Recent observations on central nervous system lupus erythematosus

Neurologic characteristics of childhood lupus erythematosus

Records of 108 patients with lupus erythematosus beginning in childhood (1953-1990) were reviewed; 25 had recorded neurologic findings. This is the largest group of childhood lupus erythematosus patients with neurologic disease that has been reported. The average age of children at the time of diagnosis of lupus was 154 months. There were 22 girls and 3 boys in the group. All patients met at least four of the 1982 American Rheumatism Association criteria for the classification of systemic lupus erythematosus. Average age at onset of neurologic difficulties was 168 months. In 4 patients, the neurologic symptoms preceded the diagnosis: 1 month (spastic diplegia), 1 month (bilateral weakness and spasticity), 24 months (chorea), and 26 months (chorea), respectively. Four patients had neurologic symptoms coincident with the diagnosis of lupus erythematosus. In those patients whose symptoms followed the diagnosis of lupus erythematosus, the average elapsed time until symptoms appeared was 33 months; the single lowest and highest outliers were discounted. Most frequent findings were headache (16/25) and behavioral aberrations (10/25). All behavioral manifestations were depression except in 1 patient. Other prevalent findings included hemichorea or chorea (7/25), cerebrovascular accident with hemiplegia or diplegia (7/25), seizures (5/25), visual loss (3/25), and cranial neuropathy (2/25). Vertigo and myelopathy occurred in 1 patient each. All patients were treated primarily with corticosteroids and azathioprine; in the presence of active disease, the drug dosages were increased with significant improvement in neurologic symptoms. Resolution usually occurred from days to months; most improved in a few days to a few weeks; 3-4 months was the longest period until symptoms subsided.

A neuropathological study of a case of lupus erythematosus with chorea

Neuropathological examination in a 48-year-women of SLE with chorea was performed. Histological examination of the putamen showed a widespread neuronal loss associated with reactive astrocyte proliferation and neuropil rarefaction at both sides. Disappearance of large neurons was more prominent than that of small ones. Although a few old and fresh microinfarcts were scattered in the same area, there was no significant pathological abnormality in small vessels. The caudate nuclei also showed a few irregular microinfarcts and spotty loss of neurons associated with reactive astrocytosis. These neuropathological changes might be related to the appearance of choreatic movement in patients with SLE.

Parkinson-like symptoms as a manifestation of systemic lupus erythematosus

A 42-year-old Japanese woman with systemic lupus erythematosus (SLE) developed Parkinsonian-like movements. Steroid pulse therapy was most effective and additional anti-Parkinsonian drugs were not required. Although psychosis, seizures and meningitis are common central nervous system (CNS) manifestations in SLE patients, Parkinsonian-like symptoms are extremely rare. The putative genesis and treatment of CNS lupus are discussed.

Stroke in systemic lupus erythematosus

We investigated the clinical and pathologic characteristics of stroke in 234 patients with systemic lupus erythematosus. Thirteen patients (5.6%) developed cerebrovascular disease. Cerebral infarction was noted in eight, cerebral hemorrhage in two, and subarachnoid hemorrhage in three. In seven (54%) of these 13 patients, stroke occurred less than or equal to 5 years after systemic lupus erythematosus was diagnosed. Among the predisposing risk factors for stroke, hypertension was the most important. Lupus anticoagulant was detected in three (38%) and anticardiolipin antibody in three (43% of seven investigated) of the patients with infarction. Evaluation of the clinical manifestations and autoantibodies indicated that renal involvement and high titers of anti-deoxyribonucleic acid antibody were more frequent in the stroke group than in the non-stroke group. Autopsy studies on six of the patients with stroke revealed small infarcts and hemorrhages in all, but in no case was true angiitis observed. Libman-Sacks endocarditis was found in two of the three patients with infarction. In conclusion, the important contributory factor to the development of stroke in patients with systemic lupus erythematosus is considered to be hypertension mediated by immunologic abnormalities. Antiphospholipid antibodies and Libman-Sacks endocarditis are closely associated with occlusive cerebrovascular disease.

