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Valdés Cabrera D, El Tal T, Mohamed I, Arciniegas SE, Fevrier S, Ledochowski J, Knight AM. Effects of systemic lupus erythematosus on the brain: a systematic review of structural MRI findings and their relationships with cognitive dysfunction. Lupus Sci Med 2024; 11:e001214. [PMID: 39153821 PMCID: PMC11332008 DOI: 10.1136/lupus-2024-001214] [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: 03/28/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Cognitive dysfunction (CD) is highly prevalent in systemic lupus erythematosus (SLE), yet the underlying mechanisms are poorly understood. Neuroimaging utilising advanced MRI metrics may yield mechanistic insights. We conducted a systematic review of neuroimaging studies to investigate the relationship between structural and diffusion MRI metrics and CD in SLE. METHODS We systematically searched several databases between January 2000 and October 2023 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Retrospective and prospective studies were screened for search criteria keywords (including structural or diffusion MRI, cognitive function and SLE) to identify peer-reviewed articles reporting advanced structural MRI metrics and evaluating CD in human patients with SLE. RESULTS Eighteen studies (8 structural MRI, 9 diffusion MRI and 1 with both modalities) were included; sample sizes ranged from 11 to 120 participants with SLE. Neurocognitive assessments and neuroimaging techniques, parameters and processing differed across articles. The most frequently affected cognitive domains were memory, psychomotor speed and attention; while abnormal structural and/or diffusion MRI metrics were found more consistently in the hippocampus, corpus callosum and frontal cortex of patients with SLE, with and without clinically diagnosed central nervous system involvement. CONCLUSION Advanced structural MRI analysis can identify total and regional brain abnormalities associated with CD in patients with SLE, with potential to enhance clinical assessment. Future collaborative, longitudinal studies of neuroimaging in SLE are needed to better characterise CD, with focus on harmonised neurocognitive assessments, neuroimaging acquisitions and postprocessing analyses and improved clinical characterisation of SLE cohorts.
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Affiliation(s)
- Diana Valdés Cabrera
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tala El Tal
- Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ibrahim Mohamed
- Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Stephanie Fevrier
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Andrea M Knight
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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2
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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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Vahedi M, Nejad Shahrokh Abadi R, Malek A, Toosi FS, Naseri M, Hashemi N. Rapidly progressing pediatric Lupus with Diffuse Alveolar Hemorrhage and CNS involvement. Clin Case Rep 2024; 12:e9106. [PMID: 38947540 PMCID: PMC11211088 DOI: 10.1002/ccr3.9106] [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: 04/26/2024] [Revised: 06/02/2024] [Accepted: 06/05/2024] [Indexed: 07/02/2024] Open
Abstract
Key Clinical Message Systemic Lupus Erythematosus (SLE) can have an insidious onset and a fatal prognosis in children. Patients presenting without typical signs of SLE should undergo further evaluation if they are not responding to the initial diagnosis and treatment. This is especially true for patients with rapidly progressing symptoms and deterioration in spite of treatment. Abstract Pediatric Systemic Lupus Erythematosus is a chronic autoimmune disorder with various organ involvement pulmonary involvement in the course of this disorder is a rare yet potentially life-threatening complication. In this case report we highlight the findings of a 16-year-old girl acutely and initially presenting with cough and fever, eventually complicating to diffuse alveolar hemorrhage and gradual loss of consciousness. Although the patient was started on immunosuppressive treatment after the diagnosis of lupus, based on renal and hematological impairment, was made and initially responded, she eventually deteriorated.
