Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 37-1988. A 35-year-old woman with recurrent strokes, an intracardiac lesion, anemia, and thrombocytopenia

False positive VDRL (BFP-STS) and systemic lupus erythematosus; new data in clinico-laboratory associations

AIM

To investigate the relationships between clinical features and serological parameters in systemic lupus erythematosus (SLE) patients with false positive venereal disease research laboratory (VDRL) test (BFP-STS) and those without.

METHODS

The records of 74 patients with SLE were reviewed. These were divided on the basis of the presence of a biologically false positive serological test (BFP-STS) (n = 18) or its absence (n = 56). The clinical features and serological parameters were subsequently evaluated in each group.

RESULTS

A biologically false positive serological test was found in 18 patients (24.5%). Clinically, they had a significantly higher frequency of malar rash (P < 0.02), hemolytic anaemia (P < 0.02) and SLE-related antiphospholipid (APL) syndrome (P < 0.02). Neuropsychiatric lupus was more frequent in the group without BFP-STS. Moreover, subacute cutaneous LE (SCLE), Raynaud's phenomenon, livedo reticularis (LR) and cardiopulmonary complications were present only in the latter group. There was no significant association between BFP-STS and other autoantibodies including Extractable nuclear antigen (ENAs), however, there was a significant association with C3 hypocomplementemia (P < 0.05). Half of the patients with BFP-STS were positive for anticardiolipin antibodies (aCL Abs) vs. 28% in the negative group (P = NS).

CONCLUSIONS

The study suggests that the clinical and serological relevance of BFP-STS in lupus patients may vary from those described in relation to other antiphospholipid determinants. Our patients appeared to have sparing of certain major organ systems, yet there was a greater tendency to developing Antiphospholipid (APL) syndrome and hemolytic anaemia.

Lupus nephritis in childhood and adolescence

Lupus nephritis in childhood usually presents after the age of 10 years, and presentation under 5 years is very rare. More males (F:M ratio 4.5:1) are affected than in adult-onset cases, but the ratio is the same in prepubertal and pubertal children. The incidence of clinically evident renal disease is greater at onset than in adults (82%), the usual presentation being with proteinuria, 50% having a nephrotic syndrome. Half the children show World Health Organisation class IV nephritis in renal biopsies. Neuropsychiatric lupus is present at onset in 30%, may complicate 50% at some point and remains a major problem. Prognosis has improved greatly over the past 30 years, at least in part the result of immunosuppressive treatment. Treatment of the initial phase may be guided by the severity of the renal biopsy appearances, more aggressive treatment including cytotoxic agents, i.v. methylprednisolone and perhaps plasma exchange, although the value of exchange is not established. Controversy persists as to the most effective cytotoxic treatment in the acute phase, both oral and i.v. cyclophosphamide and azathioprine being used in different units. In the chronic maintenance phase it seems established both clinically and histologically that addition of a cytotoxic agent improves outcome, but again the drug and route of administration are contentious. Azathioprine has the advantage of being safe for pregnancy and not gonadotoxic, whilst i.v. cyclophosphamide has been demonstrated to improve results over prednisolone alone in controlled trials and has advantages in non-compliant patients. No trial comparing the two regimes has been carried out, and one is needed. Today children much less commonly go into renal failure, and the main causes of actual death (15% of patients over 10 years) are now infections and extra-renal manifestations of lupus, principally neurological. Morbidity of the disease and the treatment remain a major problem, especially when treatment exacerbates complications of the disease itself, such as infections, osteonecrosis, thrombosis, vascular disease and possibly neoplasia.

Migraine and antiphospholipid antibodies

Antiphospholipid antibodies have been detected in patients with transient neurologic symptoms including migraine aura. The role of these antibodies in the pathogenesis of migraine is not fully understood. The available data suggest an association between the migraine-like phenomena and antiphospholipid antibodies, but not between migraine headache and antiphospholipid antibodies. To elucidate the actual role of antiphospholipid antibodies in migraine, prospective, controlled studies are needed.

Visual scotomata resulting from lupus anticoagulant in a patient with lymphoma in remission

Episodic cerebro or retinovascular ischemic events without apparent cause occur in patients with cancer. We report a patient in remission from lymphoma whose multiple episodes of presumed ocular ischemia occurred in the setting of a circulating lupus anticoagulant. Symptoms resolved following therapy with Warfarin.

Visual scotomata resulting from lupus anticoagulant in a patient with lymphoma in remission

Episodic cerebro or retinovascular ischemic events without apparent cause occur in patients with cancer. We report a patient in remission from lymphoma whose multiple episodes of presumed ocular ischemia occurred in the setting of a circulating lupus anticoagulant. Symptoms resolved following therapy with Warfarin.

Antiphospholipid antibodies

Lupus anticoagulants and anticardiolipin antibodies, known collectively as antiphospholipid antibodies, are becoming established as markers for increased risk of thrombosis, including ischemic cerebrovascular disease. In this brief review, we highlight evidence for and against a pathogenetic role of these antibodies in ischemic brain disease and comment on currently available laboratory studies to detect them. Future research on the association of antiphospholipid antibodies with neurological disease should focus on establishing the pathogenicity of these antibodies, identifying groups at high risk for recurrent ischemic cerebrovascular events, and initiating prospective multicenter natural history and treatment protocols.