Neuropsychiatric lupus erythematosus, cerebral infarctions, and anticardiolipin antibodies

Anticardiolipin antibody (aCL) has been associated with thromboembolic phenomena, including stroke, in certain patients with systemic lupus erythematosus (SLE); however, the relation between this antibody and the central nervous system manifestations of SLE is unknown. Serum samples and cerebrospinal fluid from five patients with SLE and acute central nervous system manifestations were assayed for the presence of aCL. Anticardiolipin antibody was identified in sera from four of the five patients but in none of the cerebrospinal fluid samples. Nuclear magnetic resonance imaging showed 'infarct-like' lesions in these four patients. This preliminary study suggests that a correlation between serum aCL and cerebral infarcts in central nervous system lupus may potentially exist. From this limited study it seems unlikely that aCL has a direct pathogenic role in the diffuse encephalopathy of acute central nervous system lupus.

Magnetic resonance and computed tomographic imaging in the evaluation of acute neuropsychiatric disease in systemic lupus erythematosus

Magnetic resonance (MR) imaging and computed tomography (CT) are useful for the evaluation of central nervous system (CNS) lupus. This report describes the use of cranial MR and CT in 21 patients with systemic lupus erythematosus (SLE) with acute neuropsychiatric symptoms manifested by headache, seizures, focal neurological deficits, psychosis, or organic brain syndrome. Computed tomography was found to be insensitive and detected only diffuse atrophy (two cases), cerebral infarct (one case), and intracerebral haemorrhage (one case) in the 21 patients. Cranial MR images obtained with a General Electric 1.5 tesla Signa unit detected labile and fixed areas of increased proton intensity interpreted as focal oedema (eight cases), infarct (10 cases), haemorrhage (one), atrophy (seven), and acute sinusitis (two). Focal oedema was characterised by labile, high intensity lesions in the gray or white matter of the cerebellum, cerebrum, or brain stem, which completely resolved after aggressive corticosteroid treatment. Most high intensity reversible or fixed lesions evident on MR were not apparent on cranial CT images. In several patients sequential MR images were valuable in monitoring the efforts of treatment. Although histological confirmation of the high intensity brain lesions apparent on MR is desirable, prior necropsy studies suggest that pathological confirmation may be difficult owing to the paucity of recognisable brain lesions in patients with CNS lupus. It is concluded that for the evaluation of acute neuropsychiatric SLE MR is useful and provides more information than cranial CT.

Frequency, etiology, and prevention of stroke in patients with systemic lupus erythematosus

We retrospectively and prospectively reviewed the incidence of stroke in 105 patients with systemic lupus erythematosus (SLE). Stroke occurred in 14 (15%) of 91 consecutive patients with documented SLE; nine (64%) of the 14 had multiple cerebral infarcts. Factors associated with stroke and the frequency of stroke were systemic thrombosis (30%), elevated partial thromboplastin time (36%), spontaneous abortion (50%), age over 60 years (57%), transient ischemic attacks (57%), previous stroke (64%), and cardiac valvular disease (86%). The major period of risk for the first stroke was during the first 5 years of SLE. The most frequent etiology was a cardiogenic embolus or an antibody-mediated hypercoagulable state, with cerebral vasculitis occurring only in association with infection. Because of the decreased fibrinolysis seen in patients with SLE, anticoagulant therapy may be the most effective preventive treatment currently available. Anticoagulant therapy seemed to prevent recurrent focal cerebral ischemia in our patients and was associated with relatively few and minor complications. Patients with a history of transient ischemic attacks or cardiac valvular lesions are at high (57% and 87%, respectively) risk of stroke. Patients who have had a stroke are at high (64%) risk for a recurrent stroke. Anticoagulant therapy is recommended for all of these patients.

Neuropsychological correlates of serum lymphocytotoxic antibodies in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by frequent neuropsychiatric (NP) manifestations. At least two different pathogenetic mechanisms have been proposed for NP-SLE, including vasculitis and antibodies against neuronal antigens, the latter as expressed by the presence of brain cross-reactive lymphocyte antibodies. We have previously reported a high prevalence of cognitive dysfunction in SLE which can remain subclinical and which cannot be accounted for on the basis of disease activity, general distress, or steroid medication. In the present study, we undertook the same extensive, standardized neuropsychological testing in 98 consecutive female SLE patients in order to evaluate central nervous system functioning in relation to serum lymphocyte antibodies which were measured at the time of neuropsychological testing by a microcytotoxicity test. A significant association was observed between the presence of serum lymphocytotoxic antibodies (LCA) and cognitive impairment in patients with SLE. The pattern of impairment which predominated in the LCA-positive patients involved deficits in anteriorly associated, primarily visuospatial functions. These findings support the hypothesis of localization of a particular antigen-antibody interaction in the brain in SLE, suggesting the existence of immunological control mechanisms for normal brain functioning.

