Neuropsychiatric Abnormalities in Systemic Lupus Erythematosus

Ocular findings in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease. Ocular complications occur in up to one-third of patients with SLE. The ocular findings may represent the initial manifestation of the disease and may lead to severe ocular morbidity and loss of vision. Early diagnosis and prompt management of patients with SLE are mandatory and require collaboration between the ophthalmologist and the rheumatologist.

DSM-III-R classification of psychiatric symptoms in systemic lupus erythematosus

DSM-III-R criteria applied in the evaluation of 88 systemic lupus erythematosus patients revealed a point prevalence rate of 18.2% for psychiatric disorders, the most common diagnosis being adjustment disorder (11.4%). No patients had disorders compatible with a functional psychosis. Psychiatric morbidity was not associated with increased disease activity, corticosteroid use, brain magnetic resonance imaging abnormalities, or electroencephalogram abnormalities. High scores on a life event scale were associated with psychiatric disorders, suggesting that psychosocial stress is etiologically important. Cognitive testing showed that poor performance on the Stroop Colour-Word Inference Test was associated with psychiatric disorders.

Antinuclear antibodies in psychiatric patients

To investigate whether unrecognized systemic lupus erythematosus (SLE) might occur more frequently among psychiatric patients than expected on clinical examination, sera of 100 patients from a psychiatric hospital were tested for the presence of antibodies against nuclear antigens (ANA) and antibodies against DNA. The occurrence of sera positive for ANA was compared with the test results of serum samples of 859 individuals randomly selected from the general population. Positive tests for ANA were found in 7% of the psychiatric patients and 4% of the individuals selected from the population. Antibodies against dsDNA were not found in sera of the psychiatric patients. After categorizing both groups for age and sex, no difference was found as for the frequency of ANA positive sera between both groups, indicating that on the basis of serology, no evidence exists that SLE might be underestimated among psychiatric patients.

Suicide in patients with systemic lupus erythematosus: a clinical analysis of seven suicidal patients

Despite many suicidal cases in patients with systemic lupus erythematosus (SLE), literature on this subject is lacking. To elucidate and prevent this phenomenon, we re-evaluated the clinical records of seven suicidal patients with SLE. Six patients had photosensitivity and insomnia. At the time of the suicide attempt, hypocomplementemia was observed in five of six patients. Diffuse slowing on electroencephalograms were observed in four of five patients. One patient successfully committed suicide while on no therapy while five patients made their attempts under the tapering courses of steroids. Five patients manifested psychoses whereas two patients displayed no psychotic findings. All patients attempted suicide shortly after admission (mean time 20 days). The subsequent courses of the survivors who received more medication were favorable. Therefore, it appears that disease activity was not fully controlled in these patients. Furthermore, signs of an imminent suicide attempt were missed in some cases. Psychosis, insomnia, history of photosensitivity, an incompletely controlled disease state, receiving tapering steroid dose, diffuse slowings on electroencephalograms and the presence of hypocomplementemia appeared to be risks for attempting suicide in SLE. We would recommend that such patients be under psychiatric care for at least 2 months to prevent suicide. When the patient is still psychotic or unstable, further medical care will be required.

Late-onset atypical psychosis: a case involving neuroleptic drug toxicity and autoimmune serological abnormalities

Serious or significant neuroleptic toxicity (Kurlan et al. 1984; Lazarus 1985; Levenson 1985; Pearlman 1986) may complicate the diagnosis and management of patients who develop acute medical problems while under treatment with neuroleptics (Levenson and Simpson 1986). We have found that in some cases it is difficult, if not impossible, to determine whether neuroleptics have contributed to the cause of an acute medical illness, or if the occurrence of acute medical problems precipitated the signs of neuroleptic toxicity by altering the disposition or the pharmacologic effects of the drugs.

Antibodies against central nervous system tissue (anti-CNS) detected by ELISA and western blotting: marker antibodies for neuropsychiatric manifestations in connective tissue diseases

Organ specific antibodies against epitopes of the central nervous system (CNS) tissue were detected by ELISA and Western blotting (WB) in sera from patients with ANA positive collagen disorders using a 100,000 g supernatant from beef or rat brain. The corresponding CNS-antigens consist of six major determinants at molecular weights 29, 48, 56, 68 kD and six minor determinants at 130, 110, 86, 60, 38, 34 kD. All except the 38 kD polypeptide were organ specific. Forty-six of 91 patients with ANA positive collagen disorders reacted with at least one of these determinants; 43 of them had cerebral symptoms in contrast to only three of the 43 anti-CNS negative patients. Sera from patients with other disorders did not react with these epitopes. We conclude that anti-CNS antibodies detected by Western blotting may be marker for neuropsychiatric manifestations in patients with collagen disorders.

Transverse myelitis occurring during pregnancy in a patient with systemic lupus erythematosus

Myelopathy is a well recognised but infrequent neurological manifestation of systemic lupus erythematosus (SLE). The case of a 27 year old woman with SLE of seven years' duration who developed a spastic paraparesis during her second pregnancy is reported. Magnetic resonance imaging did not show any intrinsic abnormality of the spinal cord. Anticardiolipin antibody was weakly positive and C4 was low. The patient responded dramatically to steroids.

Neuropathological features of a lupus-like disorder in autoimmune mice

Neurological syndromes are prominent in systemic lupus erythematosus, but the neuropathological and mechanisms resulting in neurological dysfunction are unknown. We report a neuropathological study of the central nervous system in female NZB/W F1 mice, an animal model of systemic lupus erythematous. NZB/W mice were studied at 3, 5, 8, 12, and 14 months of age, and 36-month-old female C57B16N/NIA mice were studied as aged controls. A lymphoproliferative process was identified in the central nervous system of 39% of 8- to 12-month-old and all 14-month-old NZB/W mice. Infiltrates of lymphocytes and plasma cells were seen in subarachnoid, choroid plexus interstitial, and Virchow-Robin spaces. Lymphoid cells occasionally infiltrated brain parenchyma or accumulated as nodular masses. Concomitant visceral lymphoid infiltration was noted in 14-month-old mice. Dense deposits were seen ultrastructurally in the basal lamina of brain parenchymal capillaries of 14-month-old NZB/W mice. These dense deposits were similar in appearance to immune complexes described in glomerular basal lamina, and appeared concomitantly with an advanced lupus-like glomerulopathy. Similar deposits were not observed in choroid plexus. The possible relevance of these neuropathological changes to human central nervous system lupus is discussed.

Systemic lupus erythematosus: important considerations in the adolescent

Systemic Lupus Erythematosus (SLE) may be particularly devastating to the adolescent female because of the marked changes in appearance which may result from the disease and by its treatment. Attention is drawn to the potential of the patient manipulating her medications in response to these changes. Other special considerations include the unique side-effects of corticosteroid and antimalarial drugs, the need to distinguish psychological reactions to SLE from true organic involvement and an added risk for a flare of disease activity in the sexually active patient. A case of a teenage female with SLE is used to illustrate some of the management problems which may be encountered.

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.

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.

Systemic lupus erythematosus. A prospective analysis

The spectrum of organ involvement in 50 patients with systemic lupus erythematosus has been assessed in a prospective study. All patients were admitted to hospital electively for 2 days and a complete clinical and laboratory assessment protocol completed. Subsequent hospital admissions depended on clinical status. The overall mean observation period was 29 months. Widespread multisystem involvement was found in every patient. Subclinical abnormalities of respiratory and cerebral function were common even in patients in clinical remission. A more conservative approach than has been generally recommended was used for the management of systemic lupus erythematosus and is supported by the estimated 5-year survival of 98%.