Moderate and severe neutropenia in patients with systemic lupus erythematosus

The prevalence of neutropenia and association with infections in patients with systemic lupus erythematosus: a Swedish single-center study conducted over 14 years

Hematologic abnormalities are common manifestations of SLE, although neutropenia is observed less frequently and is not included in the classification criteria. Nonetheless, neutropenia is a risk factor for infections, especially those caused by bacteria or fungi. We aimed to evaluate the impact of neutropenia in SLE through a systematic investigation of all infections in a large cohort of well-characterized patients, focusing on neutropenia, lymphopenia, and hypocomplementemia. Longitudinal clinical and laboratory parameters obtained at visits to the Rheumatology Unit, Linköping University Hospital, and linked data on all forms of healthcare utilization for all the subjects included in our regional SLE register during 2008-2022 were assessed. Data regarding confirmed infections were retrieved from the medical records. Overall, 333 patients were included and monitored during 3,088 visits to a rheumatologist during the study period. In total, 918 infections were identified, and 94 occasions of neutropenia (ANC < 1.5 × 109/L) were detected in 40 subjects (12%). Thirty neutropenic episodes in 15 patients occurred in association with infections, of which 13 (43%) required in-hospital care, 4 (13%) needed intensive care, and 1 (3%) resulted in death. Bayesian analysis showed that patients with ≥ 1 occasion of neutropenia were more likely to experience one or more infections (OR = 2.05; probability of association [POA] = 96%). Both invasiveness (OR = 7.08; POA = 98%) and severity (OR = 2.85; POA = 96%) of the infections were significantly associated with the present neutropenia. Infections are common among Swedish SLE patients, 12% of whom show neutropenia over time. Importantly, neutropenia is linked to both the invasiveness and severity of infections. Awareness of the risks of severe infections in neutropenic patients is crucial to tailor therapies to prevent severe illness and death.

Disease duration and herpes zoster infection related to neutropenia in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease involving several organs. Neutropenia in patients with SLE may be a factor associated with infection leading to higher morbidity and mortality. There are several inconsistent predictors of neutropenia in patients with SLE. The present study is a retrospective, analytical study, which aimed to identify other predictors of neutropenia in patients with SLE. Patients with SLE who had been regularly followed up for ≥1 year were included in this study. Clinical factors, including history of disease, comorbidities, previous infection, laboratory results and treatment, were collected. The primary analyzed indicator was the occurrence of neutropenia. Factors associated with neutropenia were calculated by multivariate logistic regression analysis. A total of 84 patients met the study criteria. Of those 84 patients, 36 (42.86%) developed neutropenia. There were seven factors placed in the predictive model for neutropenia. Two factors were independently associated with the presence of neutropenia: Disease duration and herpes zoster infection. The first factor was negatively related with neutropenia with an adjusted odds ratio of 0.70 (95% confidence interval, 0.54, 0.92), whereas herpes zoster infection was an independent risk factor for neutropenia with an adjusted odds ratio of 8.46 (95% confidence interval, 1.30, 54.80). In conclusion, the present study revealed that short duration of disease and herpes zoster infection are predictors of neutropenia in patients with SLE.

A Practical Perspective of the Hematologic Manifestations of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with an unknown etiology that can affect any organ or system of the human body. Hematological, renal, or central nervous system manifestations in these patients result in great morbidity because high doses of glucocorticoids, cytotoxic medications, or biological drugs are required to control these manifestations. It is noteworthy that hematological involvement predominates during the first years of the disease and tends to last over time, with the premise that it may be the initial manifestation of the disease. Clear examples of this are the cases of hemolytic anemia and immune thrombocytopenia that can be initially classified as idiopathic or primary to be later classified as secondary when associated with infections, medications, neoplasms, or autoimmune diseases. The spectrum of hematologic manifestations in SLE is very broad, including lymphopenia, anemia, thrombocytopenia, or pancytopenia. In some cases, lymphadenopathy and splenomegaly are also identified. The vast majority of these manifestations denote high disease activity. However, many of these alterations have a multifactorial cause that must be taken into account to adopt a more complete therapeutic approach. The objective of this review is to characterize in detail the hematological manifestations of SLE to offer clinicians a practical vision of its diagnosis and treatment.

The Clinical Characteristics of Leukopenia in Patients with Systemic Lupus Erythematosus of Han Ethnicity in China: A Cross-Sectional Study

Introduction

The characteristics of leukopenia in patients with systemic lupus erythematosus (SLE) in different studies are different, which may be related to region, race, and sample size. Moreover, the extent of leukocyte count decline remains to be studied. This study aimed to analyze the clinical characteristics of leukopenia in patients with SLE of Han ethnicity in China.

Methods

A single-center, retrospective, cross-sectional study was conducted in Chinese Han patients with SLE from June 2013 to August 2020.

Results

A total of 125 patients with SLE were included in the study, and 104 age- and sex-matched healthy controls were recruited. The prevalence of leukopenia, neutropenia, and lymphopenia was 40.0, 20.8, and 55.2%, respectively. The median leukocyte count in the leukopenia group was 2.80 × 10⁹/l, the median neutrophil count in the neutropenia group was 1.40 × 10⁹/l, and the median lymphocyte count in the lymphopenia group was 0.60 × 10⁹/l, which was 47.06, 40.58, and 30.00% of the median of the healthy control group, respectively. The lymphocyte count of SLE patients without lymphopenia was also lower than that of healthy controls, and the lymphocyte count was negatively correlated with the SLE disease activity index 2000 score in all patients with SLE. Independent risk factors for neutropenia include decreased platelet count and lymphocyte count, as well as the presentation of cylindruria. For lymphopenia, the independent risk factors were positivity for anti-dsDNA antibody and Coombs’ test, decreased platelet count, and cylindruria.

Conclusions

In Han Chinese patients with SLE, leukopenia, neutropenia, and lymphopenia are common clinical manifestations, and the degree of reduction in blood cell count was also remarkable. Lymphopenia is associated with disease severity in patients with SLE. The correlation between Coombs’ test results and lymphopenia deserves further study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00336-6.

Misunderstandings Between Platelets and Neutrophils Build in Chronic Inflammation

Regulated hemostasis, inflammation and innate immunity entail extensive interactions between platelets and neutrophils. Under physiological conditions, vascular inflammation offers a template for the establishment of effective intravascular immunity, with platelets providing neutrophils with an array of signals that increase their activation threshold, thus limiting collateral damage to tissues and promoting termination of the inflammatory response. By contrast, persistent systemic inflammation as observed in immune-mediated diseases, such as systemic vasculitides, systemic sclerosis, systemic lupus erythematosus or rheumatoid arthritis is characterized by platelet and neutrophil reciprocal activation, which ultimately culminates in the generation of thrombo-inflammatory lesions, fostering vascular injury and organ damage. Here, we discuss recent evidence regarding the multifaceted aspects of platelet-neutrophil interactions from bone marrow precursors to shed microparticles. Moreover, we analyse shared and disease-specific events due to an aberrant deployment of these interactions in human diseases. To restore communications between the pillars of the immune-hemostatic continuum constitutes a fascinating challenge for the near future.

Lymphopenia and neutropenia are associated with subsequent incident proteinuria in Danish patients with systemic lupus erythematosus

Objective: The aim of this study was to investigate whether incident proteinuria in patients with systemic lupus erythematosus (SLE) was preceded by changes in blood lymphocytes and neutrophil counts and/or neutrophil-lymphocyte ratio (NLR).Method: SLE patients with no proteinuria before or at the time of classification were included. Longitudinal data on SLE manifestations, vital status, and SLE-associated medications were collected during clinical visits and chart review. Laboratory data were collected through a nationwide database. Lymphopenia, severe lymphopenia, and neutropenia were defined as values below 0.8 × 10⁹, 0.5 × 10⁹, and 2.0 × 10⁹ cells/L, respectively. High NLR was defined as values above the median. Proteinuria was defined by at least two measurements of elevated urine protein excretion (> 0.5 g/day). Hazard ratios (HRs) were calculated by Cox modelling using time-dependent continuous and binary covariates based on multiple laboratory measurements adjusted for use of immunosuppressants.Results: In total, 260 SLE patients were available for the analysis, of whom 30 (12%) developed incident proteinuria following the diagnosis of SLE. Median follow-up time was 73.5 months. Lymphocyte and neutrophil counts, but not NLR, were associated with incident proteinuria. HRs for incident proteinuria were 2.71 for lymphopenia [95% confidence interval (CI) 1.20-6.11], 4.73 for severe lymphopenia (95% CI 1.93-11.59), and 2.54 for neutropenia (95% CI 1.14-5.65).Conclusion: Lymphopenia and neutropenia predicted the risk of first-time proteinuria independently of immunosuppressants.

Immunological and Clinical Characteristics of Systemic Lupus Erythematosus: A Series from Morocco

Systemic Lupus Erythematosus (SLE) is a complex autoimmune disease with a high female predominance. To date, studies about SLE in Morocco are few. This retrospective study describes the clinical and immunological features in a series of 50 SLE Moroccan patients in University Hospital Center of Rabat, Morocco, between December 2011 and December 2013. All patients were screened for antinuclear antibodies (ANA) and anti-DNA antibodies by indirect immunofluorescence, followed by identification of anti-extractable nuclear antigen antibodies by ELISA. The female to male ratio was 6.1:1. Mean age was 31.72 years. The main clinical manifestations were arthritis (82%), mucocutaneous manifestations (80%), renal manifestations (50%), and hematological features (46%). Of the mucocutaneous features, the highest frequencies were observed in the malar rash (68%) and photosensitivity (60%). Of the hematological features, lymphopenia was most frequently observed in 30% of patients, followed by hemolytic anemia in 16% and leucopenia and thrombocytopenia in 8%. Central nervous system was involved in 10%. ANA were found in 88%, anti-DNA antibodies in 56%, and anti-Sm antibodies in 50%. Anti-SSA, anti-SSB, anti-Sm/RNP, and anti-Scl70 antibodies were detected in 38%, 10%, 48%, and 8%, respectively. Our data show that, in our patients, the main clinical and immunological features of SLE remain comparable to patients from other Arab countries.

The role of neutrophils in skin damage induced by tissue-deposited lupus IgG

Skin injury is the second most common clinical manifestation in patients with systemic lupus erythematosus (SLE). Neutrophils are crucial effector cells in the immune system but the significance of neutrophils in the pathogenesis of SLE is not clear. This study is to explore the role of neutrophils in the skin damage of SLE. We used lupus-prone mice and a C57BL/6 mouse model of lupus serum IgG-induced skin inflammation to investigate the role of neutrophils in skin damage of SLE. We found that a few neutrophils infiltrated the inflammatory sites of skin in lupus-prone mice and the lupus-IgG-induced skin damage mouse model. Depletion of neutrophils did not affect the development of skin inflammation caused by lupus IgG, and lupus IgG can induce apoptosis of neutrophils. The apoptosis of neutrophils induced by lupus IgG is related to FcγRIII and Fas/Fas ligand pathways. Our study indicates that neutrophils are not major contributors in the skin damage caused by tissue-deposited lupus IgG but death of neutrophils caused by lupus IgG may provide a resource of a large amount of autoantigens in SLE.

Zytopenien

Hematological alterations can often be observed during rheumatic diseases. The effects can be clinically severe, ranging from anemia of different grades of severity, through increased risk of hemorrhage due to thrombocytopenia up to severe infections as a result of high-grade leukocytopenia. The clinical sequelae for patients are predominantly determined by the extent of cytopenia. The underlying disease itself can initially be considered as the cause. Examples are anemia as a result of chronic inflammation, antibody-mediated thrombocytopenia as in systemic lupus erythematosus (SLE) or granulocytopenia within the framework of Felty's syndrome. Immunosuppressive treatment also often leads to alterations in the blood constituents. Although some substances, such as cyclophosphamide can suppress all three cell types, there are also selective effects, such as isolated thrombocytopenia under treatment with tocilizumab and JAK inhibitors. The differential diagnostic clarification of cytopenia can be difficult and necessitates a systematic work-up of the course of the disease and the subsequent treatment. The reviews of anemia, leukocytopenia and thrombocytopenia presented here summarize the most important components of the differentiation of hematological alterations in patients with rheumatic diseases.

Clinical and immunological characteristics of 150 systemic lupus erythematosus patients in Jamaica: a comparative analysis

Background

Epidemiological studies in systemic lupus erythematosus have been reported in the literature in many countries and ethnic groups. Although systemic lupus erythematosus in Jamaica has been described in the past, there has not been a detailed evaluation of systemic lupus erythematosus patients in urban Jamaica, a largely Afro-Caribbean population. The goal of this study was to describe the clinical features, particularly disease activity, damage index and immunological features, of 150 systemic lupus erythematosus subjects.

Methods

150 adult patients (≥18 years) followed in rheumatology clinic at a tertiary rheumatology hospital centre (one of two of the major public referral centres in Jamaica) and the private rheumatology offices in urban Jamaica who fulfilled Systemic Lupus International Collaborating Clinics (SLICC) criteria were included. Data were collected by detailed clinical interview and examination and laboratory investigations. Hence demographics, SLICC criteria, immunological profile, systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) and SLICC/American College of Rheumatology (ACR) damage index (SDI) were documented.

Results

Of the 150 patients, 145 (96.7%) were female and five (3.3%) were male. The mean age at systemic lupus erythematosus onset was 33.2 ± 10.9. Mean disease duration was 11.3 ± 8.6 years. The most prevalent clinical SLICC criteria were musculoskeletal, with 141 (94%) of subjects experiencing arthralgia/arthritis, followed by mucocutaneous manifestations of alopecia 103 (68.7%) and malar rash 46 (30.7%), discoid rash 45 (30%) and photosensitivity 40 (26.7%). Lupus nephritis (biopsy proven) occurred in 42 (28%) subjects and 25 (16.7%) met SLICC diagnostic criteria with only positive antinuclear antibodies/dsDNA antibodies and lupus nephritis on renal biopsy. The most common laboratory SLICC criteria were positive antinuclear antibodies 136 (90.7%) followed by anti-dsDNA antibodies 95 (63.3%) and low complement (C3) levels 38 (25.3%). Twenty-seven (18%) met SLICC diagnostic criteria with only positive antinuclear antibodies/anti-dsDNA antibodies and lupus nephritis on renal biopsy. Mean SLEDAI score was 6.9 ± 5.1 with a range of 0–32. Organ damage occurred in 129 (86%) patients; mean SDI was 2.4 ± 1.8, with a range of 0–9.

Conclusion

These results are similar to the clinical manifestations reported in other Afro-Caribbean populations; however, distinct differences exist with respect to organ involvement and damage, particularly with respect to renal involvement, which appears to be reduced in our participants.

ANA-Negative Presentation of SLE in Man with Severe Autoimmune Neutropenia

Background. Systemic lupus erythematosus (SLE) is a chronic, inflammatory, connective tissue disease that commonly affects the joints and a variety of organs due to an overactivation of the body's immune system. There is wide heterogeneity in presentation of SLE patients, including lung, central nervous system, skin, kidney, and hematologic manifestations. Case Presentation. We report a case of atypical manifestation of SLE in a 53-year-old man who presented with neutropenic fever. Physical findings of interest included oral ulcers on the lower lip, a malar-like rash across the bridge of the nose, and a discoid-like rash on extensor surfaces of the elbows and knees. Labs include ANC <100, weakly positive anti-dsDNA, negative ANA, ferritin 1237 ng/mL, low C3/C4, and positive direct Coombs' test. A thorough workup for infection and hematologic malignancy was negative. Two days after initiation of therapy with 25 mg IV solumedrol twice a day, the patient's daily fevers resolved. ANC drastically improved to 2000 after two weeks of steroid treatment. He was later found to have a high titer of anti-neutrophil antibodies. Discussion. Autoimmune leukopenia is a common presentation in SLE, occurring in 50-60% of patients. Severe autoimmune neutropenia is uncommon and may correlate with high anti-neutrophil antibody activity despite a negative ANA. As neutropenia is usually mild, there are currently no guidelines for therapy. For our patient, we started him on low dose IV solumedrol and found that he responded drastically to treatment. Given strongly positive nonspecific anti-neutrophil antibodies in the setting of a negative ANA noted in our patient, it is likely that there are other currently unknown antibodies associated with SLE which may correlate strongly with autoimmune neutropenia.

An atypical case of late-onset systemic lupus erythematosus with systemic lymphadenopathy and severe autoimmune thrombocytopenia/neutropenia mimicking malignant lymphoma

Here, we report a rare case of systemic lupus erythematosus (SLE) with conspicuous manifestation of hematological abnormalities. At onset, the 52-year-old male patient showed systemic lymphadenopathy and splenomegaly, severe autoimmune thrombocytopenia, and autoimmune neutropenia. Bone marrow examination and lymph node biopsy excluded the possibility of malignant lymphoma. Based on laboratory findings, he was finally diagnosed with combined autoimmune cytopenia coupled with SLE. Atypical clinical manifestations of SLE prompted us to explore the possibility of autoimmune lymphoproliferative syndrome (ALPS). However, we did not detect an increased number of CD4^-/CD8^-, CD3⁺, TCRαβ⁺ double-negative T cells in the circulating blood or dysfunctional T cell apoptosis in the Fas/Fas ligand pathway due to mutations in the FAS, FASLG or CASP10 genes. Combined autoimmune cytopenia is a rare clinical entity that in some cases co-occurs with other autoimmune diseases. Given that most SLE patients presenting atypical hematological manifestations at an early stage subsequently exhibit typical systemic manifestations, the present case raises the possibility that initial hematological abnormalities may be signs of unexpected SLE manifestations.

Understanding chronic neutropenia: life is short

The pathophysiological mechanisms underlying chronic neutropenia are extensive, varying from haematopoietic stem cell disorders resulting in defective neutrophil production, to accelerated apoptosis of neutrophil progenitors or circulating mature neutrophils. While the knowledge concerning genetic defects associated with congenital neutropenia or bone marrow failure is increasing rapidly, the functional role and consequences of these genetic alterations is often not well understood. In addition, there is a large group of diseases, including primary immunodeficiencies and metabolic diseases, in which chronic neutropenia is one of the symptoms, while there is no clear bone marrow pathology or haematopoietic stem cell dysfunction. Altogether, these disease entities illustrate the complexity of normal neutrophil development, the functional role of the (bone marrow) microenvironment and the increased propensity to undergo apoptosis, which is typical for neutrophils. The large variety of disorders associated with chronic neutropenia makes classification almost impossible and possibly not desirable, based on the clinical phenotypes. However, a better understanding of the regulation of normal myeloid differentiation and neutrophil development is of great importance in the diagnostic evaluation of unexplained chronic neutropenia. In this review we propose insights in the pathophysiology of chronic neutropenia in the context of the functional role of key players during normal neutrophil development, neutrophil release and neutrophil survival.

Haematological manifestations of lupus

Our purpose was to compile information on the haematological manifestations of systemic lupus erythematosus (SLE), namely leucopenia, lymphopenia, thrombocytopenia, autoimmune haemolytic anaemia (AIHA), thrombotic thrombocytopenic purpura (TTP) and myelofibrosis. During our search of the English-language MEDLINE sources, we did not place a date-of-publication constraint. Hence, we have reviewed previous as well as most recent studies with the subject heading SLE in combination with each manifestation. Neutropenia can lead to morbidity and mortality from increased susceptibility to infection. Severe neutropenia can be successfully treated with granulocyte colony-stimulating factor. While related to disease activity, there is no specific therapy for lymphopenia. Severe lymphopenia may require the use of prophylactic therapy to prevent select opportunistic infections. Isolated idiopathic thrombocytopenic purpura maybe the first manifestation of SLE by months or even years. Some manifestations of lupus occur more frequently in association with low platelet count in these patients, for example, neuropsychiatric manifestation, haemolytic anaemia, the antiphospholipid syndrome and renal disease. Thrombocytopenia can be regarded as an important prognostic indicator of survival in patients with SLE. Medical, surgical and biological treatment modalities are reviewed for this manifestation. First-line therapy remains glucocorticoids. Through our review, we conclude glucocorticoids do produce a response in majority of patients initially, but sustained response to therapy is unlikely. Glucocorticoids are used as first-line therapy in patients with SLE with AIHA, but there is no conclusive evidence to guide second-line therapy. Rituximab is promising in refractory and non-responding AIHA. TTP is not recognised as a criteria for classification of SLE, but there is a considerable overlap between the presenting features of TTP and SLE, and a few patients with SLE have concurrent TTP. Myelofibrosis is an uncommon yet well-documented manifestation of SLE. We have compiled the cases that were reported in MEDLINE sources.

Hematological disorders in patients with systemic lupus erythematosus

This article is a review of different management strategies for the hematological manifestations of systemic lupus erythematosus (SLE), the strategies include immunosuppressive drugs, some noval therapies and B-cell depletion for refractory thrombocytopenia in patients with SLE and in antiphospholipid antibody syndrome associated with SLE. The researcher questions the validity of the current classic treatment modes and the article explores the relationships between SLE hematological manifestations and the level of morbidity and mortality burden and focuses on the pathophysiology, diagnostic approaches and management strategies of these manifestations. The researcher focuses on hematological abnormalities because they are the commonest among most manifestations in SLE seen in Anemia, leucopenias and thrombocytopenia. They commonly result from an immune mediated bone marrow failure, excessive peripheral cells destruction or certain drugs and infections. There is also an association between anti-phospholipid antibody syndrome (APS) and SLE referred to as secondary APS or SLE-APS. Furthermore, it was recently found that mycophenolatemofetil acts as corticosteroids and as cyclophosphamide sparing agent. Although there is no specific therapy for cytopenias in SLE, corticosteroids remain the mainstay in the treatment of these patients along with less used other conventional treatment options such as azathioprine, cyclophosphamide and human normal immunoglobulin. There are other novel therapies such as thrombopoietin receptor agonists in thrombocytopenia and the use of autologous hematopoitic stem cells transplantation in refractory SLE-APS that are under review. Some of these therapies include thrombopoietin receptor agonists in thrombocytopenia and the use of autologous hematopoitic stem cells transplantation in refractory SLE-APS. The study concludes that treatment of hematological abnormalities is challenging because the treatment itself can cause undue complications sometimes such as granulocytosis due to infection or the use of high doses of steroids and may occur during acute exacerbations of SLE. It is important to take these factors into consideration for disease therapy and management.

PUBLICATION ABSTRACT

This article is a review of different management strategies for the hematological manifestations of systemic lupus erythematosus (SLE). The strategies include immunosuppressive drugs, some novel therapies and B-cell depletion for refractory thrombocytopenia in patients with SLE and in anti-phospholipid antibody syndrome associated with SLE. The researcher questions the validity of the current classic treatment modes and the article explores the relationships between SLE hematological manifestations and the level of morbidity and mortality burden while it focuses on the pathophysiology, diagnostic approaches and management strategies. The study concludes that hematological abnormalities are the commonest among most manifestations in SLE, and that their treatment is challenging because the treatment itself can cause undue complications sometimes such as granulocytosis due to infection or the use of high doses of steroids and may occur during acute exacerbations of SLE. It is important to take these factors into consideration for disease therapy and management.

An evaluation of the association of leukopenia and severe infection in patients with systemic lupus erythematosus

BACKGROUND

Leukopenia is a common finding in systemic lupus erythematosus (SLE) and may contribute to severe infections.

OBJECTIVES

The objectives of this study were to determine the prevalence of leukopenia in SLE patients and examine the association between these conditions and severe infections noting the risk factor of severe infections.

METHODS

This study was a prospective inception lupus cohort of newly diagnosed SLE patients seen between May 2007 and June 2011. Only cases that had been observed for a minimum of 1 year or died during the study were included.

RESULTS

There were 89 SLE patients (92% females), with their mean (SD) age and disease duration at the study entry of 31.7 (12.2) years and 2.4 (2.9) months. Leukopenia was found at the diagnosis in 51.6% of the cases. The cumulative prevalence of leukopenia, lymphopenia, and neutropenia was observed in 57.3%, 96.6%, and 60.7%, respectively. Persistent lymphopenia, noted continuously for more than or equal to 75% of the observation period, was found in 41.6%, but there was no persistent neutropenia. The incidence rate of severe infection was 12.4 per 100 patient-years. There was no difference of severe infection-free survival rate between patients who ever and never had leukopenia. In the multivariate analysis, using cyclophosphamide was the independent predictor for severe infection in SLE (hazard ratio, 2.73; 95% confidence interval, 1.10-6.77).

CONCLUSIONS

Leukopenia was common in SLE but usually not persistent. In this study, the presence of leukopenia at any time was not the risk factor for severe infection in SLE. Cyclophosphamide was the important predictor for severe infection in SLE.

A case of an SLE patient with febrile neutropenia who experienced exacerbation of cutaneous manifestations after the administration of G-CSF

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease. Although hematological anomalies are commonly found in SLE, severe polymorphonuclear leukocyte depletion is rare. Most episodes of severe granulocytopenia in SLE patients tend to occur as part of drug toxicity-induced medullar hypoplasia, and recombinant human (rh) granulocyte colony-stimulating factor (G-CSF) has been shown to be effective for treating neutropenia associated with SLE. However, flares of some autoimmune diseases, including flares in six SLE patients, have been reported after G-CSF therapy. This report presents the case of a patient with SLE who experienced exacerbation of skin symptoms after G-CSF therapy. There is sufficient evidence to suggest that G-CSF can exacerbate inflammatory disease. Furthermore, the possibility that several factors other than rhG-CSF may affect the disease activity of SLE should be considered when SLE patients with neutropenia require the administration of rhG-CSF. Therefore rhG-CSF should be used with considerable caution in neutropenic patients with SLE.

Why is my patient neutropenic?

Neutropenia is a common reason for hematology consultations in the inpatient and outpatient settings and is defined as an absolute neutrophil count less than 1500 cells/μL. Neutropenia varies in severity, with more profound neutropenia being associated with higher rates of infections and infection-related deaths. The causes for neutropenia are diverse and include congenital and acquired conditions (ie, autoimmune, drugs, infection, and malignancy). This article outlines the most common causes of neutropenia and discusses differential diagnoses, treatment modalities, and the mechanisms by which neutropenia occurs.

Clinical assessment and management of cytopenias in lupus patients

Anemia, leukopenia, and/or thrombocytopenia can occur as a result of non-immune- and immune-mediated mechanisms in patients with systemic lupus erythematosus. Although the differential diagnosis of these cytopenias is broad and warrants a thorough evaluation, lupus disease activity and medications are common etiologic factors. Corticosteroids are the mainstay of initial treatment for immune-mediated hemolytic anemia and severe thrombocytopenia; immunosuppressive agents such as mycophenolate mofetil or azathioprine are often added for their steroid-sparing effects. Rituximab and intravenous immunoglobulin can be considered for refractory cytopenias based on a large body of anecdotal evidence and case series. Newer biologic agents such as belimumab or epratuzumab have yet to be studied specifically in systemic lupus erythematosus-mediated hematologic disorders.

Pediatric lupus--are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus?

Some complement deficiencies predispose to systemic lupus erythematosus (SLE) early in life. Currently, there are no known unique physiologic or genetic pathways that can explain the variability in disease phenotypes. Children present with more acute illness and have more frequent renal, hematologic, and central nervous system involvement compared to adults with SLE. Almost all children require corticosteroids during the course of their disease; many are treated with immunosuppressive drugs. Mortality rates remain higher with pediatric SLE. Children and adolescents accrue more damage, especially in the renal, ocular and musculoskeletal organ systems. Conversely, cardiovascular mortality is more prevalent in adults with SLE.

Invasive fungal infections in patients with systemic lupus erythematosus: experience from affiliated hospitals of Catholic University of Korea

The purpose of study was to determine the nature, outcomes and associated risk factors of invasive fungal infection (IFI) in patients with systemic lupus erythematosus (SLE), and compare the incidence of IFI in patients with rheumatoid arthritis (RA). A total of 1155 patients with SLE and 2004 patients with RA were retrospectively reviewed between 1992 and 2007. Twelve cases of IFI patients were identified in SLE patients (6 Aspergillus spp.; 5 Cryptococcus spp.; 1 Candida spp.). The incidence of IFI was significantly higher in patients with SLE than RA (1.04 vs. 0.15%). Among 12 patients with SLE, 10 had high Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores (≥8). The most commonly involved organ was the lung (n = 6), followed by the meninges (n = 4). Most of SLE patients with IFI (91.7%) had taken steroids prior to IFI. Three SLE patients resulted in death. Notably, these patients were all infected with Aspergillus spp. The mortality was associated with the presence of leukopenia, high anti-DNA antibodies and high SLEDAI. Collectively, IFI is more common in patients with SLE than in patients with RA. High disease activity in patients with SLE might contribute to increased risk of IFI. In addition, mortality was associated with aspergillus infection, leukopenia and high anti-DNA antibodies.

Clinical and immunological manifestations in 151 SLE patients living in Dubai

To gain better understanding of systemic lupus erythematosus (SLE) in Dubai we studied the clinical and immunological manifestations in a cohort of 151 patients attended Rheumatology Clinic in Dubai Hospital between January 2002 and January 2007. We found that the female to male ratio was 20.5:1, with a mean age of 35.5 years (0.9). The mean age at disease onset was 28.9 years (0.8) and mean disease duration 6.7 years (0.4). Five-year survival rate in our cohort was 94%. The commonest clinical manifestations in this cohort were arthritis (88%), haematological abnormalities (61.6%), and malar rash (60.3%). Leucopenia, fever, hair loss and proteinuria were observed in approximately half of the patients. Anaemia was found in 44.3% but only 9.9% had haemolytic anaemia. Photosensitive rash was seen in 43% of patients. Approximately one-third of the patients had serositis and mouth ulcers, 30.5 and 27.2% respectively. Vasculitis was observed in 19.2% of patients. Neuropsychiatric manifestations (15.9%), discoid lupus lesions (12.6%), and brain infarcts (13.2%) were infrequent. Subacute cutaneous lupus (6%) was also uncommon. Anti-nuclear antibodies were detected in 98%, anti-double stranded DNA antibodies in 88.7%, anti-Sm antibodies in 19.7%, anti-RNP in 40.4%, anti-Ro antibodies in 52.3% and anti-La antibodies in 19.8%. Anti-cardiolipin IgM and IgG were detected in 25.3 and 22.4%, respectively. This study suggests that Arabs with SLE residing in Dubai have comparable clinical features to their counterparts in other Arab countries and Western countries. The high prevalence of positive anti-Ro antibodies among our Arab patients probably reflects a character, that is, commonly seen in SLE patients of Middle East origin.