Myelopathy in neonatal and infantile lupus erythematosus

Two children with lupus erythematosus and myelopathy were studied. The first child developed the neonatal lupus erythematosus syndrome associated with transplacentally acquired anti-Ro/SSA antibodies. The cutaneous manifestations of neonatal lupus erythematosus disappeared but a residual myelopathy was confirmed at 16 months of age. The second child developed cutaneous lupus erythematosus at 3 months of age associated with a total deficiency of the Clr component of complement. A myelopathy and mesangial glomerulonephritis developed at 2 years of age which required treatment with corticosteroids. These two children with CNS lupus erythematosus, one associated with transplacentally acquired antibodies and the other associated with a complement deficiency, may suggest an immune-mediated mechanism for the pathogenesis of myelopathy in childhood lupus erythematosus.

Migraine and the lupus anticoagulant. Case reports and review of the literature

Lupus anticoagulants (LA) are antiphospholipid serum immunoglobulins generally associated with autoimmune conditions, especially systemic lupus erythematosus (SLE). They have recently been linked to thrombotic events, including stroke. A possible association of migraine with LA is now forwarded with the presentation of two cases and a literature review. Our two patients, both in their forties, had migrainous phenomena without SLE or thrombotic events. Eight other cases were found in the literature, suggesting more than a chance association. Relevance to migraine pathophysiology is discussed and may come from the ability of the LA to alter prostaglandins and platelet activity and to interact with neuronal phospholipids. Further, larger studies are needed to support this association.

Recurrent transverse myelitis associated with collagen disease

A 43-year-old woman who had four recurrences of acute transverse myelitis (ATM) at the fifth thoracic vertebral level in 7 years is reported. Her haematological and immunological abnormalities included antibodies to DNA and nRNP and markedly reduced serum complement during the course of the disease. These findings suggest systemic lupus erythematosus although she had no symptoms other than those of ATM. Methylprednisolone and prednisolone were effective in treating the ATM.

Anaphylatoxin C5a modulation of an alpha-adrenergic receptor system in the rat hypothalamus

C5a anaphylatoxin injected via implanted cannulae into the perifornical region of the hypothalamus stimulated eating in sated rats. C5a also attenuated carbamyl choline-induced drinking, and carbamyl choline inhibited C5a-induced eating, a mutual inhibition characteristic of the adrenergic-cholinergic interactions at this site. The increased food intake induced by C5a was also reversed by phentolamine, an alpha-adrenergic antagonist. Granulocytes infiltrating as a result of C5a-mediated leukotaxis did not arrive at the site in time to influence C5a activity. We propose that C5a in some way activates an alpha-adrenergic receptor system in the hypothalamus, and that anaphylatoxins could mediate neuropsychiatric symptoms sometimes associated with immune complex diseases affecting the central nervous system.

Effect of immune complex-forming reactants on catecholamine-modulated behaviors in the rat hypothalamus

Injection of immune complex-forming reactants via implanted cannulae to the perifornical hypothalamus stimulated eating in sated rats and increased the eating response to exogenous norepinephrine (NE). Immune complex-induced eating was not seen after carbamyl choline injection, and immune complex treatment had no effect on water intake under any of the test conditions. The effects of immune complex activity occurred only 6 hours after administration, a time associated with heavy polymorphonuclear leukocyte infiltration of the cannula site. Immune complex activity mimics that following NE injection of this site. Because the immune complex-forming reactants are not specific to any neural antigen, we propose that their effects are indirectly mediated by anaphylatoxins produced by activation of the complement cascade.

Psychopharmacological activity of anaphylatoxin C3a in rat hypothalamus

C3a anaphylatoxin injected into the perifornical hypothalamic region of sated rats increased the eating response to norepinephrine and the drinking response to carbamyl choline but had no effect on food or water intake in sated, saline control animals. This potentiation of drug-stimulated intakes was reversible by intrahypothalamic injection of catecholamine receptor antagonists haloperidol and phentolamine. We propose that C3a acts as a catecholamine agonist in the central nervous system. The results suggest that C3a may play a role in mediating the neuropsychiatric manifestations associated with immune complex formation or deposition in the central nervous system.

