among patients with delirium was significantly higher than that in the other patient groups (x2 = 12.967, p = 0.024). SLEDAI-2K score was not significantly correlated with mortality (r = 0.123, p = 0.087). Antipsychotics use was associated with mortality (odds ratio 0.053, p = 0.021). Conclusion Antipsychotic use may decrease death risk for patients with NPSLE. Early psychiatric consultation is necessary for patients with SLE who have developed or have suspected psychiatric symptoms in order to establish a comprehensive intervention plan.
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Affiliation(s)
- Wenqi Geng
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jinya Cao
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Boheng Zhu
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yanping Duan
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xia Hong
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Wei
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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20
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Athanassiou P, Athanassiou L. Current Treatment Approach, Emerging Therapies and New Horizons in Systemic Lupus Erythematosus. Life (Basel) 2023; 13:1496. [PMID: 37511872 PMCID: PMC10381582 DOI: 10.3390/life13071496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/18/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
Systemic lupus erythematosus (SLE), the prototype of systemic autoimmune diseases is characterized by extreme heterogeneity with a variable clinical course. Renal involvement may be observed and affects the outcome. Hydroxychloroquine should be administered to every lupus patient irrespective of organ involvement. Conventional immunosuppressive therapy includes corticosteroids, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine, cyclosporine and tacrolimus. However, despite conventional immunosuppressive treatment, flares occur and broad immunosuppression is accompanied by multiple side effects. Flare occurrence, target organ involvement, side effects of broad immunosuppression and increased knowledge of the pathogenetic mechanisms involved in SLE pathogenesis as well as the availability of biologic agents has led to the application of biologic agents in SLE management. Biologic agents targeting various pathogenetic paths have been applied. B cell targeting agents have been used successfully. Belimumab, a B cell targeting agent, has been approved for the treatment of SLE. Rituximab, an anti-CD20 targeting agent is also used in SLE. Anifrolumab, an interferon I receptor-targeting agent has beneficial effects on SLE. In conclusion, biologic treatment is applied in SLE and should be further evaluated with the aim of a good treatment response and a significant improvement in quality of life.
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Affiliation(s)
| | - Lambros Athanassiou
- Department of Rheumatology, Asclepeion Hospital, Voula, GR16673 Athens, Greece
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21
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Marinho A, Delgado Alves J, Fortuna J, Faria R, Almeida I, Alves G, Araújo Correia J, Campar A, Brandão M, Crespo J, Marado D, Matos-Costa J, Oliveira S, Salvador F, Santos L, Silva F, Fernandes M, Vasconcelos C. Biological therapy in systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren's syndrome: evidence- and practice-based guidance. Front Immunol 2023; 14:1117699. [PMID: 37138867 PMCID: PMC10150407 DOI: 10.3389/fimmu.2023.1117699] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and Sjögren's syndrome (SS) are heterogeneous autoimmune diseases. Severe manifestations and refractory/intolerance to conventional immunosuppressants demand other options, namely biological drugs, and small molecules. We aimed to define evidence and practice-based guidance for the off-label use of biologics in SLE, APS, and SS. Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice in autoimmune disease management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2021. Preliminary recommendations were drafted by working groups for each disease. A revision meeting with all experts anticipated the consensus meeting held in June 2021. All experts voted (agree, disagree, neither agree nor disagree) during two rounds, and recommendations with at least 75% agreement were approved. A total of 32 final recommendations (20 for SLE treatment, 5 for APS, and 7 for SS) were approved by the experts. These recommendations consider organ involvement, manifestations, severity, and response to previous treatments. In these three autoimmune diseases, most recommendations refer to rituximab, which aligns with the higher number of studies and clinical experience with this biological agent. Belimumab sequential treatment after rituximab may also be used in severe cases of SLE and SS. Second-line therapy with baricitinib, bortezomib, eculizumab, secukinumab, or tocilizumab can be considered in SLE-specific manifestations. These evidence and practice-based recommendations may support treatment decision and, ultimately, improve the outcome of patients living with SLE, APS, or SS.