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Affiliation(s)
- Mahdieh Vahedi
- Department of Pediatrics, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
- Clinical Research Development Unit of Akbar Hospital, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Reza Nejad Shahrokh Abadi
- Clinical Research Development UnitGhaem Hospital, Faculty of Medicine, Mashhad University of Medical SciencesMashhadIran
| | - Abdolreza Malek
- Department of Pediatrics, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
- Clinical Research Development Unit of Akbar Hospital, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Farrokh Seilanian Toosi
- Department of Radiology, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Maryam Naseri
- Department of Pediatrics, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Narges Hashemi
- Department of Pediatrics, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
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4
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der Heijden HV, Rameh V, Golden E, Ronen I, Sundel RP, Knight A, Chang JC, Upadhyay J. Implications of Inflammatory Processes on a Developing Central Nervous System in Childhood-Onset Systemic Lupus Erythematosus. Arthritis Rheumatol 2024; 76:332-344. [PMID: 37901986 PMCID: PMC10922196 DOI: 10.1002/art.42736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/20/2023] [Accepted: 10/25/2023] [Indexed: 10/31/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is increasingly affecting pediatric and adult populations. Neuropsychiatric manifestations (ie, cognitive dysfunction and mood disorders) appear to occur with greater severity and poorer prognosis in childhood-onset SLE (cSLE) versus adult-onset SLE, negatively impacting school function, self-management, and psychosocial health, as well as lifelong health-related quality of life. In this review, we describe pathogenic mechanisms active in cSLE, such as maladaptive inflammatory processes and ischemia, which are hypothesized to underpin central phenotypes in patients with cSLE, and the role of alterations in protective central nervous system (CNS) barriers (ie, the blood-brain barrier) are also discussed. Recent findings derived from novel neuroimaging approaches are highlighted because the methods employed in these studies hold potential for identifying CNS abnormalities that would otherwise remain undetected with conventional multiple resonance imaging studies (eg, T2-weighted or fluid-attenuated inversion recovery sequences). Furthermore, we propose that a more robust presentation of neuropsychiatric symptoms in cSLE is in part due to the harmful impact of a chronic inflammatory insult on a developing CNS. Although the immature status of the CNS may leave patients with cSLE more vulnerable to harboring neuropsychiatric manifestations, the same property may represent a greater urgency to reverse the maladaptive effects associated with a proneuroinflammatory state, provided that effective diagnostic tools and treatment strategies are available. Finally, considering the crosstalk among the CNS and other organ systems affected in cSLE, we postulate that a finer understanding of this interconnectivity and its role in the clinical presentation in cSLE is warranted.
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Affiliation(s)
- Hanne Van der Heijden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
- Faculty of Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Vanessa Rameh
- Division of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Emma Golden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Itamar Ronen
- Clinical Imaging Science Center, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Andrea Knight
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Joyce C. Chang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Jaymin Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA USA
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5
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Nikolaidou A, Beis I, Dragoumi P, Zafeiriou D. Neuropsychiatric manifestations associated with Juvenile Systemic Lupus Erythematosus: An overview focusing on early diagnosis. Brain Dev 2024; 46:125-134. [PMID: 38061949 DOI: 10.1016/j.braindev.2023.11.008] [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: 07/02/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 02/17/2024]
Abstract
Juvenile systemic lupus erythematosus (jSLE) is a chronic multisystem inflammatory disease that manifests before the age of 16 years, following a remitting - relapsing course. The clinical presentation in children is multifaceted, most commonly including constitutional, hematological, cutaneous, renal, and neuropsychiatric symptoms. Neuropsychiatric manifestations range widely, affecting approximately 14-95 % of jSLE patients. They are associated with high morbidity and mortality, particularly at a younger age. Headaches, seizures, cognitive dysfunction, and mood disorders are the most frequent neuropsychiatric manifestations. The pathophysiological mechanism is quite complex and has not yet been fully investigated, with autoantibodies being the focus of research. The diagnosis of neuropsychiatric jSLE remains challenging and exclusionary. In this article we review the clinical neuropsychiatric manifestations associated with jSLE with the aim that early diagnosis and prompt treatment is achieved in children and adolescents with the disease.
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Affiliation(s)
- Anna Nikolaidou
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Beis
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
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Tamanini JVG, Sabino JV, Cordeiro RA, Mizubuti V, Villarinho LDL, Duarte JÁ, Pereira FV, Appenzeller S, Damasceno A, Reis F. The Role of MRI in Differentiating Demyelinating and Inflammatory (not Infectious) Myelopathies. Semin Ultrasound CT MR 2023; 44:469-488. [PMID: 37555683 DOI: 10.1053/j.sult.2023.03.017] [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: 04/09/2023]
Abstract
Demyelinating and inflammatory myelopathies represent a group of diseases with characteristic patterns in neuroimaging and several differential diagnoses. The main imaging patterns of demyelinating myelopathies (multiple sclerosis, neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, and myelin oligodendrocyte glycoprotein antibody-related disorder) and inflammatory myelopathies (systemic lupus erythematosus-myelitis, sarcoidosis-myelitis, Sjögren-myelitis, and Behçet's-myelitis) will be discussed in this article, highlighting key points to the differential diagnosis.