Central nervous system involvement in childhood systemic lupus erythematosus

The records of 37 patients with systemic lupus erythematosus (SLE) followed at The Children's Hospital of Philadelphia between 1968 and 1978 were reviewed for evidence of central nervous system (CNS) involvement. Criteria for CNS involvement included evidence of organic brain syndrome, electroencephalographic abnormalities with symptoms referable to CNS, or objective neurologic signs. Sixteen of 37 children had CNS involvement (43%). Thirteen patients had CNS involvement at the onset of SLE. Three patients had late onset CNS manifestations 1 to 2 years after the diagnosis of SLE. The most frequently observed symptoms were headache, behavior disorder, lethargy, diplopia, blurred vision, memory alteration, dizziness, and alteration of consciousness. The most frequently observed neurologic signs were seizures, cranial nerve palsy, ataxia, papilledema, nystagmus, meningitis, tremor, rigidity, cortical blindness, and coma. Neuropsychiatric manifestations included organic brain syndrome, functional psychosis, and personality disorder. Laboratory tests showed elevated cerebrospinal fluid opening pressure and protein, negative cultures, and abnormal electroencephalograms and computerized axial tomography scans. Fourteen of 16 children with CNS manifestations are alive. Thirteen had a mean IQ of 89 by the Wechsler Intelligence Tests. Twelve are in educational programs. One required long-term psychiatric care. A residual neurologic abnormality, a seizure disorder, was present in 3. CNS involvement with SLE in children carries a favorable prognosis.

Neurological complications of connective tissue and other "collagen-vascular" diseases

A variety of neurological complications may occur in the various connective tissue and "collagen-vascular" diseases. Most of these complications are due to vasculitis affecting various sites in the central or peripheral nervous system. While the evidence for definitive vasculitis in SLE is not strong, small vessel damage usually is present in anatomic sites which correlate well with clinical features. Although patients with rheumatoid arthritis also may have vasculitis, neurological complications are usually related to nerve compression by rheumatoid nodules or the arthritic process itself. Considerable controversy exists regarding the accuracy of various diagnostic tests. While corticosteroids are the mainstay of therapy for these conditions, there are no definitive studies proving their efficacy.

Spinal cord involvement in systemic lupus erythematosus

A review is made of the literature on central nervous system involvement in systemic lupus erythematosus (CNS-SLE). Particular attention is focused on lupus myelopathy. Referring to two well-documented personal cases, the authors describe the characteristic multisystem involvement, protean clinical pattern, serum and cerebrospinal fluid changes, histoimmunologic findings, response to corticosteroids and immunosuppressive agents and some prognostic features.

Neuropsychiatric problems in mixed connective tissue disease

A group of 20 patients with mixed connective tissue disease, followed for up to five years, was found to have a 55 per cent incidence of neuropsychiatric problems. An aseptic meningitis-like syndrome was the most common presentation and was rapidly responsive to corticosteroid therapy. Other findings were psychosis, convulsions, peripheral neuropathy, trigeminal neuropathy and cerebellar ataxia. An abnormal cerebrospinal fluid was found in five patients; mild pleocytosis, an increased protein content and a first phase colloidal gold curve were the main abnormalities. These neuropsychiatric problems have not been a cause of mortality in this group of patients with mixed connective tissue disease.

Brain scan diagnosis of central nervous system involvement in systemic lupus erythematosus

Twenty-five patients with 29 episodes of active systemic lupus erythematosus with central nervous system involvement were studied according to a uniform protocol. Brain scans were found to be abnormal in all patients studied, and electroencephalograms were abnormal in 20/25 patients. Serial brain scanning was found to be useful in the diagnosis of exacerbations and the monitoring of corticosteroid dosage.

Correlation between anti-DNA antibody titre and psychiatric manifestations in systemic lupus erythematosus

A patient with systemic lupus erythematosus with predominant psychiatric involvement was followed during two psychotic exacerbations of her disease. A high correlation was found between disease activity and the titre of anti-DNA antibodies. Disease activity was preceded and accompanied by a high titre, while remission was associated with low titre. The significance of this correlation for the pathogenesis, diagnosis and managment of the psychiatric symptoms of systemic lupus erythematosus are discussed.