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Affiliation(s)
- António Marinho
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
- Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School, Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira - Centro Hospitalar Alto Ave, Guimarães, Portugal
| | - João Araújo Correia
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Santarém, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
- Linha de Investigação Clínica e Interdisciplinar em Meio Ambiente, Genética e Oncobiologia (CIMAGO), Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Milene Fernandes
- Real-World Evidence & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, Lisboa, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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22
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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: 2] [Impact Index Per Article: 2.0] [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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Monahan RC, Beaart-van de Voorde LJJ, Fronczek R, de Bresser J, Eikenboom J, Kloppenburg M, Middelkoop HAM, Terwindt GM, van der Wee NJA, Huizinga TWJ, Steup-Beekman GM. Clinical outcome in patients with suspected inflammatory neuropsychiatric lupus treated with immunosuppression: an observational cohort study. Lupus Sci Med 2023; 10:10/1/e000850. [PMID: 36737098 PMCID: PMC9900068 DOI: 10.1136/lupus-2022-000850] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The short-term and long-term outcome of inflammatory neuropsychiatric SLE (NPSLE) with immunosuppressive treatment is largely unknown. We used clinical data from our tertiary referral centre for NPSLE to investigate the type of inflammatory NPSLE manifestations, type of immunosuppressive treatment prescribed for these manifestations and clinical outcomes. METHODS All patients with SLE visiting the Leiden University Medical Centre NPSLE clinic between 2007 and 2021 receiving immunosuppressive therapy for neuropsychiatric symptoms were included. Clinical, immunological and radiological information was collected in as standardised way during a 1-day multidisciplinary assessment. In a multidisciplinary consensus meeting, the presence of NPSLE and the type of NPSLE manifestations and treatment were determined. For this study, short-term (0-6 months) and long-term outcomes (7-24 months) of the NP symptoms were assessed by two independent readers and scored on a 7-point Likert scale, ranging from death to resolved. RESULTS In total, 95 out of 398 (24%) patients visiting the NPSLE clinic between 2007 and 2021 received any form of immunosuppressive treatment for 101 separate NPSLE events. The most common NP manifestation was cognitive dysfunction (50%) as identified by formal cognitive assessment, often present in combination with other NPSLE manifestations. Treatment modalities were induction (24%), induction and maintenance (73%) and other therapy (3%). The treatments mostly consisted of (combinations of) prednisone (97%), methylprednisolone (53%), azathioprine (generally 2 mg/kg daily) (49%) and cyclophosphamide (generally induction 750 mg/m2 every 4 weeks for 24 weeks or 500mg biweekly for 12 weeks) (42%). Short-term outcome showed improvement on the Likert scale in 73% (improved: 22%, much improved: 29%, resolved: 22%), no change in 21% and worsening in 6% of patients. Long-term outcome was available for 78 out of 101 events and showed improvement in 70% (improved: 14%, much improved: 28%, resolved: 28%), no change in 17%, worsening in 10% and death in 3% of patients (none directly NPSLE-related). CONCLUSION The outcome of inflammatory NPSLE after immunosuppressive treatment is generally good, with improvement of neuropsychiatric symptoms occuring in approximately 70% of events.
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Affiliation(s)
- Rory C Monahan
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | | | - Rolf Fronczek
- Department of Neurology, LUMC, Leiden, The Netherlands,SEIN, Hoofddorp, The Netherlands
| | | | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, LUMC, Leiden, The Netherlands
| | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Huub A M Middelkoop
- Department of Neurology, LUMC, Leiden, The Netherlands,Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
| | | | - Nic J A van der Wee
- Department of Psychiatry, LUMC, Leiden, The Netherlands,Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands,Department of Rheumatology, Haaglanden Medical Centre, the Hague, The Netherlands
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24
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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.
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25
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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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Téllez Arévalo AM, Quaye A, Rojas-Rodríguez LC, Poole BD, Baracaldo-Santamaría D, Tellez Freitas CM. Synthetic Pharmacotherapy for Systemic Lupus Erythematosus: Potential Mechanisms of Action, Efficacy, and Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:56. [PMID: 36676680 PMCID: PMC9866503 DOI: 10.3390/medicina59010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
The pharmacological treatment of systemic lupus erythematosus (SLE) aims to decrease disease activity, progression, systemic compromise, and mortality. Among the pharmacological alternatives, there are chemically synthesized drugs whose efficacy has been evaluated, but which have the potential to generate adverse events that may compromise adherence and response to treatment. Therapy selection and monitoring will depend on patient characteristics and the safety profile of each drug. The aim of this review is to provide a comprehensive understanding of the most important synthetic drugs used in the treatment of SLE, including the current treatment options (mycophenolate mofetil, azathioprine, and cyclophosphamide), review their mechanism of action, efficacy, safety, and, most importantly, provide monitoring parameters that should be considered while the patient is receiving the pharmacotherapy.
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Affiliation(s)
- Angélica María Téllez Arévalo
- Department of Physiological Sciences, School of Medicine, Pontificia Universidad Javeriana, Carrera 7 No. 40–62, Bogotá 110231, Colombia
| | - Abraham Quaye
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Luis Carlos Rojas-Rodríguez
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Brian D. Poole
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Daniela Baracaldo-Santamaría
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
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Neuropsichiatric Manifestations of Systemic Lupus Erythematosus: Diagnosis and Treatment Approach. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2017-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Neuropsychiatric involvement in systemic lupus erythematosus includes heterogeneous manifestations involving both the central and peripheral nervous system. A major issue in clinical evaluation is the attribution of neuropsychiatric symptoms to systemic lupus erithematosus. Antiphospholipid antibodies, immune complex, microangiopathy, early and accelerated arteriosclerosis are factors that have the main role in pathogenesis of neuropsychiatric manifestations of systemic lupus erithematosus. There are no neurological symptoms specific to systemic lupus erithematosus, but they can also occur very commonly in the general population. Lesions of nervous system can be focal or diffuse and may be due to systemic lupus erithematosus itself (primary lesions), but it also may be caused by other diseases or disbalances. Therapy of the neuropsychiatric manifestations depends on the nature of the pathological process (dominant inflammation or thrombosis). If it is result of an inflammatory neurotoxic process and in the presence of an increased activity of systemic lupus erithematosus, therapy includes glycocorticoids independently or in combination with immunosuppressives. Focal neuropsychiatric syndrome with antiphospholipid antibodies positivity should be treated with anticoagulant and/or antiplatelet therapy. In addition, control of classical cardiovascular risk factors, stop smoking, and treatment with hydroxychloroquine is recommended.
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28
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Warchoł-Biedermann K, Mojs E, Sikorska D, Kotyla P, Teusz G, Samborski W. Psychological Implications to the Therapy of Systemic Lupus Erythematosus. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16021. [PMID: 36498095 PMCID: PMC9737561 DOI: 10.3390/ijerph192316021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/20/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic and multi-systemic autoimmune disease, which has a deleterious impact on patients' psychological well-being. This paper aims to review the existing literature on empirical research on psychological outcomes of SLE and psychological interventions to improve well-being in SLE patients. A search of significant English language articles was conducted in PubMed, Medline, ScienceDirect, Scopus, and ResearchGate databases. Titles and abstracts were screened for the relevant terms, including "systemic lupus erythematosus", "childhood-onset systemic lupus erythematosus", "juvenile systemic lupus erythematosus", "lupus nephritis", and their respective synonyms along with "depression", "anxiety", "fatigue", "medical adherence", "health-related quality of life", "self-management" or "intervention". The articles were evaluated by independent reviewers and the lists of eligible publications were compared whilst disagreements were settled by discussion. Of the 59 publications sought for retrieval, 35 papers were shortlisted based on predefined inclusion/exclusion criteria. They were classified according to their content and the methodology applied. Research topics including "anxiety and depression in SLE" and "self-management interventions for SLE patients" were identified and are presented in this review. As the prognosis and life expectancy of SLE patients are improving, further research on the psychological outcomes of SLE and the evidence-based psychological interventions to improve patients' well-being are justified.
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Affiliation(s)
| | - Ewa Mojs
- Department of Clinical Psychology, Poznan University of Medical Sciences, 60-812 Poznan, Poland
| | - Dorota Sikorska
- Department of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Sciences, 61-545 Poznan, Poland
| | - Przemysław Kotyla
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Medical University of Silesia Katowice, 40-635 Katowice, Poland
| | - Grażyna Teusz
- Faculty of Educational Studies, Adam Mickiewicz University, 61-712 Poznan, Poland
| | - Włodzimierz Samborski
- Department of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Sciences, 61-545 Poznan, Poland
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29
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Moore E, Huang MW, Reynolds CA, Macian F, Putterman C. Choroid Plexus-Infiltrating T Cells as Drivers of Murine Neuropsychiatric Lupus. Arthritis Rheumatol 2022; 74:1796-1807. [PMID: 35637551 PMCID: PMC9825865 DOI: 10.1002/art.42252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/02/2022] [Accepted: 05/24/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE T cells are critical in the pathogenesis of systemic lupus erythematosus (SLE) in that they secrete inflammatory cytokines, help autoantibody production, and form autoreactive memory T cells. Although the contribution of T cells to several forms of organ-mediated damage in SLE has been previously demonstrated, the role of T cells in neuropsychiatric SLE (NPSLE), which involves diffuse central nervous system manifestations and is observed in 20-40% of SLE patients, is not known. Therefore, we conducted this study to evaluate how behavioral deficits are altered after depletion or transfer of T cells, to directly assess the role of T cells in NPSLE. METHODS MRL/lpr mice, an NPSLE mouse model, were either systemically depleted of CD4+ T cells or intracerebroventricularly injected with choroid plexus (CP)-infiltrating T cells and subsequently evaluated for alterations in neuropsychiatric manifestations. Our study end points included evaluation of systemic disease and assessment of central nervous system changes. RESULTS Systemic depletion of CD4+ T cells ameliorated systemic disease and cognitive deficits. Intracerebroventricular injection of CP-infiltrating T cells exacerbated depressive-like behavior and worsened cognition in recipient mice compared with mice who received injection of splenic lupus T cells or phosphate buffered saline. Moreover, we observed enhanced activation in CP-infiltrating T cells when cocultured with brain lysate-pulsed dendritic cells in comparison to the activation levels observed in cocultures with splenic T cells. CONCLUSION T cells, and more specifically CP-infiltrating antigen-specific T cells, contributed to the pathogenesis of NPSLE in mice, indicating that, in the development of more targeted treatments for NPSLE, modulation of T cells may represent a potential therapeutic strategy.
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Affiliation(s)
- Erica Moore
- Department of Microbiology and Immunology, Division of RheumatologyAlbert Einstein College of MedicineNew York
| | - Michelle W. Huang
- Department of Microbiology and Immunology, Division of RheumatologyAlbert Einstein College of MedicineNew York
| | - Cara A. Reynolds
- Department of PathologyAlbert Einstein College of MedicineNew York
| | - Fernando Macian
- Department of PathologyAlbert Einstein College of MedicineNew York
| | - Chaim Putterman
- Azrieli Faculty of Medicine of Bar‐Ilan University, Safed, Israel, Galilee Research Institute, Nahariya, Israel, and Department of Microbiology and Immunology, Division of RheumatologyAlbert Einstein College of MedicineNew York
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Tanaka S, Kawaguchi T, Kudo R, Kimura M, Rikitake Y, Iwao C, Rikitake M, Iwao K, Aizawa A, Kariya Y, Matsuda M, Miyauchi S, Takajo I, Umekita K. Neuropsychiatric Systemic Lupus Erythematosus with Cerebral Vasculitis and Lupus Nephritis Successfully Treated with High-dose Glucocorticoids and Mycophenolate Mofetil. Intern Med 2022; 61:3131-3135. [PMID: 35283391 PMCID: PMC9646341 DOI: 10.2169/internalmedicine.9123-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) with cerebral vasculitis is rare, and its prognosis is unfavorable. High-dose glucocorticoids and cyclophosphamide are widely used for the treatment of NPSLE, but cyclophosphamide has a risk of cervical intraepithelial neoplasia and ovarian insufficiency, which may discourage its use in young women. We experienced a case of NPSLE with cerebral vasculitis and lupus nephritis that responded successfully to glucocorticoids and mycophenolate mofetil (MMF). MMF might be a treatment option for NPSLE without concern for reproductive toxicity. However, there are only a few reports on the efficacy of MMF in NPSLE, and further investigations are needed.
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Affiliation(s)
- Saki Tanaka
- Center for Post-Graduation Training, University of Miyazaki Hospital, Japan
| | - Takeshi Kawaguchi
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Risa Kudo
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Masatoshi Kimura
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Yuki Rikitake
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Chihiro Iwao
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Mao Rikitake
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Kosho Iwao
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Ayako Aizawa
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Yumi Kariya
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Motohiro Matsuda
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Shunichi Miyauchi
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Ichiro Takajo
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Kunihiko Umekita
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
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Schattner A. Unusual Presentations of Systemic Lupus Erythematosus: A Narrative Review. Am J Med 2022; 135:1178-1187. [PMID: 35671786 DOI: 10.1016/j.amjmed.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/01/2022] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by an almost 10:1 female predominance, the presence of deleterious nuclear autoantibodies, a tendency for flare, and striking protean manifestations. Early diagnosis is associated with less damage accrual, lower costs, and improved quality of life due to timely treatment. However, early disease may not uncommonly show nonspecific presentation, a single classification criterion, or an unusual organ involvement contributing to frequent, often substantial diagnostic delays. We reviewed the literature (1982-2022) to accumulate and classify all reports of rare, atypical, and unusual presentations. These can involve almost every organ and system, and thus, present to physicians in every discipline and setting. Increasing physicians' awareness of the potential of occult SLE to appear in varied, diverse, and unexpected presentations, may encourage the inclusion of SLE in the differential. Informed history and examination focusing on systemic and joint symptoms and mucocutaneous involvement, and basic tests (focusing on leukopenia, thrombocytopenia, and proteinuria; followed by antinuclear antibodies and complement levels) will correctly diagnose most patients on presentation or within the following months and enable timely treatment.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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Goodman BD, Al-Saghir T, Alles H, Youssef RM, Shaban H. Immunosuppressant Responsive Neuropsychiatric Systemic Lupus Erythematosus Manifestations Initially Diagnosed As Schizophrenia and Bipolar Disorder. Cureus 2022; 14:e29287. [PMID: 36277536 PMCID: PMC9580603 DOI: 10.7759/cureus.29287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2022] [Indexed: 11/30/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a well-documented multi-system autoimmune disease with increased frequency noted in younger females and among minority populations. Disease-defining signs and symptoms can vary widely and involve multiple organ systems including the nervous system. Involvement of the nervous system, known as neuropsychiatric SLE (NPSLE) can present as manifestations consistent with central nervous system or peripheral nervous system pathologies, with the former including presentations of psychiatric illnesses. This case report reviews a 21-year-old Black female’s presentation that was most notable for psychosis with other findings on examination and laboratory investigation resulting in a diagnosis of NPSLE. Our patient had a positive initial response to high-dose steroids with improvement of her psychosis and was planned for further treatment with the well-known chemotherapy and immunomodulatory agent, cyclophosphamide.
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Liu Y, Tu Z, Zhang X, Du K, Xie Z, Lin Z. Pathogenesis and treatment of neuropsychiatric systemic lupus erythematosus: A review. Front Cell Dev Biol 2022; 10:998328. [PMID: 36133921 PMCID: PMC9484581 DOI: 10.3389/fcell.2022.998328] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease with a complex pathogenesis. Neuropsychiatric systemic lupus erythematosus (NPSLE) is a serious complication of SLE that involves the nervous system and produces neurological or psychiatric symptoms. After decades of research, it is now believed that the diverse clinical manifestations of NPSLE are associated with intricate mechanisms, and that genetic factors, blood-brain barrier dysfunction, vascular lesions, multiple autoimmune antibodies, cytokines, and neuronal cell death may all contribute to the development of NPSLE. The complexity and diversity of NPSLE manifestations and the clinical overlap with other related neurological or psychiatric disorders make its accurate diagnosis difficult and time-consuming. Therefore, in this review, we describe the known pathogenesis and potential causative factors of NPSLE and briefly outline its treatment that may help in the diagnosis and treatment of NPSLE.
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Affiliation(s)
- Yuhong Liu
- Department of Rheumatology, Third Affifiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhihua Tu
- Department of Rheumatology, Panyu Hospital of Chinese Medicine, Guangzhou, China
| | - Xi Zhang
- Department of Rheumatology, Third Affifiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Keqian Du
- Department of Rheumatology, Third Affifiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhengquan Xie
- Department of Rheumatology, Panyu Hospital of Chinese Medicine, Guangzhou, China
- *Correspondence: Zhiming Lin, ; Zhengquan Xie,
| | - Zhiming Lin
- Department of Rheumatology, Third Affifiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zhiming Lin, ; Zhengquan Xie,
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Neuropsychiatric Lupus and Lupus Nephritis Successfully Treated with Combined IVIG and Rituximab: An Alternative to Standard of Care. Case Rep Rheumatol 2022; 2022:5899188. [PMID: 36071987 PMCID: PMC9441403 DOI: 10.1155/2022/5899188] [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: 04/25/2022] [Revised: 07/22/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with unpredictable course and flares. The clinical manifestation can vary from mild to severe and life-threatening disease. Infection is the primary cause of mortality in hospitalized SLE patients. There is a paucity of evidence to support the co-management of SLE with major organ involvement and sepsis. We describe the clinical response of a 35-year-old male diagnosed with SLE; then, he developed severe sepsis and a flare of SLE with major organ involvement including lupus nephritis (LN), myocarditis, and neuropsychiatric systemic lupus erythematosus (NPSLE). Based on the patient’s condition, a treatment dilemma was encountered, and after a multidisciplinary meeting, the decision was made to use a combination of rituximab (RTX), intravenous immunoglobulin (IVIG), and pulse steroid. Shortly, the patient’s condition started to improve, and his symptoms were resolved. In conclusion, our clinical case suggests that combined RTX, IVIG, and pulse steroid seem to be effective and safe in achieving clinical response, thus representing a good choice for managing severe SLE flares in sepsis.
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Dramatic Response of Lupus Enteritis, Nephritis, and Pancytopenia to Plasmapheresis and Rituximab. Case Rep Gastrointest Med 2022; 2022:3443141. [PMID: 35706566 PMCID: PMC9192312 DOI: 10.1155/2022/3443141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Background Although lupus enteritis is a rare manifestation of systemic lupus erythematosus yet results in significant distress. This disorder contributes to diagnostic and therapeutic dilemma leading to enhanced mortality. Case Description. We report a case history of a 29-year-old female who presented with severe abdominal pain, watery stools, and vomiting, and later on, she developed pancytopenia and renal impairment. On intensive workup, diagnosis of lupus-associated enteritis, nephritis, and pancytopenia was discovered. She improved drastically on initiation of plasmapheresis followed by low-dose intravenous rituximab. One year posttreatment, she remained in complete remission. Conclusion From this case, it can be suggested that in a young female with intractable abdominal pain, the remote possibility of lupus enteritis must be kept in mind. Besides this, plasmapheresis can have a potential role in refractory lupus enteritis. Furthermore, low-dose intravenous rituximab can be a safe and cost-effective treatment option in achieving sustained remission of clinical and laboratory parameters in lupus enteritis.
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Smith EMD, Egbivwie N, Jorgensen AL, Ciurtin C, Al-Abadi E, Armon K, Bailey K, Brennan M, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, Malik G, McLaren Z, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Wood F, Beresford MW, Hedrich CM. Real world treatment of juvenile-onset systemic lupus erythematosus: Data from the UK JSLE cohort study. Clin Immunol 2022; 239:109028. [PMID: 35513304 DOI: 10.1016/j.clim.2022.109028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the absence of clinical trials evidence, Juvenile-onset Systemic Lupus Erythematosus (JSLE) treatment plans vary. AIM To explore 'real world' treatment utilising longitudinal UK JSLE Cohort Study data. METHODS Data collected between 07/2009-05/2020 was used to explore the choice/sequence of immunomodulating drugs from diagnosis. Multivariate logistic regression determined how organ-domain involvement (pBILAG-2004) impacted treatment choice. RESULT 349 patients met inclusion criteria, median follow-up 4-years (IQR:2,6). Mycophenolate mofetil (MMF) was most commonly used for the majority of organ-domains, and significantly associated with renal involvement (OR:1.99, 95% CI:1.65-2.41, pc < 0.01). Analyses assessing the sequence of immunomodulators focused on 197/349 patients (meeting relevant inclusion/exclusion criteria). 10/197 (5%) solely recieved hydroxychloroquine/prednisolone, 62/197 (31%) received a single-immunomodulator, 69/197 (36%) received two, and 36/197 patients (28%) received ≥three immunomodulators. The most common first and second line immunomodulator was MMF. Rituximab was the most common third-line immunomodulator. CONCLUSIONS Most UK JSLE patients required ≥two immunomodulators, with MMF used most commonly.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK.
| | - Naomi Egbivwie
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK; Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | | | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Daniel P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Zoe McLaren
- Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Annie Ratcliffe
- Department of Paediatrics, Taunton & Somerset NHS Foundation Trust - Musgrove Park Hospital, Taunton, UK
| | - Phil Riley
- Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Arani Sridhar
- Leicester Children's Hospital, University Hospitals of Leicester NHS trust, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Fiona Wood
- Department of Paediatrics, University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
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Mrak D, Bonelli M, Radner H. Neuropsychiatric Systemic Lupus Erythematosus: a remaining challenge. Curr Pharm Des 2022; 28:881-891. [PMID: 35549864 DOI: 10.2174/1381612828666220512102824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/13/2022] [Indexed: 11/22/2022]
Abstract
Systemic Lupus Erythematosus (SLE) is an autoimmune disease, which affects a wide range of organs with variable clinical features. Involvement of the nervous system is a challenging and multifaceted manifestation of the disease, presenting with a broad range of symptoms. Neuropsychiatric lupus (NPSLE) encompasses seven syndromes of the peripheral and 12 of the central nervous system, associated with a high disease burden. Despite advances in the management of SLE, NP manifestations still pose a challenge to clinicians. First, diagnosis and attribution to SLE is difficult due to the lack of specific biomarkers or imaging modalities. Second, therapeutic options are limited, and evidence is mainly based on case reports and expert consensus, as clinical trials are sparse. Moreover, no validated outcome measure on disease activity exists. Current recommendations for treatment include supportive as well as immunosuppressive medication, depending on the type and severity of manifestations. As NPSLE manifestations are increasingly recognized, a broader spectrum of therapeutic options can be expected.
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Affiliation(s)
- Daniel Mrak
- Medical University of Vienna, Vienna, Austria
| | - Michael Bonelli
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Helga Radner
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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Ragab SM, Ibrahim AM. Neuropsychiatric lupus erythematosus in a cohort of Egyptian patients. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00464-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The neuropsychiatric lupus erythematosus (NPSLE) is a severe complication of systemic lupus erythematosus (SLE) that is characterized by a variety of neurological manifestations involving both central and peripheral nervous system with variable mechanisms. This study aimed to investigate the frequency of NPSLE and its relation to other clinical and laboratory findings in SLE patients.
Results
We retrieved the medical records of 134 SLE patients during the study period; of them, 68 patients (50.7%) had NPSLE. Headache (55. 9%) was the most frequent NPSLE manifestation followed by seizures (54.4%), psychosis was the third most frequent one with a percentage of 41.2. The demographic data didn’t differ in patients with and without NPSLE. NPSLE patients had lower complement 3 (C3) (p = 0.025) and C4 (p = 0.008) levels, more lupus anticoagulant level (p = 0.033) and more frequency of antiphospholipid syndrome (p = 0.030). There was no statistical difference regarding the drug intake or other laboratory findings. Disease activity and damage indices didn’t differ in both groups.
Conclusion
The prevalence of NPSLE in this study was 50.7%. Headache, seizures and psychosis were the most frequent neuropsychiatric manifestations in the studied patients. SLE patients with neuropsychiatric manifestations had lower complement levels, higher lupus anticoagulant antibodies and antiphospholipid syndrome.
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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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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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Choi S, Kim YS. Successful treatment with rituximab in a patient with lupus cerebritis and posterior reversible encephalopathy syndrome: a case report. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Neuropsychiatric systemic lupus erythematosus (NPSLE) has a diverse and broad spectrum of severity and prognosis, with some devastating manifestations. However, its diagnosis and treatment remain unclear and controversial. Case Report: A 19-year-old woman with SLE presented with fever, headache, quadriparesis, and tremor. Brain magnetic resonance imaging (MRI) showed sulcal enhancement in the cortical sulcus, and intravenous methylprednisolone (500 mg/day) and immunoglobulin (2 g/kg for 5 days) were started under the suspicion of aseptic lupus meningitis. However, the patient’s neurologic symptoms worsened; brain MRI showed a newly developed brain parenchymal lesion, suggesting lupus cerebritis and posterior reversible encephalopathy syndrome. Two cycles of rituximab (850 mg/day, 1-week interval) were administered for the treatment of refractory NPSLE. Her neurologic symptoms gradually improved after the second cycle, and she was discharged with minimal neurologic symptoms. Conclusion: Rituximab may be a therapeutic option for refractory lupus cerebritis. Further research is needed to accurately determine its efficacy.
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Bankole AA, Kazmi TR, Strazanac AR. Determination of the Risk Factors Contributing to the Development of Neuropsychiatric Lupus in a Systemic Lupus Erythematosus Cohort. Cureus 2021; 13:e20129. [PMID: 35003967 PMCID: PMC8723701 DOI: 10.7759/cureus.20129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/17/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a complex, varied clinical presentation that is both more common and has poor outcomes in women of color. SLE outcomes also seem to be influenced by socioeconomic factors. Neuropsychiatric lupus (NPL) is a common manifestation of SLE that is difficult to diagnose and treat and has poor clinical outcomes. There is no clear relationship between NPL and SLE-related autoantibodies, and this contributes to the difficulty in diagnosing NPL. As a result, NPL is a significant contributor to morbidity and mortality in patients with SLE. Objective The purpose of this study was to examine the relationship between serological and socioeconomic factors in the development of NPL in our patient cohort and determine the risk factors for the development of NPL. Methods This was an SLE single-center, retrospective chart review study that was performed at a university-based tertiary referral center. Patients aged 18 and older who meet the American College of Rheumatology (ACR) 1997 criteria and were seen between June 1st, 2015, and June 1st, 2019, were included in this study. Overall, 629 patients with SLE were identified, and 263 patients were included. Demographic and serological data were collected. Supplemental socioeconomic information for each zip code in Southwest Virginia was obtained from the United States Government Census website. Continuous variables were analyzed using the T-test or Mann-Whitney U test. Categorical variables were analyzed using chi-square tests or Fisher’s exact tests. Statistical analysis was performed using SAS9.4, and p-value < 0.05 was considered statistically significant. Results We reviewed a number of risk factors including age, sex, race, and median household income (MHI), noting no statistical relationship between these factors and the diagnosis of NPL. We did find that the presence of antiphospholipid antibodies (aPL) was significantly associated with a diagnosis of NPL and that complement 4 (C4) levels trended toward statistical significance. Conclusion In our cohort of patients, there was no relationship between age, sex, race, and median household income, and the diagnosis of NPL. There was a statistically significant relationship between aPL and the diagnosis of NPL. Other SLE-related antibodies showed no statistical relationship with the diagnosis of NPL. Although not statistically significant, there was a trend toward significance between complement 4 (C4) levels and the diagnosis of NPL.
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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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Sarwar S, Mohamed AS, Rogers S, Sarmast ST, Kataria S, Mohamed KH, Khalid MZ, Saeeduddin MO, Shiza ST, Ahmad S, Awais A, Singh R. Neuropsychiatric Systemic Lupus Erythematosus: A 2021 Update on Diagnosis, Management, and Current Challenges. Cureus 2021; 13:e17969. [PMID: 34667659 PMCID: PMC8516357 DOI: 10.7759/cureus.17969] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) experience neuropsychiatric symptoms. The term neuropsychiatric SLE (NPSLE) is a generic term that refers to a series of neurological and psychiatric symptoms directly related to SLE. In approximately 30% of patients with neuropsychiatric symptoms, SLE is the primary cause (NPSLE), and symptoms manifest more frequently around SLE onset. Neurovascular and psychotic conditions can also lead to NPSLE. Pathogenesis of NPSLE is implicated in both neuroinflammatory and ischemic mechanisms, and it is associated with high morbidity and mortality. After diagnosing and assigning causality, NPSLE treatment is individualized according to the type of neuropsychiatric manifestations, type of the predominant pathway, activity of SLE, and severity of the clinical manifestations. There are many problems to be addressed with regards to the diagnosis and management of NPSLE. Controlled clinical trials provide limited guidance for management, and observational cohort studies support symptomatic, antithrombotic, and immunosuppressive agents. The purpose of this review was to provide a detailed and critical review of the literature on the pathophysiology, diagnosis, and treatment of NPSLE. This study aimed to identify the shortcoming in diagnostic biomarkers, novel therapies against NPSLE, and additional research needs.
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Affiliation(s)
- Sobia Sarwar
- Neurology, Independent Medical College, Faisalabad, PAK
| | | | - Sylvette Rogers
- Family Medicine, Caribbean Medical University, Des Plaines, USA
| | - Shah T Sarmast
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Saurabh Kataria
- Neurology, Ochsner Louisiana State University Health Sciences Center - Shreveport, Shreveport, USA.,Neurology and Neurocritical Care, University of Missouri Health Care, Columbia, USA.,Neurology, West Virginia University, Morgantown, USA
| | - Khalid H Mohamed
- Anatomical Sciences, St. George's University - School of Medicine, St. George's, GRD
| | | | | | - Saher T Shiza
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Sarfaraz Ahmad
- Internal Medicine, Saint James School of Medicine, Chicago, USA
| | - Anum Awais
- Internal Medicine, Fatima Jinnah Medical University, Lahore, PAK
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Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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Cheng H, Zhao CS, Yan CL, Gao C, Wen HY. Efficacy of Belimumab for refractory systemic lupus erythematosus (SLE) involving the central nervous system. Eur J Intern Med 2021; 92:117-120. [PMID: 34226115 DOI: 10.1016/j.ejim.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Hao Cheng
- Department of Rheumatology, Shanxi Medical University, the Second Hospital of Shanxi Medical University, No.382 WuYi Road, Taiyuan, Shanxi province, China, 030001
| | - Chen-Sheng Zhao
- Department of Neurology, Shanxi Provincial Cardiovascular Hospital, No.18 Yifen Street, Taiyuan, Shanxi province, China, 030024
| | - Cheng-Lan Yan
- Department of Rheumatology, Shanxi Medical University, the Second Hospital of Shanxi Medical University, No.382 WuYi Road, Taiyuan, Shanxi province, China, 030001
| | - Chong Gao
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Hong-Yan Wen
- Department of Rheumatology, Shanxi Medical University, the Second Hospital of Shanxi Medical University, No.382 WuYi Road, Taiyuan, Shanxi province, China, 030001.
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Khalid MZ, Rogers S, Fatima A, Dawe M, Singh R. A Flare of Systemic Lupus Erythematosus Disease After COVID-19 Infection: A Case of Lupus Cerebritis. Cureus 2021; 13:e16104. [PMID: 34350072 PMCID: PMC8325872 DOI: 10.7759/cureus.16104] [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] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 01/10/2023] Open
Abstract
The association between coronavirus disease 19 (COVID-19) and autoimmune disease has been mounting, and literature on COVID-19-induced flare-up of systemic lupus erythematosus (SLE) disease is lacking. We describe a case of lupus cerebritis triggered by COVID-19 in a young female with SLE, who presented with fluctuated mentation, psychomotor retardation, slow speech, and intermittent choreiform movement in the upper part of the body. She had a history of COVID-19 infection three weeks back. Her serum immunoglobulin G antibodies were positive against COVID-19. On examination, she had psychomotor agitation, intermittent choreiform movements of upper limbs, and poor speech. Brain magnetic resonance imaging revealed hyperintense signals in the white matter of both hemispheres, suggestive of lupus cerebritis secondary to COVID-19 infection and lack of any other identifiable risk factor. Management included methylprednisolone, prednisone, and olanzapine. The patient was also placed on monthly intravenous cyclophosphamide, and her condition started improving gradually.
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Affiliation(s)
| | - Sylvette Rogers
- Family Medicine, Caribbean Medical University, Des Plaines, USA
| | - Ayesha Fatima
- Gynaecology & Obstetrics, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Manal Dawe
- Internal Medicine, Capital Medical University, Beijing, CHN
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Likhitweerawong N, Boonchooduang N, Morakote W, Louthrenoo O. Scurvy mimicking as systemic lupus erythematosus. BMJ Case Rep 2021; 14:14/6/e242958. [PMID: 34155029 DOI: 10.1136/bcr-2021-242958] [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] [Indexed: 11/04/2022] Open
Abstract
Scurvy is a disease caused by chronic vitamin C deficiency. The greater prevalence was found in the paediatric population with neurodevelopmental disorders such as autism spectrum disorders due to their restricted dietary intake. Our case reported a child with autism who presented with arthralgia and anaemia. Systemic lupus erythematosus was the first diagnostic impression, resulting in over investigation and delayed diagnosis of vitamin C deficiency. After the child was treated with ascorbic acid, the child's symptoms resolved. This case highlighted the importance of developmental and nutritional history taking in the paediatric population. Furthermore, parents and physicians should be concerned about nutritional status, especially in children with restrictive dietary intake.
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Affiliation(s)
| | | | - Wipawee Morakote
- Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Orawan Louthrenoo
- Paediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Temmoku J, Sato S, Matsumoto H, Fujita Y, Suzuki E, Yashiro-Furuya M, Matsuoka N, Asano T, Ito E, Nakatani-Enomoto S, Kobayashi H, Watanabe H, Hashimoto Y, Migita K. IgG4-Related Disease Complicated by Brain Parenchymal Lesions Successfully Treated with Corticosteroid Therapy: A Case Report. TOHOKU J EXP MED 2021; 251:161-168. [PMID: 32641642 DOI: 10.1620/tjem.251.161] [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] [Indexed: 11/18/2022]
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is distinguished by the infiltration of IgG4-positive plasma cells in a variety of tissues and organs including the pancreas, salivary glands, retroperitoneal lesions, kidney, and lymph nodes with elevated serum IgG4 levels. Even so, central nervous system (CNS) lesions such as brain parenchymal lesions associated with IgG4-RD are scarce. So far, only six cases of IgG4-RD in relation with brain parenchymal lesions have been described, with its characteristics still being not clear. Here we have detailed a case of IgG4-RD with brain parenchymal lesions and reviewed previously-reported cases of IgG4-RD with brain parenchymal lesions. A 62-year-old Japanese male suffering from lung silicosis was admitted to our hospital for abdominal discomfort and altered consciousness. He has shown no major neurologic abnormalities except for drowsiness, urinary retention, and fecal incontinence. Brain magnetic resonance imaging has shown scattered hyperintense signals in the brain parenchyma. The serum IgG4 levels were elevated and systemic lymph nodes were enlarged. Biopsy from inguinal lymph nodes has shown massive infiltration of IgG4-positive plasma cells: the ratio of IgG4-positive/IgG-positive plasma cells was nearly 100%. Based on clinical courses, images, laboratory data, and pathological findings, a diagnosis of IgG4-RD that was complicated by brain parenchymal lesions and sacral nerve disturbance was confirmed. The patient was then given methylprednisolone pulse therapy (1g for 3 days) succeeding oral prednisolone (1 mg per body weight). The clinical and radiological improvements together with steroid therapy proposed IgG4-RD to be the cause of the lesions.
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Affiliation(s)
- Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Erina Suzuki
- Department of Diagnostic Pathology, Fukushima Medical University School of Medicine
| | | | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Eiichi Ito
- Department of Neurology, Fukushima Medical University School of Medicine
| | | | - Hiroko Kobayashi
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Yuko Hashimoto
- Department of Diagnostic Pathology, Fukushima Medical University School of Medicine
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
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50
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Qiao X, Wang H, Lu L, Chen J, Cheng Q, Guo M, Hou Y, Dou H. Hippocampal microglia CD40 mediates NPSLE cognitive dysfunction in mice. J Neuroimmunol 2021; 357:577620. [PMID: 34062352 DOI: 10.1016/j.jneuroim.2021.577620] [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: 09/08/2020] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is the most serious and complicated clinical manifestation of lupus erythematosus. Cognitive dysfunction is the most common symptom of NPSLE. A variety of potential mechanisms or mediators related to the pathogenesis of NPSLE cognitive dysfunction have been proposed. However, the involvement of microglia CD40 has not been reported yet. This study aimed to investigate whether hippocampal microglia CD40 of MRL/MpJ-Faslpr (MRL/lpr) mice was involved in NPSLE cognitive dysfunction. This study found, using quantitative polymerase chain reaction, western blotting and immunohistochemistry, that hippocampal CD40 was aberrantly overexpressed in the MRL/lpr lupus mice. It also determined using flow cytometry and immunofluorescence that the aberrantly overexpressed CD40 was mainly derived from hippocampal microglia. The adeno-associated virus was used to inhibit microglia CD40 expression, and the brain damage and cognitive dysfunction of MRL/lpr mice improved. Also, imiquimod (IMQ)-induced lupus mice had the same NPSLE cognitive dysfunction, brain damage, and overexpressed hippocampal microglia CD40 as MRL/lpr mice. Therefore, IMQ-induced lupus mouse was proposed as one of the mouse models for studying NPSLE cognitive dysfunction for the first time in this study. The findings indicated that hippocampal microglia CD40 was involved in the development of NPSLE cognitive dysfunction, thus providing a novel research direction for the study of the pathogenesis of NPSLE.
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Affiliation(s)
- Xiaoyue Qiao
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China
| | - Hailin Wang
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China
| | - Li Lu
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China
| | - Jinglei Chen
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China
| | - Qinpei Cheng
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China
| | - Meng Guo
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China
| | - Yayi Hou
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China; Jiangsu Key Laboratory of Molecular Medicine, Nanjing University, Nanjing 210093, China.
| | - Huan Dou
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing 210093, China; Jiangsu Key Laboratory of Molecular Medicine, Nanjing University, Nanjing 210093, China.
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