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Shobha V, Rajasekhar L, Manuel S, V N, Gupta R, Tripathy SR, Ghosh P, Kavadichanda C, Mathew AJ, Rathi M, Jain A, Selvam S, Aggarwal A. Critical peripheral ischemia: Higher prevalence in Indian systemic lupus erythematosus inception cohort for research (INSPIRE). Lupus 2024; 33:974-978. [PMID: 38922692 DOI: 10.1177/09612033241263232] [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: 06/28/2024]
Abstract
INTRODUCTION There is limited literature on digital ischemia in systemic Lupus erythematosus (SLE). We report the prevalence, associations and outcome of digital infarcts and gangrene from the Indian SLE inception cohort (INSPIRE). METHODS From the web-based database of INSPIRE, we extracted information for patients with 'Digital Infarct' and 'Digital gangrene' at enrolment into cohort, together considered as critical peripheral ischemia (CPI); all others were controls. We describe the associations of CPI with SLE clinical phenotype, autoantibodies, and disease activity at enrolment. We also report short term outcomes viz. Digital tissue loss and early mortality up to 6 months and recurrence of digital ischemic events in cases till date. RESULTS Of 2503 SLE patients enrolled into the INSPIRE cohort, we identified 75 (2.9%) patients with CPI, 72 (96%) women and 6 (8%) children. Of them, 55 (73.3%) had digital gangrene and 21 (28%) patients had digital infarcts. Majority of digital gangrene resulted in amputation distal to terminal phalanx (63.6%). Multivariable analysis showed that pulmonary hypertension AOR [6.34 (1.99, 20.2)], coexistent thrombosis AOR [27.8 (15.7, 48.7)], triple antiphospholipid antibody positivity AOR [5.36 (1.67, 16.9)] and the presence of anti-Scl-70-antibody AOR [5.59 (1.86, 16.7)] were more likely while patients with class 3 or 4 lupus nephritis AOR [0.37 (0.15, 0.95)] and anti-nucleosome antibodies AOR [0.47 (0.23, 0.99)] were less likely to be associated with CPI. SLEDAI and short-term mortality were similar between cases and controls. CONCLUSIONS CPI occurred in a higher proportion (2.9%) of SLE patients in the INSPIRE cohort as compared to earlier reports. Both prothrombotic state and vasculopathy contribute to its occurrence.
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Affiliation(s)
- Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - Liza Rajasekhar
- Department of Clinical Immunology & Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Sandra Manuel
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - Nayana V
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Parasar Ghosh
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education & Research, Kolkata, India
| | - Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education& Research, Puducherry, India
| | - Ashish J Mathew
- Department of Clinical Immunology & Rheumatology, Christian Medical College, Vellore, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, SMS Medical College & Hospital, Jaipur, India
| | - Sumitra Selvam
- Division of Epidemiology and Biostatistics, St John's Research Institute, St John's Medical College Hospital, Bengaluru, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Hui M, Zhou J, Li M, Wang Q, Zhao J, Hou Y, Xu D, Zeng X. Digital gangrene in systemic sclerosis patients: not only due to the microvascular disease. Clin Rheumatol 2024; 43:1083-1092. [PMID: 38302817 DOI: 10.1007/s10067-024-06886-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/02/2024] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE This study aims to investigate the characteristics, risk factors, and outcomes of digital gangrenes in SSc patients, and to identify whether vasculitis is one of the causes for digital gangrene. METHODS A retrospective case-control study was performed from February 2003 to April 2021. Forty-three SSc patients with digital gangrene admitted to Peking Union Medical College Hospital were included. One-hundred forty-six age- and sex-matched SSc patients without gangrene were selected as controls during the same period. Univariate and multivariate logistic regression analysis was used to determine risk factors. RESULTS Among 43 SSc patients with gangrene, 93.0% had Raynaud's phenomenon (RP) and 32.6% had current or previous digital ulcers (DU). SSc patients with digital gangrene had more ESR elevation (54.8% vs. 34.9%, p = 0.020) and higher level of high-sensitive C reactive protein (median 7.2 mg/L vs. 1.8 mg/L, p = 0.045) compared with controls. In the multivariable logistic regression analysis, smoking history (OR 4.119, p = 0.037), anti-centromere antibody positivity (OR 3.542, p = 0.016), anti-neutrophil cytoplasmic antibody positivity (OR 22.605, p = 0.037), and anti-phospholipid antibody positivity (OR 16.563, p = 0.001), as well as elevated ESR (OR 2.524, p = 0.038) were identified as independent risk factors for gangrenes. Most (79.1%) cases were treated with combination of immunosuppressive and vasodilating therapy, and four cases also got remised after treatment of only glucocorticoid and immunosuppressive agent. CONCLUSION Smoking history; positive-ACA, ANCA, and anti-phospholipid antibodies; and increased ESR were independent risk factors for digital gangrenes in SSc. Vasculitis and macrovascular disease may contribute to the progression of digital gangrenes. Key Points •18.6% of SSc patients with digital gangrene had macrovascular stenosis. •Smoking, positive-ACA, ANCA, aPL, and increased ESR were indicators for digital gangrenes in SSc. •Vasculitis and macrovascular disease may involve in the pathogenesis.
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Affiliation(s)
- Min Hui
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yong Hou
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology State Key Laboratory of Complex Severe and Rare Diseases Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
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Jain H, Mittal A, Didel S, Kumar P, Singh K. Use of prostaglandin and cyclophosphamide for pediatric lupus with digital gangrene: Back to safety before hitting the axe! Lupus 2023; 32:1572-1578. [PMID: 37876266 DOI: 10.1177/09612033231208850] [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: 10/26/2023]
Abstract
Digital gangrene is a rare presenting feature of childhood lupus and only a reported incidence of 1.3%. We describe two cases of pediatric onset systemic lupus erythematosus (SLE), both 16 years old, presenting with digital gangrene and the successful salvage of the digits after using intravenous cyclophosphamide for immunosuppression and use of intravenous prostaglandin E1 infusions for limb reperfusion. Both of the patients responded exceptionally to the infusions with resolution of gangrene and near-total preservation of the functionality of toes.
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Affiliation(s)
- Hritvik Jain
- Intern, Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, India
| | - Aliza Mittal
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
| | - Siyaram Didel
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
| | - Prawin Kumar
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
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Asadourian PA, Chen AZ, Aristega Almeida B, Gordon JK, Burge AJ, Fufa DT. Magnetic Resonance Angiography of the Hand Vasculature in Patients With Systemic Sclerosis and Systemic Lupus Erythematosus. Hand (N Y) 2023; 18:553-561. [PMID: 34963371 PMCID: PMC10233638 DOI: 10.1177/15589447211064358] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND When patients with systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) develop digital ischemia, conventional angiography (CA) is traditionally used to assess hand vasculature. Recently, Chang et al described an angiographic classification system for patients with SSc. Conventional angiography uses intravascular contrast agents that are nephrotoxic and vasoconstrictive. Owing to these limitations, this study assesses the use of contrast-enhanced magnetic resonance angiography (MRA) as an alternative to CA to evaluate hand vasculature in patients with digital ischemia. METHODS This retrospective case series reports on 38 contrast-enhanced MRAs of hand vasculature from 30 symptomatic patients with SSc (N = 21) or SLE (N = 9). The radial and ulnar arteries (RA, UA) and the superficial and deep palmar arches were evaluated at standard reference points both quantitatively and qualitatively for their diameter, patency, and Chang classification. RESULTS In SSc MRAs (n = 26), the UA was significantly smaller than the RA and was occluded in 46%. In SLE MRAs (n = 12), the UA and RA had no difference in diameter and the UA was occluded in 25%. In SSc, the most common Chang classification was type 2 (UA involvement) in 44%. In SLE, the most common Chang classification was type 4 (UA and RA involvement) in 45%, with 18% classified as type 2. CONCLUSIONS Contrast-enhanced MRA used to assess hand vasculature in SSc patients with digital ischemia shows similar patterns of vascular involvement as previously demonstrated by CA. While vascular involvement in SSc predominantly involves the UA, the RA is also frequently involved in SLE.
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Zhao L, Kong X, Zhao J, Zhou J, Zhang S, Xu D, Tian X, Zeng X, Zhang F. Identifying risk and prognostic factors in polyarteritis nodosa patients with digital gangrene. Int J Rheum Dis 2023; 26:236-241. [PMID: 36261880 DOI: 10.1111/1756-185x.14467] [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: 04/21/2022] [Revised: 08/19/2022] [Accepted: 09/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many patients with polyarteritis nodosa (PAN) complicated by digital gangrene have poor outcomes and related research information is limited. Our aim is to identify the associated risk and prognostic factors in PAN patients with digital gangrene. PATIENTS AND METHODS We conducted a retrospective study of 148 PAN patients admitted to Peking Union Medical College Hospital from Octorber 2001 to December 2018. Forty-seven (31.8%) PAN patients had digital gangrene. The average age was 40.4 ± 17.9 years. RESULTS The presence of digital gangrene was correlated with current smoking (P = .008, odds ratio [OR] 2.99, 95% CI, 1.33-6.73), eosinophil elevation (P = .003, OR 4.21, 95% CI, 1.62-10.91) and elevated leukocytes (P = .001, OR 4.26, 95% CI, 1.86-9.78). Thirty-two (68.1%) gangrene patients received methylprednisolone pulse therapy and all of these patients were treated with cyclophosphamide. Nine patients suffered irreversible organ injury and 2 died. Survival analysis showed higher serum C-reactive protein (CRP) was associated with poor prognosis in patients with gangrene (log-rank P = 0.042 and generalized Wilcoxon P = .020). CONCLUSIONS PAN patients with current smoking and eosinophil elevation were more prone to digital gangrene and a high serum CRP level predicted poor outcomes. The CRP level should be efficiently controlled to ensure a good prognosis.
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Affiliation(s)
- Lin 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), Beijing, China.,The Department of Rheumatology, 2nd Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaodan Kong
- The Department of Rheumatology, 2nd Affiliated Hospital of Dalian Medical University, Dalian, 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), Beijing, China
| | - Jiaxin Zhou
- 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), 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), 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), Beijing, China
| | - Xinping Tian
- 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), Beijing, 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), Beijing, China
| | - Fengchun 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), Beijing, China
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Rijal P, Kaur G, Yadav B, Raina R, Pathania M. Bilateral Upper Limb Symmetrical Digital Gangrene: A Rare Presentation of Anti-Phospholipid Syndrome. Cureus 2022; 14:e29516. [PMID: 36312664 PMCID: PMC9595255 DOI: 10.7759/cureus.29516] [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] [Accepted: 09/23/2022] [Indexed: 11/21/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease present most commonly in young women, characterized by the presence of antibodies against various phospholipids and culminating in alteration of the flow of blood, leading to arterial and venous thrombosis. Although it can present with a wide range of manifestations, digital gangrene is one of the important ones. We present a case of a young female with antiphospholipid syndrome who presented with acute onset bilateral upper limb symmetrical digital gangrene with prior history of multiple fetal losses. Acute onset, symmetrical gangrene, limited to the bilateral upper limbs without venous system involvement, that too in association with systemic lupus erythematosus (SLE) which does not usually manifest as such make this case a unique and interesting one.
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Boussaid S, Ben Majdouba M, Rekik S, Jemmali S, Zouaoui K, Rahmouni S, Sahli H, Elleuch M. Case Report: Extensive digital gangrene as a primary manifestation of late-onset systemic lupus erythematosus. F1000Res 2022; 11:922. [PMID: 38813136 PMCID: PMC11134139 DOI: 10.12688/f1000research.124225.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 05/31/2024] Open
Abstract
Background: Digital gangrene is a rare but serious complication of systemic lupus erythematosus (SLE). It occurs usually in middle-aged patients with longer disease duration. Case: Herein we report the case of a 56-year-old man (with no history suggestive of Raynaud's phenomenon, diabetes mellitus, smoking, trauma, infection, or chemical exposure), who presented with SLE and digital gangrene was among the first signs. He presented with a one-month history of joint pain, hair loss, photosensitivity, mouth ulcers, malar rash, dyspnea, and digital pain. Physical examination revealed painful and diffuse erythematous skin lesions in the extremities and back, as well as cyanosis in the fingers. We noted lymphocytopenia (600 cells/mm 3), and an elevated C-reactive protein (15.1 mg/l) on laboratory tests. Immunological tests were positive for antinuclear antibodies (ANA) with Title 1:400. Pulmonary computed tomography revealed pulmonary fibrosis, and pulmonary function tests revealed the restrictive pulmonary disease. Diagnosis of SLE with lung involvement was retained. The immunological assessment in search of elements in favor of a vascular origin of the patient's skin lesions was negative. Treatment was initiated with 200 mg/day hydroxychloroquine. For dermal and pulmonary involvement, intravenous (IV) pulse therapy was used with methylprednisolone (1,000 mg/d for three consecutive days monthly) and cyclophosphamide (1 g/month). Calcium blocking agents were also prescribed. However, the lesions did not improve. The patient was given two infusions of rituximab (1 g) at a 14-day interval with a marked improvement ofthe majority of vasculitis lesions, and a partial improvement of dyspnea. Conclusions: Digital gangrene is a rare complication of late-onset SLE, especially as a primary manifestation.
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Affiliation(s)
- Soumaya Boussaid
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Marouene Ben Majdouba
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Sonia Rekik
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Samia Jemmali
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Khaoula Zouaoui
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Safa Rahmouni
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Hela Sahli
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Mohamed Elleuch
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
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Cravero K, Maddy AJ, Motaparthi K. Digital ulcers as presenting symptom of secondary antiphospholipid syndrome. JAAD Case Rep 2022; 29:1-5. [PMID: 36186414 PMCID: PMC9519777 DOI: 10.1016/j.jdcr.2022.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Vijayan N, Vijayvergia P, Bohra GK, Garg MK, Gopalakrishnan M. Clinical characteristics and outcomes of digital gangrene in connective tissue disorders: a longitudinal single-centre experience from Jodhpur, India. Clin Rheumatol 2022; 41:3543-3549. [PMID: 35780227 DOI: 10.1007/s10067-022-06265-1] [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] [Received: 10/18/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 11/26/2022]
Abstract
Epidemiology, clinical presentation, and outcomes for digital gangrene in connective tissue disorders (CTD) remain underreported from tropical countries like India. In this series, we aimed to explore the clinical profile and outcomes of patients who presented with digital gangrene and a diagnosis of CTD. Hospital-based longitudinal observational study. Patients with digital gangrene and underlying diagnosis of CTD presenting to our tertiary-care centre in Jodhpur, India between1st January 2018 and 31st June 2021 were included. Clinical outcomes including mortality, limb outcomes, functional status and other systemic involvement were assessed. Of the 312 patients registered in the rheumatology clinic during this period, 22 (7%) patients were found to satisfy the inclusion criteria. Mean age was 46 years and 90% were females. The most common underlying diagnosis was Mixed connective tissue disorder (MCTD). Digital gangrene was the presenting symptom in 13 (60%) patients. Half of the patients received only corticosteroids as immunosuppression. Two died due to systemic complications. Complete resolution occurred in 17 (85%), autoamputation in 3, and infection requiring surgical drainage in one patient. All surviving patients reported good functional limb outcome on 6 months follow-up. MCTD is an important cause of digital gangrene in rheumatology practice. In patients presenting with digital gangrene, an active search for an underlying CTD is imperative, as this could result in timely initiation of appropriate limb-saving therapy. Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in CTD. Key Points • Mixed connective tissue disorder is an important cause of digital gangrene in rheumatology practice in western India. • In patients presenting with digital gangrene, an active search for an underlying connective tissue disorder is imperative, as this could result in timely initiation of appropriate therapy and can prove limb saving. • Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in connective tissue disorders.
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Affiliation(s)
- Neeraja Vijayan
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Parag Vijayvergia
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Gopal Krishna Bohra
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India.
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Abstract
Systemic lupus erythematosus is an autoimmune disorder that affects several organs and systems in the human body. Digital gangrene is known to be a rare and severe complication of systemic lupus erythematosus that could lead to amputation. We report a case of an adolescent who presented with an autoimmune disorder and multiple comorbidities and developed gangrenous toes.
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Management of Severe Refractory Systemic Lupus Erythematosus: Real-World Experience and Literature Review. Clin Rev Allergy Immunol 2020; 60:17-30. [PMID: 33159635 DOI: 10.1007/s12016-020-08817-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 12/11/2022]
Abstract
Systemic lupus erythematosus (SLE) is a highly heterogeneous disease affecting multiple organs and is characterized by an aberrant immune response. Although the mortality of SLE has decreased significantly since the application of glucocorticoids, severe or refractory SLE can potentially cause irreversible organ damage and contribute to the disease morbidity and mortality. Early recognition of severe SLE or life-threatening conditions is of great challenge to clinicians since the onset symptoms can be rapid and aggressive, involving the visceral organs of the neuropsychiatric, gastrointestinal, hematologic, renal, pulmonary, and cardiovascular systems, etc. Additionally, SLE patients with specific comorbidities and detrimental complications could lead to a clinical dilemma and contribute to poor prognosis. Prompt and adequate treatment for severe refractory SLE is crucial for a better prognosis. However, as evidence from well-designed randomized controlled trials is limited, this review aims to provide real-world evidence based on cohort studies from Peking Union Medical College Hospital, the national tertiary referral center in China, together with the literature, on clinical characteristics, risks and prognostic factors, and treatment strategies for severe and/or refractory SLE.
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Mokhtari S, Benzirar A, El Mahi O. [Critical ischemia of the lower limb revealing Lupus disease in a young woman]. Ann Cardiol Angeiol (Paris) 2020; 69:93-95. [PMID: 32220415 DOI: 10.1016/j.ancard.2020.03.009] [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: 09/08/2019] [Accepted: 03/04/2020] [Indexed: 11/25/2022]
Abstract
The diversity of juvenile arterial disease aetiologies requires a systematic investigation when limb critical ischemia is diagnosed before the age of 50. We would like to share a rare case of a young woman who was diagnosed with Lupus disease revealed by distal ischemia of the foot.
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Affiliation(s)
- S Mokhtari
- Université Mohammed Premier d'Oujda. Service de Chirurgie vasculaire, Centre Hospitalier Universitaire Mohammed VI, Oujda, Maroc.
| | - A Benzirar
- Université Mohammed Premier d'Oujda. Service de Chirurgie vasculaire, Centre Hospitalier Universitaire Mohammed VI, Oujda, Maroc.
| | - O El Mahi
- Université Mohammed Premier d'Oujda. Service de Chirurgie vasculaire, Centre Hospitalier Universitaire Mohammed VI, Oujda, Maroc.
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14
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Systemic Lupus Erythematosus with Multiple Autoimmune Disease Presented with Extensive Peripheral Gangrene. Case Rep Rheumatol 2020; 2020:8278275. [PMID: 32231842 PMCID: PMC7085827 DOI: 10.1155/2020/8278275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/15/2020] [Accepted: 02/17/2020] [Indexed: 11/20/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease and can be associated with other autoimmune diseases. SLE usually presents with skin change and rarely presents with gangrene. SLE gangrene usually involves the digits of upper extremities. We report the first case of SLE associated with an extremely rare constellation of neuromyelitis Optica (NMO) and diabetes mellitus type 1, presented with a rare form of the SLE gangrene which involves bilateral lower extremities up to midlegs, a case that has not yet been reported in the literature. Although SLE gangrene may respond to immunosuppressants, it has a high risk of complications that can end up with amputations.
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15
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Alalawi ZM, Alkenany S, Almahroos F, Albloushi B. Peripheral Gangrene as the Initial Presentation of Systemic Lupus Erythematosus in Emergency Department. Cureus 2020; 12:e6667. [PMID: 31966953 PMCID: PMC6964793 DOI: 10.7759/cureus.6667] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystemic autoimmune disease. Among the cutaneous manifestations of SLE, digital gangrene is considered to be very rare. This complication, which may lead to severe ischemic necrosis and amputation, is suggested to be the result of poor perfusion that is usually caused by vasculitis, vasospasm, thromboembolism, or atherosclerosis. Digital gangrene is seen mostly at a late stage of the disease proposing that a long history of SLE is a considered risk factor. Only 0.2% of patients with SLE presented initially as digital necrosis. This is a case report of a 20-year-old Saudi female who presented to the emergency room primarily with acute painful localized dry digital gangrene associated with bilateral lower limbs petechial rash. Her medical history was not suggestive of autoimmune diseases. Serology was positive for SLE. A diagnosis of SLE, lupus nephritis, and vasculitis has been established clinically and serologically. The patient adequately responded to rituximab and steroids as a medical therapy. To our knowledge, cases of acute peripheral gangrene as the initial and only presentation of SLE have rarely been documented in Emergency Medicine.
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Affiliation(s)
- Zainab M Alalawi
- Emergency Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, SAU
| | - Samar Alkenany
- Emergency Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, SAU
| | - Fatemah Almahroos
- Emergency Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, SAU
| | - Basmah Albloushi
- Emergency Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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16
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Sonkar SK, Kumar S, Atam V, Chaudhary SC. Digital dry gangrene as a primary manifestation of systemic lupus erythematosus. BMJ Case Rep 2019; 12:12/12/e230869. [PMID: 31818886 DOI: 10.1136/bcr-2019-230869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Digital dry gangrene is commonly seen in cases of connective tissue disease such as systemic sclerosis. In systemic lupus erythematosus (SLE) digital gangrene is rare. As initial manifestation, it is again a rare phenomenon because it occurs late in the course of disease. Here we are reporting the case of a woman who was having extensive cutaneous gangrene of her fingers and toes, as a first and foremost presentation without any other typical signs and symptoms of SLE. Her serology was positive for SLE. The patient was treated conservatively and responded well.
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Affiliation(s)
| | - Satish Kumar
- Medicine, King George's Medical University, Lucknow, India
| | - Virendra Atam
- Medicine, King George's Medical University, Lucknow, India
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17
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Stewart S, Brenton-Rule A, Dalbeth N, Aiyer A, Frampton C, Rome K. Foot and ankle characteristics in systemic lupus erythematosus: A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 48:847-859. [PMID: 30093237 DOI: 10.1016/j.semarthrit.2018.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/14/2018] [Accepted: 07/06/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine characteristics of the foot and ankle in people with systemic lupus erythematosus (SLE). METHODS Medline, CINAHL, Sports-Discus, Scopus and Cochrane Library databases were searched up to January 2018. Studies reporting foot- and ankle-related outcomes in the following domains were included: vascular, neurological, musculoskeletal, cutaneous (skin and nail) or pain/function. The Quality Index tool was used to assess methodological quality. Where appropriate, odds ratio (OR) and mean difference meta-analyses were conducted for case-control studies; and pooled mean prevalence meta-analyses for studies assessing characteristics in SLE. RESULTS Forty-nine studies were included with mean (range) quality scores of 75% (38-100%). Twenty-three studies assessed vascular characteristics, followed by musculoskeletal (n = 16), neurological (n = 11), cutaneous (n = 5) and pain/function (n = 4). Foot and ankle characteristics in people with SLE included impaired vascular supply, abnormal nerve function, musculoskeletal pathology, skin and nail pathology, and pain and functional disability. Twenty-four studies were included in meta-analyses. Pooled OR for abnormal ankle brachial index was 3.08 for SLE compared with controls. Pooled mean difference in brachial-ankle pulse-wave velocity between SLE and controls was significant (161.39 cm/s, P = 0.004). Pooled prevalence was 0.54 for intermittent claudication, 0.50 for Raynaud's phenomenon, 0.28 for chilblains, 0.00 for gangrene, 0.30 for hallux valgus, 0.15 for onychomycosis, 0.76 for history of foot pain, and 0.36 for current foot pain. CONCLUSION People with SLE experience a wide range of foot and ankle manifestations. Published research highlights the impact of peripheral arterial disease, peripheral neuropathy, musculoskeletal deformity, skin and nail pathology and patient-reported foot pain and disability.
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Affiliation(s)
- Sarah Stewart
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand.
| | - Angela Brenton-Rule
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand
| | - Nicola Dalbeth
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand; Department of Rheumatology, Auckland District Health Board, New Zealand
| | - Ashok Aiyer
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand
| | - Christopher Frampton
- Biostatistics Department, University of Otago, PO Box 7343, Wellington South, New Zealand
| | - Keith Rome
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand
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18
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Gangrene of All Digits and Toes Attributable to Systemic Lupus Erythematosus With Negative Antiphospholipid Antibodies. J Clin Rheumatol 2017; 25:e79-e80. [PMID: 29280819 DOI: 10.1097/rhu.0000000000000678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Ha-Ou-Nou FZ, Zahlane M, Benjilali L, Essaadouni L. [Extensive digital gangrene revealing late-onset systemic lupus erythematosus]. JOURNAL DE MÉDECINE VASCULAIRE 2017; 42:50-53. [PMID: 28705448 DOI: 10.1016/j.jdmv.2017.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/30/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Late-onset systemic lupus erythematosus represents a specific sub-group of the disorder, beginning after 50 years of age. The incidence is rarer and the course of the disease is considered to be more benign. Digital gangrene is an uncommon complication of systemic lupus erythematosus reported especially among middle-aged patients with long disease duration. OBSERVATION We report a 53-year-old man, who presented with systemic lupus erythematosus revealed by an extensive digital gangrene. CONCLUSION Digital gangrene is a rare complication of late onset systemic lupus erythematosus. Clinicians should be aware of this complication in order to initiate early and aggressive treatment.
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Affiliation(s)
- F Z Ha-Ou-Nou
- Service de médecine interne, hôpital ARRAZI, centre hospitalier universitaire Mohammed VI, avenue Ibn Sina Amerchich, 2360 Marrakech, Maroc.
| | - M Zahlane
- Service de médecine interne, hôpital ARRAZI, centre hospitalier universitaire Mohammed VI, avenue Ibn Sina Amerchich, 2360 Marrakech, Maroc
| | - L Benjilali
- Service de médecine interne, hôpital ARRAZI, centre hospitalier universitaire Mohammed VI, avenue Ibn Sina Amerchich, 2360 Marrakech, Maroc
| | - L Essaadouni
- Service de médecine interne, hôpital ARRAZI, centre hospitalier universitaire Mohammed VI, avenue Ibn Sina Amerchich, 2360 Marrakech, Maroc
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20
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Wang X, Qiao Y, Yang L, Song S, Han Y, Tian Y, Ding M, Jin H, Shao F, Liu A. Leptin levels in patients with systemic lupus erythematosus inversely correlate with regulatory T cell frequency. Lupus 2017; 26:1401-1406. [PMID: 28409523 DOI: 10.1177/0961203317703497] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Leptin levels are increased in patients with systemic lupus erythematosus (SLE) but little is known on how this correlates with several disease characteristics including the frequency of regulatory T cells (Tregs). Here we compared serum leptin levels with frequency of circulating Tregs in 47 lupus patients vs. 25 healthy matched controls. Correlations with lupus disease activity were also analyzed, as well as Treg proliferation potential. It was found that leptin was remarkably increased in SLE patients as compared to controls, particularly in SLE patients with moderate and severe active SLE, and the increase correlated with disease activity. Importantly, increased leptin in lupus patients inversely correlated with the frequency of Tregs but not in controls, and leptin neutralization resulted in the expansion of Tregs ex vivo. Thus, hyperleptinemia in lupus patients correlates directly with disease activity and inversely with Treg frequency. The finding that leptin inhibition expands Tregs in SLE suggests possible inhibition of this molecule for an enhanced Treg function in the disease.
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Affiliation(s)
- X Wang
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Y Qiao
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - L Yang
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - S Song
- 2 Department of Laboratory Medicine, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Y Han
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Y Tian
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - M Ding
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - H Jin
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - F Shao
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - A Liu
- 1 Department of Immunology and Rheumatology, Second Hospital of Hebei Medical University, Shijiazhuang, China
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21
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Otter SJ, Kumar S, Gow P, Dalbeth N, Corkill M, Rohan M, Davies KA, Pankathelam S, Rome K. Patterns of foot complaints in systemic lupus erythematosus: a cross sectional survey. J Foot Ankle Res 2016; 9:10. [PMID: 27006702 PMCID: PMC4802627 DOI: 10.1186/s13047-016-0143-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Foot complaints are common in inflammatory arthropathies such as rheumatoid arthritis and cause considerable disability. However, little is published about the nature and extent of foot complaints in systemic lupus erythematosus (SLE). We aimed to explore foot complaints among people with (SLE) and to evaluate the associations between foot pain and self-reported activities of daily living and well-being. METHODS We developed and tested a new 40-item item self-administered questionnaire, using a five-stage development process utilising patient involvement throughout to ensure face and content validity. The self-administered instrument was posted to 406 people with SLE attending adult rheumatology clinics across three health boards in Auckland, New Zealand. The questionnaire enquired about symptoms of foot pain, extra-articular features, anatomical distribution of symptoms according to validated foot-mannequins and the impact of foot symptoms on activities of daily living and well-being. RESULTS In total, 406 questionnaires were posted, with 131 responses (response rate 32 %). We found 89 % were women, mean (SD) age 51 (15) years, mean (SD) diagnosis 12.5 (11.1) years. Overall, 77 % of those responding to the questionnaire reported foot pain during their SLE, with 45 % reporting current foot pain. All regions of the feet were affected, with the hindfoot (32 %) and ankles (30 %) most troublesome. The most common self-reported extra-articular foot complaints were cold feet, swelling and numbness. Almost two-thirds (61 %) reported foot pain adversely affected their lives; foot pain prevented sleeping in 36 % and had a negative effect on emotions for 33 %. Only 33 % of participants had seen a podiatrist. Significant association was found between foot pain and standing longer than 15 min (p < 0.001), walking (p < 0.001), climbing stairs (p < 0.001) and going shopping (p < 0.001). Pain was the primary symptom to affect quality of life (47/100). CONCLUSION Foot complaints in SLE are heterogeneous in nature, and may have a substantial negative impact on patient well-being. Foot complaints need to be addressed to reduce the burden of SLE and our findings support the need for wider access to specific foot care services.
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Affiliation(s)
- Simon J. Otter
- />Health and Research Rehabilitation Institute and School of Podiatry, AUT University, Auckland, New Zealand
- />School of Health Science, University of Brighton, 49 Darley Rd, Eastbourne, BN20 7UR UK
| | - Sunil Kumar
- />Rheumatology Department, Counties Manukau District Health Board, Auckland, New Zealand
| | - Peter Gow
- />Rheumatology Department, Counties Manukau District Health Board, Auckland, New Zealand
| | - Nicola Dalbeth
- />Department of Rheumatology, Auckland District Health Board and Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Michael Corkill
- />Rheumatology Department, Waitemata District Health Board, Auckland, New Zealand
| | - Maheswaran Rohan
- />Biostatistics Department, AUT University, Auckland, New Zealand
| | - Kevin A. Davies
- />Rheumatology Department, Brighton and Sussex Medical School, Brighton, UK
| | - Sam Pankathelam
- />Rheumatology Department, East Sussex Healthcare Trust, Eastbourne, UK
| | - Keith Rome
- />Health and Research Rehabilitation Institute and School of Podiatry, AUT University, Auckland, New Zealand
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22
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Affiliation(s)
- G R V Hughes
- London Lupus Centre, London Bridge Hospital, Tooley Street, London, UK
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23
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Marchal A, Mahé E, Sin C, Bagan P, Bilan P, Linder JF, Couffinhal JC, