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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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2
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Kirkpatrick KV, Nocton JJ. Unusual Presentations of Systemic Lupus Erythematosus. Med Clin North Am 2024; 108:43-57. [PMID: 37951655 DOI: 10.1016/j.mcna.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Systemic lupus erythematosus (SLE) often develops during adolescence, may affect any organ system, and may present with a wide variety of signs and symptoms. It is critical to recognize the unusual manifestations of SLE in order to make a prompt diagnosis. Earlier diagnosis allows for appropriate treatment and ultimately decreases morbidity and mortality.
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Affiliation(s)
- Kaitlin V Kirkpatrick
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA
| | - James J Nocton
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA.
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3
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Camones-Huerta J, Arias-Osorio C, Rodriguez-Hurtado D, Aguilar-Olano J. Neuropsychiatric Manifestations in Systemic Lupus Erythematosus Patients at a Tertiary Hospital in Peru. Eur J Rheumatol 2023; 10:143-147. [PMID: 37850607 PMCID: PMC10765184 DOI: 10.5152/eurjrheum.2023.22095] [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: 08/31/2022] [Accepted: 08/02/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Systemic lupus erythematosus is a prevalent autoimmune disease that affects multiples systems, exerting its most incapacitating and life-threatening impact through neuropsychiatric involvement. According to the American College of Rheumatology (ACR), 19 neuropsychiatric syndromes types of SLE are classified into categories encompassing the central and peripheral nervous systems. This study aimed to investigate the frequency of neuropsychiatric manifestations in systemic lupus erythematosus patients admitted to Hospital Cayetano Heredia in Lima, Peru, between 2008 and 2019. METHODS A retrospective observational study was conducted, entailing the review of 240 medical records of patients diagnosed with systemic lupus erythematosus during the specified period, based on the Systemic Lupus International Collaborating Clinics (SLICC) 2012 criteria. Among these records, 55 patients presented neuropsychiatric systemic lupus erythematosus (NPSLE). Data were collected using standardized form and entered into Microsoft Excel 2019 database. Statistical analysis was performed using Stata v16. RESULTS The frequency of neuropsychiatric compromise in systemic lupus erythematosus patients was found to be 22.91%. Among the 55 systemic lupus erythematosus patients, 40 demonstrated involvement of the central nervous system (72.72%), 2 exhibited involvement of the peripheral nervous system (3.63%), and 13 displayed involvement in both the central nervous system and peripheral nervous system (23.63%). The most prevalent psychiatric disorder observed was a major depressive disorder, with a prevalence rate of 30.9%. CONCLUSION The study revealed a frequency of 22.91% for neuropsychiatric involvement in systemic lupus erythematosuspatients at Cayetano Heredia Hospital between 2008 and 2019, with central nervous system manifestations prevailing. Furthermore, the findings suggest that NPSLE commonly manifested after the diagnosis of systemic lupus erythematosus.
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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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5
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Kumar A, Gupta A, Gupta P, Vasdev V, Kartik S. The Coexisting Neuromyelitis Optica Spectrum Disorder and Systemic Lupus Erythematosus: A Therapeutic Challenge. Mediterr J Rheumatol 2023; 34:372-376. [PMID: 37941871 PMCID: PMC10628875 DOI: 10.31138/mjr.20230808.tc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 11/10/2023] Open
Abstract
Neuromyelitis Optica (NMO), or Devic's disease, is an immune-mediated, usually relapsing, central nervous system (CNS) demyelination disorder associated with optic neuritis and transverse myelitis. It is characterised by the presence of longitudinally extensive transverse myelitis (LETM) and antibodies against water channel aquaporin-4 (AQP4-immunoglobulin G [IgG]). The term NMO spectrum disorder (NMOSD) includes patients with limited forms of NMO who are at risk of recurrence. Often patients with NMO or NMOSD have an associated systemic autoimmune disease, most commonly systemic lupus erythematosus (SLE) or Sjogren syndrome (SS) or a related profile of non-organ-specific autoantibodies. The intriguing aspect of coexisting NMOSD and SLE is whether they are independent diseases that can coexist with each other or the serological findings specific to both diseases in a patient is a non-specific finding of no prognostic or therapeutic concern. We have presented two cases of NMOSD coexisting with SLE and based upon the existing evidence in the literature we present that the two conditions are independent of each other, and, at times, it can throw a therapeutic challenge to any clinician.
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Affiliation(s)
- Abhishek Kumar
- Department of Rheumatology, Army Hospital Research and Referral, Delhi, India
| | - Anirban Gupta
- Department of Neurology, Army Hospital Research and Referral, Delhi, India
| | - Preeti Gupta
- Department of Radiology, Command Hospital, Alipore, Kolkata, India
| | - Vivek Vasdev
- Department of Rheumatology, Army Hospital Research and Referral, Delhi, India
| | - S Kartik
- Department of Rheumatology, Army Hospital Research and Referral, Delhi, India
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Rose J. Autoimmune Connective Tissue Diseases: Systemic Lupus Erythematosus and Rheumatoid Arthritis. Immunol Allergy Clin North Am 2023; 43:613-625. [PMID: 37394263 DOI: 10.1016/j.iac.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Systemic lupus erythematosus and rheumatoid arthritis are just 2 of several autoimmune connective tissue diseases that are primarily chronic in nature but can present to the emergency department by virtue of an acute exacerbation of disease. Beyond an acute exacerbation of disease, their predilection for invading multiple organ systems lends itself to the potential for patients presenting to the emergency department with either a single or isolated symptom or a myriad of signs and/or symptoms indicative of a degree of disease complexity and severity that warrant timely recognition and resuscitation.
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Affiliation(s)
- Jonathan Rose
- Department of Emergency Medicine, Memorial Healthcare System, Memorial Hospital West, 703 N Flamingo Road, Pembroke Pines, FL 33028, USA.
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7
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Sierra-Merlano RM, Iglesias-Jiménez Ó, Blanco-Pertuz PM, Pérez-Mingan GC, Sanjuanelo-Fontalvo AJ. Extensive Longitudinal Transverse Myelitis in Systemic Lupus Erythematosus: Presentation of a Case and Literature Review. Cureus 2023; 15:e42053. [PMID: 37601991 PMCID: PMC10432924 DOI: 10.7759/cureus.42053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Acute transverse myelitis (TM) is an inflammatory disease that manifests with motor, sensory, and autonomic symptoms of rapid progression with catastrophic outcomes; the three main causes of acute TM are demyelinating diseases, infections, and autoimmune inflammatory diseases such as systemic lupus erythematosus (SLE). TM is one of the 19 neuropsychiatric diseases associated with SLE according to the American College of Rheumatology (ACR) and has been described as affecting 1 to 2% of all cases of SLE and is frequently misdiagnosed, leading to a high rate of morbidity and mortality. This report highlights the case of a 25-year-old woman with a history of SLE who consulted for a progressive decrease in lower limb strength and loss of sphincter control, accompanied by dysesthesias from the abdomen to the feet. Upon examination, she exhibited severe paraparesis and preserved myotendinous reflexes, and a sensory level at T10 was documented. A contrast-enhanced MRI of the thoracolumbar spine was performed, showing signal hyperintensity on T2 and Short Tau Inversion Recovery (STIR) from T6 to T10. These findings are compatible with TM. Given the refractory response to initial management, the use of cyclophosphamide was required. After one week of hospital treatment, the patient achieved partial neurological recovery and was discharged for continued outpatient rheumatology care. For the diagnosis of TM in patients with SLE, a high clinical suspicion is required. Recognizing and immediately addressing this condition is crucial to prevent catastrophic outcomes and the high morbidity and mortality that stem from this association.
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Rajput HM, Hassan M, Badshah M. Clinical and radiological profile of neuromyelitis optica spectrum disorders in a Pakistani cohort. Mult Scler Relat Disord 2023; 74:104656. [PMID: 37068371 DOI: 10.1016/j.msard.2023.104656] [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: 01/20/2023] [Revised: 03/14/2023] [Accepted: 03/21/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND The clinical and radiological characteristics of neuromyelitis optica spectrum disorder (NMOSD) from Pakistan is unknown. Our study aimed to describe the clinical and radiological features of NMOSD patients presenting to a Pakistani tertiary care center. MATERIALS AND METHODS This retrospective, observational study was conducted at the Neurology Department, Pakistan Institute of Medical Sciences between January 2017 and September 2021 (56 months). The study included patients diagnosed with neuromyelitis optica spectrum disorder (NMOSD) according to the 2015 International Panel for NMO Diagnosis (IPND) criteria, with the exclusion of patients under 12 years of age and those who tested positive for Myelin oligodendrocyte glycoprotein (MOG) IgG antibody. The patients were divided into two groups based on clinical presentation and the presence of NMO-IgG antibodies: NMO-IgG positive NMO (Seropositive NMO) and NMO-IgG negative (Seronegative NMO). The clinical features of NMOSD were recorded, and data was analyzed using SPSS version 26.0. RESULTS Among 204 patients with suspected demyelination, multiple sclerosis was diagnosed in 100 individuals (49.02%), while acute disseminated encephalomyelitis (ADEM), clinically isolated syndrome (CIS), and neuromyelitis optica (NMO) were found in 5 patients each (2.45%, 2.45%, and 17.65%, respectively). Out of 36 patients with NMO, 32 (88.89%) tested positive for NMO-Ab, while the remaining 4 (11.11%) were seronegative for both NMO and anti-MOG Abs. The mean age of NMO-positive patients who tested positive for NMO antibodies was 31.03±10.12 years, compared to 27.95±2.5 years for NMO-negative patients, though this difference was not statistically significant (p>0.05). Females were more commonly affected by NMO, accounting for 72.2% of the NMO-positive group, and there was a significant difference in clinical phenotypes between the two groups (p<0.05). The NMO-positive group predominantly had relapsing NMO presentation (75%), and 72.8% of these patients showed longitudinally extensive transverse myelitis on the MRI spine. Azathioprine was the most frequently administered treatment for positive NMO patients (69.44%), followed by rituximab and MMF. The follow-up period for the study participants lasted 24 months. CONCLUSION This is the first study on NMOSD cases in Pakistan. According to the present study, NMOSD is most prevalent among women in their forties. Relapsing NMO was the most common form of presentation. 89% of patients had antibodies against AQP4. 72.8% of patients suffered from LETM during the course of their disease. There are some features of our NMOSD cases that appear comparable with those around the world, despite some limitations in testing and access to care. It is clear that the clinical and radiological spectrums of patients with NMO and NMOSD in this cohort are similar. It is reasonable to suspect NMO if demyelinating episodes are not characteristic of MS.
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Affiliation(s)
- Haris Majid Rajput
- Department of Neurology, Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad, Pakistan
| | - Muhammad Hassan
- Department of Neurology, Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad, Pakistan.
| | - Mazhar Badshah
- Department of Neurology, Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad, Pakistan
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Goyne CE, Piccioni D, Handwerker J, Rajagopal A. Radiographic evolution of myelitis in a case of glial fibrillary acidic protein (GFAP) astrocytopathy. BMJ Case Rep 2023; 16:16/3/e248921. [PMID: 36898710 PMCID: PMC10008168 DOI: 10.1136/bcr-2022-248921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Autoimmune glial fibrillar acidic protein (GFAP) astrocytopathy is a rare autoimmune neuroinflammatory disorder that affects the central nervous system. We present a case of GFAP astrocytopathy in a middle-aged male who presented with constitutional symptoms, encephalopathy and lower extremity weakness and numbness. Initially MRI of the spine was normal, but he subsequently developed longitudinally extensive myelitis and meningoencephalitis. Workup for infectious aetiologies was negative and the patient's clinical course worsened despite broad antimicrobial coverage. Ultimately, he was found to have anti-GFAP antibodies in his cerebral spinal fluid consistent with GFAP astrocytopathy. He was treated with steroids and plasmapheresis with clinical and radiographic improvement. This case demonstrates the temporal evolution of myelitis on MRI in a case of steroid-refractory GFAP astrocytopathy.
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Affiliation(s)
| | | | - Jason Handwerker
- University of California Medical Center Hillcrest, San Diego, California, USA
| | - Amutha Rajagopal
- Infectious Disease, University of California, La Jolla, California, USA
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10
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Grasso EA, Pozzilli V, Tomassini V. Transverse myelitis in children and adults. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:101-117. [PMID: 37620065 DOI: 10.1016/b978-0-323-98817-9.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Transverse myelitis is a noncompressive myelopathy of inflammatory origin. The causes are broad, ranging from infective or toxic to immuno-mediated etiology. They can be manifestations of systemic diseases, such as sarcoidosis and systemic lupus erythematous, or phenotypes of neuroinflammation; in a portion of cases, the etiology remains unknown, leading to the designation idiopathic. The clinical presentation of transverse myelitis depends on the level of spinal cord damage and may include sensorimotor deficits and autonomic dysfunction. The age of onset of the disorder can impact the symptoms and outcomes of affected patients, with differences in manifestation and prognosis between children and adults. Spinal cord magnetic resonance imaging and cerebrospinal fluid examination are the main diagnostic tools that can guide clinicians in the diagnostic process, even though the search for antibodies that target the structural components of the neural tissue (anti-aquaporin4 antibodies and anti-myelin-oligodendrocyte antibodies) helps in the distinction among the immune-mediated phenotypes. Management and outcomes depend on the underlying cause, with different probabilities of relapse according to the phenotypes. Hence, immunosuppression is often recommended for the immune-mediated diseases that may have a higher risk of recurrence. Age at onset has implications for the choice of treatment.
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Affiliation(s)
- Eleonora Agata Grasso
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valeria Pozzilli
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valentina Tomassini
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
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Odin VI, Yurkina EA, Yurkin AK, Toporkov MM, Shvartsman GI, Pervova EM. Neurological Aspects of Systemic Lupus Erythematosus in Individuals with Late Ontogenetic Debut. ADVANCES IN GERONTOLOGY 2022. [DOI: 10.1134/s2079057022040129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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12
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Das S, Ray BK, Chakraborty AP, Banerjee A, Pandit A, Das G, Dubey S. Persistent “MRI-negative” lupus myelitis-disease presentation, immunological profile and outcome. Front Neurol 2022; 13:968322. [PMID: 36388234 PMCID: PMC9659815 DOI: 10.3389/fneur.2022.968322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/11/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Myelitis is the least common neuropsychiatric manifestation in systemic lupus erythematosus (SLE). Magnetic resonance imaging (MRI)-negative myelitis is even rarer. Here, we present the largest cohort of MRI-negative lupus myelitis cases to assess their clinical and immunological profiles and outcome. Method A single-center, observational study conducted over a period of 5 years (2017–2021) was undertaken to evaluate patients with MRI-negative lupus myelitis for the epidemiological, clinical, immunological, and radiological features at baseline and followed up at monthly intervals for a year, and the outcomes were documented. Among the 22 patients that presented with MRI-negative myelopathy (clinical features suggestive of myelopathy without signal changes on spinal-cord MRI [3Tesla], performed serially at the time of presentation and 7 days, 6 weeks, and 3 months after the onset of symptoms), 8 patients had SLE and were included as the study population. Results In 8 of 22 patients presenting with MRI-negative myelopathy, the etiology was SLE. MRI-negative lupus myelitis had a female preponderance (male: female ratio, 1:7). Mean age at onset of myelopathy was 30.0 ± 8.93 years, reaching nadir at 4.9 ± 4.39 weeks (Median, 3.0; range, 1.25–9.75). Clinically, cervical cord involvement was observed in 75% of patients, and 62.5% had selective tract involvement. The mean double stranded deoxyribonucleic acid, C3, and C4 titers at onset of myelopathy were 376.0 ± 342.88 IU/ml (median, 247.0), 46.1 ± 17.98 mg/dL (median, 47.5), and 7.3 ± 3.55 mg/dL (median, 9.0), respectively, with high SLE disease activity index 2,000 score of 20.6 ± 5.9. Anti-ribosomal P protein, anti-Smith antibody, and anti-ribonuclear protein positivity was observed in 87.5, 75, and 75% of the patients, respectively. On follow-up, improvement of myelopathic features with no or minimal deficit was observed in 5 of the 8 patients (62.5%). None of the patients had recurrence or new neurological deficit over 1-year follow-up. Conclusion Persistently “MRI-negative” lupus myelitis presents with white matter dysfunction, often with selective tract involvement, in light of high disease activity, which follows a monophasic course with good responsiveness to immunosuppressive therapy. A meticulous clinical evaluation and a low index of suspicion can greatly aid in the diagnosis of this rare clinical condition in lupus.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
- *Correspondence: Biman Kanti Ray
| | - Arka Prava Chakraborty
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Abhirup Banerjee
- Department of General Medicine, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Gautam Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
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Wang M, Wang Z, Zhang L, Zhao J, Wu D, Li J, Wang Q, Su J, Xu D, Zhang S, Li M, Zeng X. Exploring the risk factors and prognosis of transverse myelitis in systemic lupus erythematosus. Ther Adv Chronic Dis 2022; 13:20406223221097330. [PMID: 35615445 PMCID: PMC9125597 DOI: 10.1177/20406223221097330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose: We aimed to describe the clinical characteristics and outcomes of patients
with transverse myelitis (TM) as a rare manifestation in systemic lupus
erythematosus (SLE) and explore the risk factors and prognosis of
SLE-related TM (SLE-TM). Methods: We conducted a retrospective case–control and cohort analysis. All patients
with SLE-TM (58 patients) and 232 with SLE without TM, as a control group,
were admitted to Peking Union Medical College Hospital between January 1993
and May 2021. Factors associated with the presence of SLE-TM and its
prognosis were assessed using logistic regression and Cox proportional
hazard models. Results: Multivariate analysis revealed that positive anti-Ro/Sjogren’s syndrome A
(anti-Ro/ SSA) (<0.01) and increased erythrocyte sedimentation rate (ESR)
(p < 0.01) were associated with SLE-TM. Regarding
prognosis, methylprednisolone (MP) pulse therapy within 2 weeks of onset
(adjusted hazard ratio (AHR), 2.12; 95% confidence interval (CI), 1.06–4.23;
p = 0.03) was associated with short-term neurological
improvement. An American Spinal Injury Association Impairment Scale (AIS)
grades of A, B, or C at onset (AHR, 0.12; 95% CI 0.05–0.28;
p < 0.001) and hypoglycorrhachia (AHR, 0.29; 95% CI,
0.13–0.65; p < 0.01) were associated with a short-term
non-improved outcome. Conclusions: The positive anti-Ro/SSA antibodies and increased ESR may be associated with
the presence of SLE-TM. An initial presentation with severe myelitis and
hypoglycorrhachia appear to be predictors of a poor neurological outcome.
Early steroid pulse therapy may improve the prognosis.
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Affiliation(s)
- Minhui Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ziqian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Di Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jing Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jinmei Su
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH)
- Key Laboratory of Rheumatology, and Clinical Immunology, Ministry of Education, Beijing, China
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14
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Mrak D, Bonelli M, Radner H. Neuropsychiatric Systemic Lupus Erythematosus: a remaining challenge. Curr Pharm Des 2022; 28:881-891. [PMID: 35549864 DOI: 10.2174/1381612828666220512102824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/13/2022] [Indexed: 11/22/2022]
Abstract
Systemic Lupus Erythematosus (SLE) is an autoimmune disease, which affects a wide range of organs with variable clinical features. Involvement of the nervous system is a challenging and multifaceted manifestation of the disease, presenting with a broad range of symptoms. Neuropsychiatric lupus (NPSLE) encompasses seven syndromes of the peripheral and 12 of the central nervous system, associated with a high disease burden. Despite advances in the management of SLE, NP manifestations still pose a challenge to clinicians. First, diagnosis and attribution to SLE is difficult due to the lack of specific biomarkers or imaging modalities. Second, therapeutic options are limited, and evidence is mainly based on case reports and expert consensus, as clinical trials are sparse. Moreover, no validated outcome measure on disease activity exists. Current recommendations for treatment include supportive as well as immunosuppressive medication, depending on the type and severity of manifestations. As NPSLE manifestations are increasingly recognized, a broader spectrum of therapeutic options can be expected.
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Affiliation(s)
- Daniel Mrak
- Medical University of Vienna, Vienna, Austria
| | - Michael Bonelli
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Helga Radner
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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15
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Wen X, Xu D, Yuan S, Zhang J. Transverse myelitis in systemic lupus erythematosus: A case report and systematic literature review. Autoimmun Rev 2022; 21:103103. [PMID: 35452852 DOI: 10.1016/j.autrev.2022.103103] [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: 04/03/2022] [Accepted: 04/18/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Acute transverse myelitis (TM) is a rare complication secondary to systemic lupus erythematosus (SLE) that can cause patients' extensive and severe neuropsychiatric disorders. Due to the rarity of the onset of acute TM, there is still no standard treatment protocol. This study was to summarize the clinical features of SLE-TM through a case report and systematic review. METHODS We report a case of acute TM with the initial symptoms of headache and fever on admission to hospital, with lesions in medulla oblongata, cervical medulla, and thoracic medulla. Furthermore, all cases of SLE combined with acute TM from January 1975 to February 2022 were concluded and reviewed to compare the disease's current treatment strategies and prognosis. RESULTS Patients with SLE-TM are mainly female (97.65%), with an average age of 36.89, a TM incidence of 24.51% and a longitudinal myelitis (LM) incidence of 67.76%. In addition, 68.63% of patients present an increased albumin, and only 16.50% of patients could recover. 32.35% of patients showed positive anti-cardiolipin antibody. Moreover, the patients who could recover are generally younger than those in the improved and paraparesis groups. After classifying the statistical results twice according to magnetic resonance imaging results and prognosis respectively, the erythrocyte sedimentation rate (ESR) in LM group was significantly higher than that in the other two groups. The positive rate of anti-DNA and anti-cardiolipin antibody (ANCL) in TM group was significantly higher than that of the other groups. According to the prognostic grouping, ESR in the recovery group was significantly higher than those in the other two groups. The positive ANCL in the poor prognosis group was slightly higher than that in the other two groups. CONCLUSION We offer a novel insight for this rare disease and hope to bring some inspiration the basic research for SLE-TM.
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Affiliation(s)
- Xiaoyue Wen
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China
| | - Dan Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China
| | - Shiying Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China..
| | - Jiancheng Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, PR China..
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16
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Rose J. Autoimmune Connective Tissue Diseases: Systemic Lupus Erythematosus and Rheumatoid Arthritis. Emerg Med Clin North Am 2021; 40:179-191. [PMID: 34782087 DOI: 10.1016/j.emc.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systemic lupus erythematosus and rheumatoid arthritis are just 2 of several autoimmune connective tissue diseases that are primarily chronic in nature but can present to the emergency department by virtue of an acute exacerbation of disease. Beyond an acute exacerbation of disease, their predilection for invading multiple organ systems lends itself to the potential for patients presenting to the emergency department with either a single or isolated symptom or a myriad of signs and/or symptoms indicative of a degree of disease complexity and severity that warrant timely recognition and resuscitation.
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Affiliation(s)
- Jonathan Rose
- Department of Emergency Medicine, Memorial Healthcare System, Memorial Hospital West, 703 N Flamingo Road, Pembroke Pines, FL 33028, USA.
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17
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Relapse rates and risk factors for unfavorable neurological prognosis of transverse myelitis in systemic lupus erythematosus: A systematic review and meta-analysis. Autoimmun Rev 2021; 21:102996. [PMID: 34798313 DOI: 10.1016/j.autrev.2021.102996] [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: 10/01/2021] [Accepted: 11/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transverse myelitis (TM) is a rare but severe systemic lupus erythematosus (SLE) manifestation. To date, the prognostic factors for SLE-associated TM have been far less well-studied. There are also controversial data on the association of antiphospholipid antibodies (aPLs), Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score, longitudinal extensive transverse myelitis (LETM), and decreased complement levels with the outcome of TM. We aimed to review the potential prognostic factors and integrate relapse rates of observational studies for SLE-associated TM. METHOD To review the prognosis for SLE-associated TM, relevant articles published up to July 30, 2021, were comprehensively and systematically identified from PubMed, EMBASE and Web of Science databases. Five studies encompassing 283 patients with SLE-related TM were included in this meta-analysis; raw data were obtained from three studies. RESULTS The risk factors for unfavorable neurological outcome included demographic features, clinical characteristics, laboratory data, among which a grade of A, B or C on the American Spinal Injury Association Impairment Scale (AIS) at the onset of TM was associated with poor prognosis (OR: 56.05, 95% CI: 6.29-499.25, P < 0.001). The presence of hypoglycorrhachia was also correlated with a worse prognosis (OR: 10.78, 95% CI: 3.74-31.07, P < 0.001). No noticeable correlation was revealed between a poor outcome and positive aPLs and different aPLs profiles (anticardiolipin antibody [aCL], anti-β2-glycoprotein I (anti-β2GPI], lupus anticoagulant [LA]). The pooled 1-, 3- and 5-year relapse rates were 22% (95% CI: 0.13-0.31), 34% (95% CI: 0.22-0.47) and 36% (95% CI: 0.14-0.58), respectively. No significant publication bias was found. CONCLUSION A grade of A, B, or C on the AIS at initial TM and the presence of hypoglycorrhachia were found to be related to a worse prognosis in patients with SLE-associated TM. Notably, aPLs and different aPLs profiles may not suggest poor neurological outcome. The long-term relapse rate of patients with SLE-associated TM was relatively high. We recommend that treatment be stratified based on the initial severity of myelitis. For patients with severe myelitis, early intensive therapy may be initiated as soon as possible.
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18
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Chiganer EH, Lessa CF, Di Pace JL, Perassolo MB, Carnero Contentti E, Alessandro L, Correale J, Farfan MF, Galiana GL, Sánchez Benavides M, Pacello F, Stagno M, Cardozo A, Nacimiento Cantero MB, Elizaur López JG, Delgadillo PD, Melgarejo P, Acosta Colman I, Vázquez Báez MA, Correa Díaz EP, Jácome Sánchez EC, Alva Linares M, Zamora Tehozol EA, Fragoso-Loyo HE, Quintanilla-González L, Batún-Garrido JADJ, Sato EI, do Reis-Neto ET, Carreño Nigro MA, Hryb JP. Transverse Myelitis in Systemic Lupus Erythematosus: Clinical Features and Prognostic Factors in a Large Cohort of Latin American Patients. J Clin Rheumatol 2021; 27:S204-S211. [PMID: 32028309 DOI: 10.1097/rhu.0000000000001322] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acute transverse myelitis (ATM) is an infrequent but severe complication of systemic lupus erythematosus (SLE). The purpose of study was to describe clinical features and prognostic factors of patients with SLE-related ATM. METHODS In this medical records review study, data were collected from 60 patients from 16 centers seen between 1996 and 2017 who met diagnostic criteria for SLE and myelitis as defined by the American College of Rheumatology/Systemic International Collaborating Clinics and the Working Group of the Transverse Myelitis Consortium, respectively. Objective neurological impairment was measured with American Spinal Injury Association Impairment Scale (AIS) and European Database for Multiple Sclerosis Grade Scale (EGS). RESULTS Among patients included, 95% (n = 57) were female, and the average age was 31.6 ± 9.6 years. Myelitis developed after diagnosis of SLE in 60% (n = 36). Symmetrical paraparesis with hypoesthesia, flaccidity, sphincter dysfunction, AIS = A/B, and EGS ≥ 8 was the most common presentation. Intravenous methylprednisolone was used in 95% (n = 57), and 78.3% (n = 47) received intravenous cyclophosphamide. Sensory/motor recovery at 6 months was observed in 75% (42 of 56), but only in 16.1% (9 of 56) was complete. Hypoglycorrhachia and EGS ≥ 7 in the nadir were associated with an unfavorable neurological outcome at 6 months (p < 0.05). A relapse rate during follow-up was observed in 30.4% (17 of 56). Hypoglycorrhachia and hypocomplementemia seem to be protective factors for relapse. Intravenous cyclophosphamide was associated with time delay to relapse. CONCLUSIONS Systemic lupus erythematosus-related ATM may occur at any time of SLE course, leading to significant disability despite treatment. Relapses are infrequent and intravenous cyclophosphamide seems to delay it. Hypoglycorrhachia, hypocomplementemia, and EGS at nadir are the most important prognostic factors.
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Affiliation(s)
| | | | | | | | | | - Lucas Alessandro
- Department of Neurology, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires
| | - Jorge Correale
- Department of Neurology, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires
| | | | | | | | - Franco Pacello
- Department of Internal Medicine, Hospital Galán y Rocha, Paysandu, Uruguay
| | - Mauro Stagno
- Department of Internal Medicine, Hospital Galán y Rocha, Paysandu, Uruguay
| | | | | | | | | | | | - Isabel Acosta Colman
- Department of Rheumatology, Hospital de Clínicas Universidad Nacional de Asunción, Asuncion, Paraguay
| | | | | | | | - Magaly Alva Linares
- Rheumatology Division, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | | | - Hilda Esther Fragoso-Loyo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City
| | - Lauro Quintanilla-González
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City
| | | | - Emilia Inoue Sato
- Rheumatology Division, Department of Medicine, Universidade Federal de Sao Paulo, São Paulo, Brazil
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19
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Pavesi-Krieger C, Rech MA, Lovett S. Atypical presentation of transverse myelitis in the emergency department. Am J Emerg Med 2021; 50:813.e5-813.e6. [PMID: 34217564 DOI: 10.1016/j.ajem.2021.06.033] [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: 05/28/2021] [Revised: 06/07/2021] [Accepted: 06/13/2021] [Indexed: 11/29/2022] Open
Abstract
Transverse myelitis (TM) is an inflammatory disorder of the spinal cord characterized by acute onset sensory loss and motor weakness below the level of the lesion. The etiology of the disease is varied, and diagnosis of TM in the Emergency Department (ED) can be difficult owing to the low incidence of the disease, and frequently insidious onset. We report a case of a 59-year-old female who presented to the ED from home with left upper quadrant abdominal pain and flank pain of sudden onset. While in the ED, she experienced left lower extremity weakness and sensory changes that slowly progressed bilaterally, and ultimately was diagnosed with transverse myelitis. Transverse myelitis rarely diagnosed in the ED setting, but it is an important clinical consideration when evaluating ED patients presenting with both pain and progressive neurologic symptoms.
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Affiliation(s)
- Clara Pavesi-Krieger
- Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Ave, Maywood, IL 60153, United States of America
| | - Megan A Rech
- Department of Emergency Medicine, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States of America
| | - Shannon Lovett
- Department of Emergency Medicine, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States of America.
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20
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Silvagni E, Chessa E, Bergossi F, D'Amico ME, Furini F, Guerrini G, Cauli A, Scirè CA, Bertsias G, Govoni M, Piga M, Bortoluzzi A. Relevant domains and outcome measurement instruments in Neuropsychiatric Systemic Lupus Erythematosus: a systematic literature review. Rheumatology (Oxford) 2021; 61:8-23. [PMID: 33788917 DOI: 10.1093/rheumatology/keab324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Although neuropsychiatric involvement in Systemic Lupus Erythematosus (NPSLE) is one of the most complex and troubling manifestations of the disease, validated outcome instruments to be used as sensitive endpoints in controlled clinical trials are lacking. We set out a systematic literature review (SLR) to identify outcome measurement instruments and domains used to assess NPSLE. METHODS The Preferred Reporting Items for systematic reviews and Meta-analysis (PRISMA) guidelines were used. Articles available in English (1967-2020), listed in PubMed, EMBASE, PsycINFO, Cochrane Library and EULAR outcome measures library were screened. All domains and outcome measurement instruments were characterized according to the OMERACT Filter 2.1, considering core areas (manifestations/abnormalities, life impact, death/lifespan, societal/resource use) and contextual factors. RESULTS Of 3,392 abstracts evaluated, 83 studies were included in the SLR (15,974 patients, females 89.9%). Eligible studies included domains and instruments pertinent to all core areas defined by OMERACT, except for "societal/resource use". The most common core areas were "manifestations/abnormalities", covering 10 domains pertinent to laboratory and instrumental markers, indexes and neuropsychiatric dimension (cognitive, neurologic and psychiatric field), and "life impact", covering 7 domains related to physical function (from both the perspective of the patient and the physician), pain and quality of life. CONCLUSION Our study revealed great heterogeneity in the instruments derived from populations with NPSLE and none of these had high-quality evidence. This supports the need to develop and further validate a core domain set and outcome measurement instruments to promote clinical research in this field, enhancing comparability across studies.
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Affiliation(s)
- Ettore Silvagni
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Elisabetta Chessa
- Rheumatology Unit, University Clinic and Azienda Ospedaliero-Universitaria of Cagliari, Cagliari (CA), Italy
| | - Francesca Bergossi
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Maria Ester D'Amico
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Federica Furini
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy.,Rheumatology Unit, Maggiore Hospital AUSL, Bologna, Italy
| | - Giulio Guerrini
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy.,Internal Medicine, State Hospital, Borgo Maggiore, Republic of San Marino
| | - Alberto Cauli
- Rheumatology Unit, University Clinic and Azienda Ospedaliero-Universitaria of Cagliari, Cagliari (CA), Italy
| | - Carlo Alberto Scirè
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy.,Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy Unit, University of Crete, Heraklion, Greece
| | - Marcello Govoni
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Matteo Piga
- Rheumatology Unit, University Clinic and Azienda Ospedaliero-Universitaria of Cagliari, Cagliari (CA), Italy
| | - Alessandra Bortoluzzi
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
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21
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A case of longitudinally extensive transverse myelitis in an 80-year-old patient with systemic lupus erythematous and anti-aquaporin 4 antibodies. Mult Scler Relat Disord 2021; 51:102899. [PMID: 33812223 DOI: 10.1016/j.msard.2021.102899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/09/2021] [Accepted: 03/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Systemic Lupus Erythematous is a systemic autoimmune disease with multiorgan inflammation. Clinical manifestations are variable and may involve the Central Nervous System. Acute transverse myelitis is a rare complication. Recent studies have shown an association between SLE, transverse myelitis and presence of anti-aquaporin 4 antibodies. CASE PRESENTATION We describe the case of an 80-year-old woman with a subacute onset of right hemiplegia followed by left-sided ataxia. Cervical MRI revealed longitudinally extensive transverse myelitis. Blood examinations showed positivity for anti-nuclear antibodies, anti-double-stranded DNA antibodies, anti-phospholipid antibodies and anti-aquaporin 4 antibodies. CONCLUSIONS Anti-aquaporin 4 antibody testing is of paramount importance in order to reach a correct diagnosis and to treat patients with the best therapeutic approach.
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22
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Bachhuber A. [Inflammatory spinal cord diseases and transverse myelitis]. Radiologe 2021; 61:251-257. [PMID: 33570678 PMCID: PMC7876978 DOI: 10.1007/s00117-021-00816-4] [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] [Accepted: 01/19/2021] [Indexed: 11/23/2022]
Abstract
Hintergrund Entzündliche Rückenmarkerkrankungen zeigen MR-morphologisch recht einheitliche Bilder, dennoch sind deren richtige Zuordnung zu einer Krankheit für die Therapie und weiteren Verlauf entscheidend. Fragestellung Welche Merkmale der Läsionen erlauben eine richtige Einordnung? Material und Methode Recherche von Artikeln in pubmed.gov, die Myelitiden verschiedener Ätiologie beschreiben. Ergebnisse Die Länge der Läsionen, deren Lokalisation im Rückenmark sowohl bezüglich Höhe als auch im Myelonquerschnitt, und das Kontrastmittelverhalten erlauben in vielen Fällen zumindest eine Eingrenzung der Differenzialdiagnosen. Zum Überblick werden die wichtigsten Charakteristika in einer Tabelle zusammengefasst. Schlussfolgerung Eine sichere Zuordnung ist nur in Ausnahmefällen möglich, da sich viele Entitäten überlappen. Besonders schwierig ist dies bei Erkrankungen, die seltener vorkommen, und deswegen diesbezüglich wenig Erfahrung vorhanden ist.
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Affiliation(s)
- A Bachhuber
- , Kirrberger Str. Geb. 90, 66424, Homburg, Deutschland.
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23
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Para-infectious anti-GD2/GD3 IgM myelitis during the Covid-19 pandemic: Case report and literature review. Mult Scler Relat Disord 2021; 49:102783. [PMID: 33513521 PMCID: PMC7826058 DOI: 10.1016/j.msard.2021.102783] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/31/2020] [Accepted: 01/17/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Even though SARS-CoV-2 is a predominantly respiratory virus, several reports have described various neurological disorders, from the beginning of the pandemic. The first para-infectious myelitis case was described in Wuhan in February 2020. Nevertheless, data from registries and reviews are scarce. METHODS A 40-year-old female with T5-T6 SARS-CoV-2 para-infectious myelitis is reported. A literature review of the published literature on the SARS-CoV-2 and para-infectious myelitis was done. Epidemiological, clinical, laboratory, image, treatment, and outcome data are described. RESULTS Particular findings of our case are that Covid-19 was asymptomatic and anti-GD2/GD3 IgM was found. 18 para-infectious myelitis occurred over a wide age range (Beh et al., 2013-67), mean age 50.7±18.6 years, with 10/18 (55.6%) women. Covid-19 involvement was variable from asymptomatic cases to severe Covid-19 resulting in death. The mean time to establish myelitis from the onset of Covid-19 symptoms was 10.3 ±7.8 days (0-24). The most common clinical form was transverse myelitis (14/18 patients, 77.7%) and the most frequent radiological form was longitudinally extensive myelitis (11/17 patients, 64.7%). In CSF mild lymphocytosis (14/16, 87.5%) with low cellularity (40.9±49.7/μL) and elevated proteins (11/16, 77.8%, mean 145.0 mg±159.0/dL) were frequent. Oligoclonal bands were usually negative (7/9, 77.7%) and mirror pattern was found in 2/7 patients (33.3%). SARS-CoV-2 PCR in CSF was negative in 10/10 cases. CONCLUSION SARS-CoV-2 can cause myelitis by immune-mediated mechanisms. Clinical-radiological characteristics of Covid-19 para-infectious myelitis were variable and non-specific.
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24
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Papachristos DA, Oon S, Hanly JG, Nikpour M. Management of inflammatory neurologic and psychiatric manifestations of systemic lupus erythematosus: A systematic review. Semin Arthritis Rheum 2020; 51:49-71. [PMID: 33360230 DOI: 10.1016/j.semarthrit.2020.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/06/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The neurological and psychiatric manifestations of systemic lupus erythematosus (NPSLE) are a heterogeneous group of conditions with variable clinical presentation and significant morbidity and mortality. OBJECTIVES Our aim was to comprehensively assess and present the evidence for treatments used in the management of inflammatory NPSLE. METHODS Medline, Embase, CINHAL and Cochrane CENTRAL were searched from 1990 to end of March 2019 using key words that related to NPSLE and treatment. Included studies comprised clinical trials, observational studies or case series with ≥5 patients and sufficient data related to treatment and outcome in NPSLE patients. RESULTS There were 7222 studies identified in the search, of which 90 were included in the review. There was a notable paucity of clinical trials, with only two randomised controlled trials and one pilot study. Treatment categories included corticosteroids (14 studies), cyclophosphamide (18 studies), synthetic DMARDs (7 studies), biologic therapies (14 studies), therapeutic plasma exchange (6 studies), intravenous immunoglobulin (2 studies), autologous stem cell transplant (3 studies), other therapies (8 studies), combination therapies (6 studies), studies with grouped outcome data (5 studies) and observational studies with therapy-specific associations (7 studies). Corticosteroids are accepted as first line treatment in NPSLE and there is low-moderate evidence supporting their benefit. Moderate evidence, based on consistent data in numerous studies and some trial data, supports the use of cyclophosphamide in the treatment of NPSLE. Limited data support some synthetic DMARDs such as mycophenolate, azathioprine and intrathecal methotrexate. In refractory disease, low-moderate evidence supports rituximab therapy and limited evidence supports benefit following autologous stem cell transplant. Regarding adjuvant treatments, limited evidence favours addition of plasma exchange, intravenous immunoglobulin and hydroxychloroquine. There exists very limited data for other therapies. CONCLUSION There are multiple therapeutic options for the management of inflammatory NPSLE including systemic, biologic and interventional therapies; however, currently there is a paucity of high-quality trial data to guide firm recommendations. In order to better understand the optimal treatment of NPSLE and its different subtypes, further well-designed clinical trials are needed.
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Affiliation(s)
- D A Papachristos
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - S Oon
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, The Royal Melbourne Hospital, Australia
| | - J G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, NS, Canada
| | - M Nikpour
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Australia.
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Elnady B, Fathy SM, Elkhouly T, Ganeb S. Neuromyelitis optica spectrum standstill in rheumatic systemic autoimmune diseases. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2020. [DOI: 10.1186/s43166-020-00018-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
Neuromyelitis optica spectrum disorders (NMOSD) are considered as an autoantibody-mediated disorder that targets aquaporin-4 (AQP4); other autoantibodies could be detected in such spectrum of diseases, including anti-nuclear antibody and antibodies to extractable nuclear antigens. Systemic autoimmune diseases such as systemic lupus erythematosus (SLE), Sjogren’s syndrome (SS), and other autoimmune diseases can overlap with NMOSD. We aimed in this review to address the current evidence describing the relation of NMOSD to systemic autoimmunity diseases, its controversy of being co-association or the same etiology, and its practical implications.
Main body
The current review was done using a search for related articles or case reports on PubMed until 2019. The keywords included neuromyelitis optica spectrum disorders in combination with autoimmune disease nomenclature. We described the literature background of this controversy, to summarize the evidence of NMOSD relationship to systemic autoimmune diseases.
Conclusion
NMOSD associated with systemic autoimmune diseases is more common in SLE and Sjogren’s syndrome rather than other autoimmune diseases, frequently affects females more than males; AQP4 antibodies should be tested for all NMOSD like manifestations associated with an autoimmune disorder; however, the clinical diagnosis of NMOSD regardless of the cord lesion length and the presence of positive AQP4 antibody can occur in systemic autoimmune diseases.
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Smith E, Jaakonmäki N, Nylund M, Kupila L, Matilainen M, Airas L. Frequency and etiology of acute transverse myelitis in Southern Finland. Mult Scler Relat Disord 2020; 46:102562. [PMID: 33059215 DOI: 10.1016/j.msard.2020.102562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/22/2020] [Accepted: 10/02/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acute transverse myelitis is a relatively rare, frequently debilitating but potentially treatable emergency. The objective of this study was to evaluate the incidence and etiology of acute transverse myelitis in two major hospital districts in Southern Finland. METHODS We identified all patients with acute transverse myelitis admitted to Turku University Hospital and Päijät-Häme Central hospital during nine years. The two hospitals serve a catchment area of 673,000 people in Southern Finland. Acute transverse myelitis was diagnosed according to the 2002 Transverse Myelitis Consortium Working Group. Patient files were reviewed for details of the clinical presentation and disease outcome, for laboratory findings and for neuroimaging. Charts were re-evaluated after an average of 7.7 years for confirmation of the acute transverse myelitis etiology. RESULTS In total 63 patients fulfilled the Transverse Myelitis Consortium Working Group diagnostic criteria for acute transverse myelitis. The frequency of the condition was hence 1.04 cases/ 100,000 inhabitants/ year. In the studied cohort, 7/63 (11%) patients had idiopathic transverse myelitis after initial evaluation and in 4/63 (6.3%) patients the idiopathic transverse myelitis remained the final diagnosis after follow-up and re-evaluation. Of the disease-associated myelitis cases MS or clinically isolated syndrome was the largest group, explaining 41% of all myelitis cases. The mean follow-up time before a patient was diagnosed with MS was 1.7 ± 2.2 years. Other etiologies included acute disseminated encephalomyelitis (ADEM), neurosarcoidosis, neuromyelitis optica (NMO), systemic autoimmune diseases and infectious diseases. CONCLUSIONS In more than half of the acute transverse myelitis cases the final diagnosis is other than MS. Careful diagnostic work-up is needed for correct early treatment and best long-term outcome.
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Affiliation(s)
- Emma Smith
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Nina Jaakonmäki
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Marjo Nylund
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Laura Kupila
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Markus Matilainen
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Laura Airas
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland.
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Wang P, Zhang S, Lv H, Qiao G, Zhong X, Li H, Zhang L. Clinical efficacy of γ-globulin combined with dexamethasone and methylprednisolone, respectively, in the treatment of acute transverse myelitis and its effects on immune function and quality of life. Exp Ther Med 2020; 20:104. [PMID: 32989383 PMCID: PMC7517252 DOI: 10.3892/etm.2020.9234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 04/29/2020] [Indexed: 11/25/2022] Open
Abstract
Effects of γ-globulin combined with dexamethasone or methylprednisolone in the treatment of acute transverse myelitis (ATM) were investigated. A retrospective analysis of medical records from 136 ATM patients admitted to Linzi District People's Hospital from July 2014 to September 2017 was performed. Patients treated with dexamethasone combined with γ-globulin were in group A (66 cases), and patients treated with methylprednisolone combined with γ-globulin were in group B (70 cases). Clinical efficacy, recovery time of bone marrow function and incidence rate of adverse reactions were analyzed and compared between the two groups. T-lymphocyte subsets in peripheral blood of both groups were detected by Flow cytometry. Quality of life of patients was assessed by the Quality of Life Scale (SF-36) developed by the American Institute of Medicine. Time of sensory recovery, self-walking, improving muscle strength at two levels and urination recovery after treatment in group B were significantly shorter than those in group A (P<0.001); effective rate of treatment in group B was significantly higher than that in group A (P<0.05); incidence rate of adverse reactions in group B was significantly lower than that in group A (P<0.05); ratios of CD3+, CD4+, CD8+ cells and CD4+/CD8+ in peripheral blood of group A and group B after treatment were significantly higher than those before treatment (P<0.05); scores of general health (GH), physical function (PF), role physical (RP), body pain (BP), social function (SF), role emotional (RE), mental health (MH) and vitality (VT) in group B after treatment were significantly higher than those in group A (P<0.05). In conclusion, clinical efficacy of γ-globulin combined with methylprednisolone in the treatment of ATM patients shows definitely fewer adverse reactions, which can improve their immune function and quality of life.
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Affiliation(s)
- Peiquan Wang
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Suhua Zhang
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Hongchun Lv
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Gang Qiao
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Xiaodong Zhong
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Hua Li
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Lili Zhang
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
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Sonoda-Shimada K, Kajihara I, Jinnin M, Ihn H. A successful case of lupus myelitis treated with intravenous pulse methylprednisolone and pulse cyclophosphamide therapy. Drug Discov Ther 2020; 14:209-210. [PMID: 32863325 DOI: 10.5582/ddt.2020.03065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lupus myelitis is a rare but serious condition characterized by myelopathy in patients with systemic lupus erythematosus (SLE). Its presentation is usually acute or subacute, and it is often refractory to treatment. We reported a rare presentation of lupus myelitis in a 38-year-old Japanese woman with a 20-year history of SLE. She developed paraparesis and bladder/bowel dysfunction 6 months prior to presentation. Magnetic resonance imaging revealed atrophy of the entire thoracic spinal cord with high intensity on T1-weighted sequence. She was initially treated with intravenous pulse steroid therapy, and prednisolone (20 mg/day) was continued; mizoribine was changed to azathioprine (100 mg/day). In addition, she underwent a rehabilitation program to improve lower-extremity muscle weakness. Moreover, because of the refractory clinical condition, intravenous cyclophosphamide pulse therapy was added. Within 1 month, she could walk with a cane and had a desire to urinate and defecate. In conclusion, early and aggressive treatment improves the permanent damage of lupus myelitis.
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Affiliation(s)
- Kanako Sonoda-Shimada
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Ikko Kajihara
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.,Department of Dermatology, Wakayama Medical University Graduate School of Medicine, Wakayama, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Topuzova MP, Bisaga GN, Alekseeva TM, Isabekova PS, Сhaykovskaya AD, Panina EB, Pavlova TA, Ternovykh IK. [Transverse myelitis syndrom as a result of neuromyelitis optica spectrum disorders, systemic lupus erythematosus and myasthenia gravis combination]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:97-106. [PMID: 32844638 DOI: 10.17116/jnevro202012007297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) - autoimmune condition characterized by an inflammatory lesions mainly of the spinal cord with the development of longitudinally extensive transverse myelitis (LETM) and/or involvement of the optic nerve with the development of usually bilateral optical neuritis (ON). In recent years, there has been increased awareness that NMOSD can be combined with other autoimmune diseases, including myasthenia gravis (MG), systemic lupus erythematosus (SLE) et al. The simultaneous presence of several autoimmune diseases in one patient can adversely affect the course of each of the diseases, causing the so-called mutual burden or «overlap syndrome». In this article, we describe our own clinical observation of a 51-year-old woman of European origin who developed acute relapsing TM seropositive for AQP4-IgG, by 23 years after the diagnosis of generalized MG seropositive for antibodies to acetylcholine receptors (AChR-Ab) and the occurrence of SLE, criterially confirmed, several months after the initial TM attack. During the fourth TM attack, partial positive dynamics was achieved only against the background of the combined use of intravenous methylprednisolone (pulse therapy), high-volume plasma exchange, rituximab and cyclophosphamide. The NMOSD is a rare disease leading to severe disability. In patients with MG, when symptoms of damage to the central nervous system appear, an analysis should be performed for AQP4-IgG and possibly for antibodies to myelin glycoprotein of oligodendrocytes (MOG-Ab), as well as markers characteristic of systemic connective tissue diseases (SCTD). In patients with STDD, when symptoms of involvement nervous systemappear, testing for AQP4-IgG (and, if necessary, for MOG-Ab) should be performed to exclude NMOSD, as well as AChR-Ab (and, if necessary, antibodies against muscle specific kinase (MuSK-Ab)) to exclude MG.
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Affiliation(s)
- M P Topuzova
- Almazov National Medical Research Centre, St Petersburg, Russia
| | - G N Bisaga
- Almazov National Medical Research Centre, St Petersburg, Russia
| | - T M Alekseeva
- Almazov National Medical Research Centre, St Petersburg, Russia
| | - P Sh Isabekova
- Almazov National Medical Research Centre, St Petersburg, Russia
| | | | - E B Panina
- Almazov National Medical Research Centre, St Petersburg, Russia
| | - T A Pavlova
- Almazov National Medical Research Centre, St Petersburg, Russia
| | - I K Ternovykh
- Almazov National Medical Research Centre, St Petersburg, Russia
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Byon JH, Park EH, Lee CH. Early Diagnosed Hirayama Disease with Unusual Symptoms Improved by Steroid Pulse Therapy. World Neurosurg 2020; 140:119-121. [PMID: 32434017 DOI: 10.1016/j.wneu.2020.05.080] [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: 03/21/2020] [Revised: 05/09/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hirayama disease (HD), or monomelic amyotrophy, is a benign neurologic disorder mostly affecting young Asian men. It usually presents with unilateral or bilateral muscular atrophy and weakening of the upper limbs. We treated a patient with HD with bilateral hand paresthesia and weakness in 1 hand and both legs. To our knowledge, this is the first HD case including lower extremity weakness and sensory abnormalities. We improved the patient's symptoms by administering steroids in parallel with conservative treatment. CASE DESCRIPTION A 22-year-old man visited our clinic with bilateral hand paresthesia and weakness in the right hand and both legs. He had been affected 40 days. Results of blood and cerebrospinal fluid tests were normal. Evoked potential study and brain magnetic resonance imaging (MRI) were normal. In cervical MRI, however, a lesion with high signal intensity of the C6 level on T2-weighted images was confirmed, and gray and white matter were extensively invaded. We performed empirical steroid pulse therapy before the results of blood tests to differentiate spinal demyelinating disease. MRI with neck flexion showed HD-related findings, and autoantibody tests showed no specific findings. After steroid pulse therapy, his neurologic symptoms improved within 7 days, leaving only paresthesia of toes of both feet when discharged. CONCLUSIONS HD occurs at a young age and therefore can damage quality of life. Although the patient had unusual symptoms, the condition was diagnosed quickly, and his symptoms improved with steroid therapy. If HD is suspected, additional tests such as MRI with neck flexion should be performed and early steroid treatment might be considered.
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Affiliation(s)
- Jung Hee Byon
- Department of Radiology, Jeonbuk National University School of Medicine and Hospital, Deokjin-gu, Jeonju, South Korea; Research Institute of Clinical Medicine, Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Deokjin-gu, Jeonju, South Korea
| | - Eun Hae Park
- Department of Radiology, Jeonbuk National University School of Medicine and Hospital, Deokjin-gu, Jeonju, South Korea; Research Institute of Clinical Medicine, Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Deokjin-gu, Jeonju, South Korea
| | - Chan-Hyuk Lee
- Department of Neurology, Jeonbuk National University School of Medicine and Hospital, Deokjin-gu, Jeonju, South Korea; Research Institute of Clinical Medicine, Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Deokjin-gu, Jeonju, South Korea.
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Zhang S, Wang Z, Zhao J, Wu DI, Li J, Wang Q, Su J, Xu D, Wang Y, Li M, Zeng X. Clinical features of transverse myelitis associated with systemic lupus erythematosus. Lupus 2020; 29:389-397. [DOI: 10.1177/0961203320905668] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective This study aimed to identify the clinical characteristics and prognostic factors of systemic lupus erythematosus with transverse myelitis (SLE-TM) in a relatively large patient series. Methods This retrospective study considered 45 SLE-TM individuals treated as inpatients and outpatients at Peking Union Medical College Hospital between 1993 and 2018. SLE-TM patients were compared with 180 controls, and SLE-TM patients with neuromyelitis optica spectrum disorder (NMOSD) were compared to those without NMOSD. Results Compared to controls, the SLE-TM group frequently had a fever and had a significantly higher positive rate of anticardiolipin and lupus anticoagulant. Among the 45 patients, 22 met the NMOSD criteria. Compared to non-NMOSD patients, NMOSD patients had a lower incidence of rash ( p = 0.023), serositis ( p = 0.042) and renal disorder ( p = 0.073); a lower prevalence of decreased complement ( p = 0.083); and lower rates of positive anti-dsDNA ( p = 0.074) and anti-Sm ( p = 0.042). Among 22 SLE-TM patients with NMOSD, 18 underwent aquaporin 4 antibody testing, with 11 showing positive results. Out of the 45 patients, 39 were given methylprednisolone pulse treatment. After treatment, 32 patients had lower-limb muscle strength recovery (recovered group), whereas 13 had no change and persistent severe neurological deficits (non-recovered group). Compared to the recovered group, the non-recovered group were younger ( p = 0.002), had a higher likelihood of having a fever ( p = 0.020), initial severe myelitis ( p < 0.001), long spinal segment involvement ( p = 0.017) and higher C-reactive protein levels ( p = 0.020). Methylprednisolone pulse given within two weeks of onset was more frequent in the recovered group than in the non-recovered group ( p = 0.082). Conclusions Disease characteristics differed between SLE-TM patients with and without NMOSD. SLE and NMOSD tended to be co-morbidities. Initial severe neurological impairment, extensive spinal cord lesions, hyper-inflammation and delayed steroid impulse treatment could be predictors of poor outcome for SLE-TM.
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Affiliation(s)
- S Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - Z Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - J Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - D i Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - J Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - Q Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - J Su
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - D Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - Y Wang
- Department of Epidemiology and Bio-statistics (YW), Institute of Basic Medical Sciences, China Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - M Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
| | - X Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Centre for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, PR China
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Monahan RC, Beaart HJL, Fronczek R, Terwindt GM, Beaart-van de Voorde LJJ, de Bresser J, Kloppenburg M, van der Wee NJA, Huizinga TWJ, Steup-Beekman GM. Suspected Transverse Myelitis with Normal MRI and CSF Findings in a Patient with Lupus: What to Do? A Case Series and Systematic Review. Neuropsychiatr Dis Treat 2020; 16:3173-3186. [PMID: 33376333 PMCID: PMC7764958 DOI: 10.2147/ndt.s267000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/27/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate the use of immunosuppressive treatment, clinical outcome and diagnostic strategy in patients with systemic lupus erythematosus (SLE) presenting with clinical features of transverse myelitis (TM), but normal MRI of the spinal cord (sMRI) and normal cerebrospinal fluid (CSF) assessment, and to suggest a clinical guideline. PATIENTS AND METHODS All patients with SLE and clinical features compatible with (sub)acute TM visiting the NPSLE clinic of the LUMC between 2007 and 2020 were included. Information on baseline characteristics, investigations, treatment and outcomes was collected from electronic medical records. In addition, a systematic review of individual participant data was performed up to April 2020 in PubMed, Embase and Web of Science, identifying all patients with TM, SLE and sMRI assessment. Data regarding sMRI, CSF analysis, treatment and outcome were extracted, and outcome was compared between patients with normal sMRI and CSF (sMRI-/CSF-) and patients with abnormalities. RESULTS Twelve SLE patients with a clinical diagnosis of TM were identified: four sMRI-/CSF- and one sMRI- with CSF not available. All patients received immunosuppressive treatment, but outcome in sMRI-/CSF- patients was worse: no recovery (n=1) or partial recovery (n=3) compared to partial recovery (n=4) and (nearly) complete recovery (n=3) in MRI+ patients. The systematic literature review yielded 146 articles eligible for inclusion, 90% case reports. A total of 427 SLE patients with TM were identified, of which only four cases were sMRI-/CSF- (1%), showing no improvement (n=1), partial improvement (n=2) and complete recovery (n=1) after immunosuppressive treatment. CONCLUSION Outcome in SLE patients presenting with clinically suspected TM with normal sMRI and CSF is less favorable, despite treatment with immunosuppressive therapy. Taking a functional neurological disorder into consideration may be helpful in order to start other therapeutic strategies. We suggest prescribing immunosuppressive treatment for a restricted period of time to evaluate its effect in cases where a functional disorder initially is considered unlikely.
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Affiliation(s)
- Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Hannelore J L Beaart
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, LUMC, Leiden, the Netherlands.,Sleep-Wake Center SEIN, Heemstede, the Netherlands
| | | | | | | | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands.,Department of Clinical Epidemiology, LUMC, Leiden, the Netherlands
| | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands.,Department of Rheumatology, Haaglanden Medical Center, The Hague, the Netherlands
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Wildner P, Stasiołek M, Matysiak M. Differential diagnosis of multiple sclerosis and other inflammatory CNS diseases. Mult Scler Relat Disord 2020; 37:101452. [DOI: 10.1016/j.msard.2019.101452] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 12/12/2022]
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35
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Williams JN, Speyer CB, Kreps DJ, Kimbrough DJ, Costenbader K, Bhattacharyya S. Spinal cord syndromes in patients with systemic lupus erythematosus: differentiating lupus myelitis, neuromyelitis optica, and multiple sclerosis. Lupus 2019; 28:1656-1662. [PMID: 31679449 DOI: 10.1177/0961203319886103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Non-infectious myelitis in systemic lupus erythematosus (SLE) may be due to SLE myelitis, comorbid multiple sclerosis (MS), or neuromyelitis optica (NMO). We compared characteristics of these three conditions in SLE patients at a large academic institution. METHODS We searched for neurologic diagnoses of SLE myelitis, NMO myelitis, and MS myelitis among 2297 patients with at least four 1997 American College of Rheumatology revised criteria for SLE between 2000 and 2015. Each subject was reviewed by a neurologist to confirm the underlying neurologic diagnosis. Demographic, clinical, laboratory, and radiographic data were extracted and compared using Fisher's exact test, analysis of variance, and Wilcoxon rank-sum test. RESULTS Fifteen of the 2297 subjects with SLE (0.7%) met criteria for a spinal cord syndrome: seven had SLE myelitis, three had AQP4 seropositive NMO, and five had MS. The median SLE Disease Activity Index 2000 score at time of neurologic syndrome presentation was higher in SLE myelitis subjects (8, interquartile range (IQR) 7-16) compared with subjects with NMO (6, IQR 0-14) or MS (2, IQR 0-4), p = 0.02. Subjects with SLE myelitis were also more likely to have elevated anti-dsDNA antibodies at presentation (86%) compared with subjects with NMO (33%) or MS (0%), p = 0.03. CONCLUSION Myelitis occurs rarely among patients with SLE. Compared with subjects with SLE + NMO and subjects with SLE + MS, subjects with SLE myelitis had higher SLE disease activity at presentation.
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Affiliation(s)
- J N Williams
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - C B Speyer
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - D J Kreps
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - D J Kimbrough
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - K Costenbader
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - S Bhattacharyya
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Vinogradova ES, Panova AP, Bulanov NM, Novikov PI, Moiseev SV. Systemic lupus erythematosus with the development of neuromyelitis optica (Devic's syndrome) is a rare combination of autoimmune diseases. MODERN RHEUMATOLOGY JOURNAL 2019. [DOI: 10.14412/1996-7012-2019-4-89-95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Neuromyelitis optica ((NMO), Devic's syndrome) is an immune-mediated inflammatory demyelinating disease characterized by transverse myelitis and optic neuritis. Determination of the level of antibodies to aquaporin 4 (NMO-IgG) is presently one of the key methods for the diagnosis and assessment of the activity of ONM, which allows this disease to be differentiated from multiple sclerosis and other demyelinating CNS lesions. ONM can occur not only as an independent disease, but also as a syndrome in different systemic diseases, such as: systemic lupus erythematosus (SLE), antineutrophilic cytoplasmic antibody-associated vasculitides, Sjögren's disease, etc. (up to 50–70%). In such situations, the clinician is always confronted with a question as whether the patient can have two rare autoimmune diseases or develop ONM as a systemic manifestation of rheumatic disease.The paper describes a clinical case of a young female patient with SLE concurrent with a CNS lesion, the manifestations of which corresponded to ONM. The patient had focal changes in the substance of the brain and spinal cord, as evidenced by magnetic resonance imaging, as well as high NMO-IgG titers. The development of ONM worsens SLE prognosis and requires active immunosuppressive therapy. The patient received three plasmapheresis sessions, ultrahigh-dose glucocorticoid and cyclophosphamide therapy, followed by replacement with azathioprine, causing a stable clinical and laboratory disease remission to be achieved.
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Affiliation(s)
- E. S. Vinogradova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia; M.V. Lomonosov Moscow State University
| | | | - N. M. Bulanov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - P. I. Novikov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - S. V. Moiseev
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia; M.V. Lomonosov Moscow State University
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Hao Y, Xin M, Wang S, Ma D, Feng J. Myelopathy associated with mixed connective tissue disease: clinical manifestation, diagnosis, treatment, and prognosis. Neurol Sci 2019; 40:1785-1797. [DOI: 10.1007/s10072-019-03935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 05/09/2019] [Indexed: 11/27/2022]
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Nagai Y, Yokogawa N, Shimada K, Sugii S. Characteristics and risk factors of an emergency department visit in patients with systemic lupus erythematosus. Rheumatol Int 2019; 39:1567-1573. [PMID: 31309295 DOI: 10.1007/s00296-019-04377-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
Abstract
This study aimed to examine the characteristics of patients with systemic lupus erythematosus (SLE) visiting the emergency department (ED) and the risk factors of an ED visit by these patients. This 4-year retrospective study was performed at a tertiary care center in Japan. We included all 205 patients with SLE who were treated in our outpatient clinic between April 1, 2008 and March 31, 2012 and divided them into two groups: those who visited the ED (the ED-user group) and those who did not (the ED-non-user group). We statistically compared the patient backgrounds and characteristics of the groups and identified the risk factors of an ED visit. Of all the patients, 118 visited the ED during study period and 87 did not. In total, 269 events were identified in the ED-user group. Of these, 91 (33.8%) were cases of infection, 32 (11.9%) were orthopedic problems, 32 (11.9%) were cases of gastrointestinal disease, 31 (11.5%) were cases of neurological disease, and 25 (9.3%) were cardiovascular events. Twenty-four events (8.9%) were due to SLE flares, of which ten (41.7%) were cases of neuropsychiatric lupus (NPSLE). The glucocorticoid dosage and the presence of a psychiatric illness, NPSLE, and lupus nephritis were higher among the ED-user group. Multivariate logistic regression analysis demonstrated high glucocorticoid dosage to be a risk factor of an ED visit. Among SLE patients, infections were the principal reason for visiting the ED. The most common reasons for an ED visit were common diseases rather than flares.
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Affiliation(s)
- Yoshiki Nagai
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan.
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan
| | - Kota Shimada
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan
| | - Shoji Sugii
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan
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Coincidence of Guillain-Barré syndrome presenting with Landry's acute flaccid paralysis and transverse myelitis. Reumatologia 2019; 57:120-122. [PMID: 31130752 PMCID: PMC6532110 DOI: 10.5114/reum.2019.84819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/25/2019] [Indexed: 11/17/2022] Open
Abstract
Transverse myelitis is one of the causes of acute transverse myelopathy; three main categories are described in the differential diagnosis of transverse myelitis: demyelination (multiple sclerosis, neuromyelitis optica), infections (herpes zoster and herpes simplex virus), and some autoimmune connective tissue disorders (systemic lupus erythematosus, vasculitis). The authors present a clinical case of a 33-year-old patient with transverse myelitis occurring in the course of acute inflammatory demyelinating polyradiculoneuropathy (Guillain-Barré syndrome). The patient's medical history was notable. The patient was diagnosed with thrombotic thrombocytopenic purpura (Moschcowitz syndrome) and leukocytoclastic vasculitis when he was 12 years old.
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Ahn SM, Hong S, Lim DH, Ghang B, Kim YG, Lee CK, Yoo B. Clinical features and prognoses of acute transverse myelitis in patients with systemic lupus erythematosus. Korean J Intern Med 2019; 34:442-451. [PMID: 29294596 PMCID: PMC6406093 DOI: 10.3904/kjim.2016.383] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/12/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND/AIMS Acute transverse myelitis (ATM) is a severe complication of systemic lupus erythematosus (SLE). This study evaluated the clinical factors related to outcome in patients with SLE-associated ATM. METHODS The medical records of patients diagnosed with SLE-associated ATM between January 1995 and January 2015 were reviewed. The patients were divided into two groups based on improvement of neurological deficits after treatment: favorable response group and unfavorable response group. During follow-up, the recurrence of ATM was also analyzed. RESULTS ATM was identified in 16 patients with SLE. All of the patients were treated with high doses of methylprednisolone (≥ 1 mg/kg daily). Although 12 patients (75%) recovered (favorable response group), four (25%) had persistent neurologic deficits (unfavorable response group) after the treatment. Compared to the favorable response group, significantly higher Systemic Lupus Erythematosus Disease Activity Index-2000, lower complement levels and initial severe neurologic deficits were found in the unfavorable response group. Among the 12 favorable response patients, five (41.7%) experienced recurrence of ATM during the followup. Patients (n = 5) who experienced relapse had a shorter duration of high-dose corticosteroid treatment (13.2 days vs. 32.9 days, p = 0.01) compared to patients who did not relapse. The mean duration of tapering-off the corticosteroid until 10 mg per day was significantly longer in non-relapse group (151.3 ± 60.8 days) than in relapse group (63.6 ± 39.4 days, p = 0.013). CONCLUSION Higher disease activity in SLE and initial severe neurologic deficits might be associated with the poor outcome of ATM. Corticosteroid slowly tapering-off therapy might be helpful in preventing the recurrence of ATM.
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Affiliation(s)
- Soo Min Ahn
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Doo-Ho Lim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byeongzu Ghang
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Bin Yoo, M.D. Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3282 Fax: +82-2-3010-6969 E-mail:
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Magnetic resonance imaging in immune-mediated myelopathies. J Neurol 2019; 267:1233-1244. [PMID: 30694379 DOI: 10.1007/s00415-019-09206-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
Immune-mediated myelopathies are a heterogeneous group of inflammatory spinal cord disorders including autoimmune disorders with known antibodies, e.g. aquaporin-4 IgG channelopathy or anti-myelin oligodendrocyte glycoprotein-associated myelitis, myelopathies in the context of multiple sclerosis and systemic autoimmune disorders with myelopathy, as well as post-infectious and paraneoplastic myelopathies. Although magnetic resonance imaging of the spinal cord is still challenging due to the small dimension of the cord cross-section and frequent movement and susceptibility artifacts, recent methodological advances have led to improved diagnostic evaluation and characterization of immune-mediated myelopathies. Topography, length and width of the lesion, gadolinium enhancement pattern, and changes in morphology over time help in narrowing the broad differential diagnosis. In this review, we give an overview of recent advances in magnetic resonance imaging of immune-mediated myelopathies and its role in the differential diagnosis and monitoring of this heterogeneous group of disorders.
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de Amorim JC, Frittoli RB, Pereira D, Postal M, Dertkigil SSJ, Reis F, Costallat LTL, Appenzeller S. Epidemiology, characterization, and diagnosis of neuropsychiatric events in systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:407-416. [DOI: 10.1080/1744666x.2019.1564040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jaqueline Cristina de Amorim
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Campinas, Brazil
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Renan Bazuco Frittoli
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Danilo Pereira
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Mariana Postal
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
| | | | - Fabiano Reis
- Departament of Radiology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Lilian TL Costallat
- Rheumatology Unit, Department of Medicine-School of Medical Science, University of Campinas, Campinas, Brazil
| | - Simone Appenzeller
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Rheumatology Unit, Department of Medicine-School of Medical Science, University of Campinas, Campinas, Brazil
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Longitudinally Extensive Transverse Myelitis Associated With Systemic Lupus Erythematosus: A Case Report and Literature Review. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2019; 7:244-249. [PMID: 31410363 PMCID: PMC6691358 DOI: 10.12691/ajmcr-7-10-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lupus myelitis is a rare but disastrous complication of systemic lupus erythematosus (SLE). The transverse myelitis (TM) may involve three or more contiguous spinal cord segments and as such is designated longitudinally extensive transverse myelitis (LETM). The neurological presentation may vary based on the location of the pathology and may consist of a combination of sensory and motor deficits. TM could be the presenting feature of SLE or present after 10 years of disease, while SLE was considered to be in remission. CASE PRESENTATION 26-year-old Black man with history of biopsy proven-lupus nephritis that had progressed to ESRD, presented with sudden onset quadriplegia that resolved upon arrival to the hospital. On exam, the temperature was 101.8°F and the neurological exam was consistent with residual weakness on the left sided-upper and lower extremities. Leukopenia, lymphopenia and thrombocytopenia, along with low complements were noted. Brain MRI was normal however, the spine MRI was suspicious for an epidural process (C2-T4) and intravenous antibiotics were commenced. After five days, neurological improvement was nil and new spine MRI revealed spinal cord edema secondary to myelitis at several spinal cord levels (C2-T4). Laboratory data was consistent with a SLE flare complicated with longitudinal extensive transverse myelitis. Pulse steroids and plasma exchange were initiated. Two weeks after admission, MRI demonstrated resolution of the epidural spinal lesion and marked improvement in spinal cord edema. CONCLUSION TM can be the presenting feature of SLE or appear later on during the course of their disease. LETM is the most frequently type of TM found among SLE patients. Given the grave nature of the disease, it is of paramount importance that clinical features of TM be promptly recognized among SLE patients, to prevent catastrophic or even life-threatening outcomes.
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From A to D: A Unique Case Report of Recovery After Longitudinal Myelitis Related to Lupus. Am J Phys Med Rehabil 2018; 98:e119-e122. [PMID: 30557157 DOI: 10.1097/phm.0000000000001117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Longitudinal myelitis secondary to an acute flare of systemic lupus erythematosus has been reported in the literature. There have been few published cases of complete functional recovery in patients with systemic lupus erythematosus-related longitudinal myelitis (systemic lupus erythematosus-related longitudinal myelitis). Of those cases, none have described in detail the rehabilitation course of treatment. In the current case, intensive rehabilitation was coupled with aggressive pharmaceutical treatment resulting in almost full functional recovery. A 23-yr-old African American woman with a history of systemic lupus erythematosus was originally admitted as an inpatient for flank pain. Overnight, she progressed rapidly to complete flaccid paraplegia classified as T3 American Spinal Injury Association Impairment Scale A based on the International Standards for Neurological Classification of Spinal Cord Injury. Throughout the next year, she participated in acute inpatient rehabilitation, followed by outpatient rehabilitation (physical, occupational, and aquatic therapies). A year after her initial hospital admission, she progressed to full community ambulation T3 American Spinal Injury Association Impairment Scale D. This case illustrates the importance of proper medical treatment and a comprehensive rehabilitation program, which improved functional outcomes for a patient with a complete spinal cord injury due to systemic lupus erythematosus-related longitudinal myelitis.
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Shahmohammadi S, Doosti R, Shahmohammadi A, Mohammadianinejad SE, Sahraian MA, Azimi AR, Harirchian MH, Asgari N, Naser Moghadasi A. Autoimmune diseases associated with Neuromyelitis Optica Spectrum Disorders: A literature review. Mult Scler Relat Disord 2018; 27:350-363. [PMID: 30476871 DOI: 10.1016/j.msard.2018.11.008] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 11/06/2018] [Accepted: 11/10/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Neuromyelitis Optica (NMO) is an autoimmune inflammatory demyelinating disease of the central nervous system (CNS) which predominantly involves optic nerves and spinal cord. Since the introduction of Neuromyelitis Optica Spectrum Disorders (NMOSD) as a separate entity, there have been many reports on its association with other disorders including systemic and organ-specific autoimmune diseases. Here, we reviewed other immune-mediated diseases associated with NMOSD and tried to categorize them. METHODS The present review was conducted using the PUBMED database based on papers from 1976 (i.e., since the first NMO comorbidity with SLE was reported) to 2017. We included all articles published in English. The keywords utilized included Neuromyelitis optica, Neuromyelitis Optica Spectrum Disorders, Devic's disease, in combination with comorbidity or comorbidities. RESULTS Diseases with immune-based pathogenesis are the most frequently reported co-morbidities associated with NMOSD, most of which are antibody-mediated diseases. According to literature, Sjogren's Syndrome (SS) and Systemic Lupus Erythematosus (SLE) are the most frequently reported diseases associated with NMOSD among systemic autoimmune diseases. Further, myasthenia gravis in neurological and autoimmune thyroid diseases in non-neurological organ-specific autoimmune diseases are the most reported comorbidities associated with NMOSD in the literature. CONCLUSIONS NMOSD may be associated with a variety of different types of autoimmune diseases. Therefore, systemic or laboratory signs which are not typical for NMOSD should be properly investigated to exclude other associated comorbidities. These comorbidities may affect the treatment strategy and may improve the patients' care and management.
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Affiliation(s)
- Sareh Shahmohammadi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Rozita Doosti
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abootorab Shahmohammadi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Azimi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Harirchian
- Iranian center for neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Asgari
- Owens-gruppen Næstved/Slagelse/Ringsted Sygehuse, Region Sjælland J.B. Winsløws Vej 9, indgang B, 1. Sal 5000, Odense C, Denmark
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Oiwa H, Kuriyama A, Matsubara T, Sugiyama E. Clinical value of autoantibodies for lupus myelitis and its subtypes: A systematic review. Semin Arthritis Rheum 2018; 48:214-220. [DOI: 10.1016/j.semarthrit.2018.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 01/28/2018] [Accepted: 02/12/2018] [Indexed: 11/25/2022]
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Campbell EJ, Clarke AE, Ramsey-Goldman R. Systemic lupus erythematosus: a case-based presentation of renal, neurologic, and hematologic emergencies. Expert Rev Clin Immunol 2018; 14:803-816. [PMID: 30173578 DOI: 10.1080/1744666x.2018.1518132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with systemic manifestations and multiorgan involvement. Although primarily diagnosed, and managed in the outpatient setting, it can occasionally present with life-threatening complications that require rapid assessment and urgent aggressive therapy. Areas covered: In our review, we explore three organ systems that are often affected in SLE, but have the potential to present as medical emergencies; these are the kidney, the central nervous system, and the hematologic system. We take a case-based approach to each clinical scenario, with information given sequentially in order to reflect "real-life" situations where management decisions need to be made with limited information. We review the acute management, pathophysiology, diagnostic approach, and treatment along with a review of the literature, for lupus nephritis presenting as rapidly progressive glomerulonephritis, acute lupus transverse myelitis, and refractory antiphospholipid syndrome. Expert commentary: At the conclusion of each section, we provide an expert commentary regarding each issue, relating to diagnosis, early management, and current evidence behind treatment recommendations.
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Affiliation(s)
- Eric J Campbell
- a Internal Medicine Resident, Department of Medicine, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Ann E Clarke
- b Professor of Medicine, Division of Rheumatology, The Arthritis Society Chair in Rheumatic Diseases, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Rosalind Ramsey-Goldman
- c Solovy Arthritis Research Society Professor of Medicine, Department of Medicine/Rheumatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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McGlasson S, Wiseman S, Wardlaw J, Dhaun N, Hunt DPJ. Neurological Disease in Lupus: Toward a Personalized Medicine Approach. Front Immunol 2018; 9:1146. [PMID: 29928273 PMCID: PMC5997834 DOI: 10.3389/fimmu.2018.01146] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/07/2018] [Indexed: 12/11/2022] Open
Abstract
The brain and nervous system are important targets for immune-mediated damage in systemic lupus erythematosus (SLE), resulting in a complex spectrum of neurological syndromes. Defining nervous system disease in lupus poses significant challenges. Among the difficulties to be addressed are a diversity of clinical manifestations and a lack of understanding of their mechanistic basis. However, despite these challenges, progress has been made in the identification of pathways which contribute to neurological disease in SLE. Understanding the molecular pathogenesis of neurological disease in lupus will inform both classification and approaches to clinical trials.
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Affiliation(s)
- Sarah McGlasson
- MRC Institute of Genetics and Molecular Medicine, Edinburgh, United Kingdom
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- The Anne Rowling Clinic, University of Edinburgh, Edinburgh, United Kingdom
| | - Stewart Wiseman
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna Wardlaw
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David P. J. Hunt
- MRC Institute of Genetics and Molecular Medicine, Edinburgh, United Kingdom
- The UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- The Anne Rowling Clinic, University of Edinburgh, Edinburgh, United Kingdom
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Flores-Silva FD, Longoria-Lozano O, Aguirre-Villarreal D, Sentíes-Madrid H, Vega-Boada F, Díaz de León-Sánchez E, Murra-Antón S, Morales-Moreno S, Quintanilla-González L, Fragoso-Loyo H, Guraieb-Chaín P, Higuera-Calleja J, Ceballos-Ceballos J, Treviño-Frenk I, González-Duarte A, Dávila-Maldonado L, Cantú-Brito C, Valdés-Ferrer SI. Natural history of longitudinally extensive transverse myelitis in 35 Hispanic patients with systemic lupus erythematosus: good short-term functional outcome and paradoxical increase in long-term mortality. Lupus 2018; 27:1279-1286. [DOI: 10.1177/0961203318770015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and objective Acute transverse myelitis (TM) is an infrequent neurological complication of systemic lupus erythematosus (SLE). Short-term outcome varies widely between cohorts. Little is known about the epidemiology and long-term functional outcome of TM associated to SLE. Methods Patients with SLE and acute TM were identified during hospital admission, visits to the Emergency Room or the Neurology Outpatient Clinic. We evaluated ambispectively those patients with SLE presenting with clinical myelopathy and corroborated with spinal MRI. Cases were divided as partial (non-paralyzing) or complete (paralyzing). We determined long-term functional outcome as well as mortality in those patients with follow-up periods of at least five years. Results We identified 35 patients (partial, n = 15; complete, n = 20) in which complete clinical and imaging data were available (26 with follow-up ≥ 5 years). Patients with complete TM were significantly older than those with partial forms. Positive antiphospholipid antibodies were observed in 80% of patients, suggesting a possible mechanistical role. Surprisingly, functional recovery at one year was in general good; however, we observed a five-year mortality of 31% because of sepsis (in 10 cases) or pulmonary embolism (in one case). Conclusions Short-term outcome of SLE-related TM is generally good, and recurrence rate is low. However, we observed a long-term fatality rate of 31% for reasons unrelated to TM, suggesting that TM is a manifestation of severe immune dysregulation and a predictor of severity and mortality in patients with SLE.
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Affiliation(s)
- F D Flores-Silva
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - O Longoria-Lozano
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - D Aguirre-Villarreal
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - H Sentíes-Madrid
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - F Vega-Boada
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E Díaz de León-Sánchez
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - S Murra-Antón
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - S Morales-Moreno
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - L Quintanilla-González
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - H Fragoso-Loyo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - P Guraieb-Chaín
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J Higuera-Calleja
- Department of Neuroimaging, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J Ceballos-Ceballos
- Department of Neuroimaging, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I Treviño-Frenk
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - A González-Duarte
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - L Dávila-Maldonado
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - C Cantú-Brito
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - S I Valdés-Ferrer
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Center for Biomedical Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
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