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Affiliation(s)
| | - João Vitor Sabino
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Rafael Alves Cordeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Sao Paulo University, SP, Brazil
| | - Vanessa Mizubuti
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - Juliana Ávila Duarte
- Department of Radiology and Diagnostic Imaging, HCPA, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernanda Veloso Pereira
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Alfredo Damasceno
- Department of Neurology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fabiano Reis
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
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7
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Chandwar K, Aggarwal A. Systemic Lupus Erythematosus in Children. Indian J Pediatr 2023:10.1007/s12098-023-04833-0. [PMID: 37713101 DOI: 10.1007/s12098-023-04833-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease, that mainly affects skin, joints and kidneys but can affect any organ in the body. It is characterized by presence of multiple autoantibodies like ANA, antibodies to dsDNA and RNA associated proteins. The major mechanism leading to tissue damage includes immune complex mediated complement activation, interferon alpha release by plasmacytoid dendritic cells, NETosis by neutrophils as well as defects in monocytes leading to poor clearance of cellular debris and direct cellular dysfunction mediated by antibodies. A child can present with pyrexia of unknown origin, immune mediated cytopenias, malar rash, oral ulcers, serositis, glomerulonephritis or nervous system dysfunction. As renal disease has a bearing on the long term impact, all children should have urine exam and blood pressure measurement done to rule out renal disease. The treatment varies depending on the severity and organs involved. In life or organ threatening situations, pulse methylprednisolone is used. Hydroxychloroquine, Mycophenolate mofetil, Azathioprine and Cyclophosphamide are the commonly used drugs in SLE. Over the years the prognosis of SLE has improved probably due to early diagnosis and better use of immunosuppressive treatment, regular follow up and treatment of co-morbidities. The 10-year survival now approaches 90% and with advent of new and targeted therapy it is hoped that the morbidity and organ damage can also be minimized.
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Affiliation(s)
- Kunal Chandwar
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, Uttar Pradesh, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, Uttar Pradesh, India.
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8
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Natoli V, Charras A, Hahn G, Hedrich CM. Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus (jSLE). Mol Cell Pediatr 2023; 10:5. [PMID: 37556020 PMCID: PMC10412509 DOI: 10.1186/s40348-023-00161-7] [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: 04/27/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a rare autoimmune/inflammatory disease with significant morbidity and mortality. Approximately 15-20% of SLE patients develop the disease during childhood or adolescence (juvenile-onset SLE/jSLE). Patients with jSLE exhibit more variable and severe disease when compared to patients with disease-onset during adulthood. Neuropsychiatric (NP) involvement is a clinically heterogenous and potentially severe complication. Published reports on the incidence and prevalence of NP-jSLE are scarce, and the exact pathophysiology is poorly understood.This manuscript provides a review of the existing literature, suggesting NP involvement in 13.5-51% of jSLE patients. Among patients with NP-jSLE affecting the CNS, we propose two main subgroups: (i) a chronic progressive, predominantly type 1 interferon-driven form that poorly responds to currently used treatments, and (ii) an acutely aggressive form that usually presents early during the disease that may be primarily mediated by auto-reactive effector lymphocytes. While this hypothesis requires to be tested in large collaborative international cohort studies, it may offer future patient stratification and individualised care.
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Affiliation(s)
- Valentina Natoli
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università degli Studi di Genova, Genoa, Italy
| | - Amandine Charras
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gabriele Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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9
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Hauptman AJ, Ferrafiat V. Neuroinflammatory syndromes in children. Curr Opin Psychiatry 2023; 36:87-95. [PMID: 36705007 DOI: 10.1097/yco.0000000000000846] [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] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Neuropsychiatric symptoms due to paediatric neuroinflammatory diseases are increasingly recognized and reported. Psychiatrists are crucial in front-lines identification, diagnosis and care of individuals with disorders such as autoimmune encephalitis and management of long-term neurobehavioral sequelae. This review summarizes recent literature on autoimmune and post-infectious encephalitis, discusses special considerations in children with neurodevelopmental conditions and presents a paradigm for evaluation and management. RECENT FINDINGS There is a growing body of evidence on neuropsychiatric symptom burdens of paediatric neuroinflammatory diseases. A particular development is the evolution of diagnostic and treatment guidelines for conditions such as autoimmune encephalitis, which take into account phenotypes of acute, short-term and long-term sequelae. Interest in inflammatory sequelae of viral illness, such as SARS-CoV-2, in children remains in early development. SUMMARY Neuroimmunological disease data are constantly evolving. New recommendations exist for multiple common neuroimmunological disorders with behavioural, emotional, cognitive and neurological sequelae. Anti-NMDA receptor encephalitis now has well-recognized patterns of symptom semiology, diagnostic and treatment recommendations, and outcome patterns. Recognizing psychiatric symptoms heralding autoimmune brain disease and understanding neuropsychiatric sequelae are now a crucial skill set for paediatric psychiatrists. Exploration of inflammatory features of other diseases, such as genetic syndromes, is a burgeoning research area.
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Affiliation(s)
- Aaron J Hauptman
- Kennedy Krieger Institute
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Vladimir Ferrafiat
- Reference Center for Inborn Errors of Metabolism
- Reference Center for Intellectual Disabilities of Rare Causes, La Timone University Hospital, Assistance Publique - Hopitaux de Marseille, Marseille, France
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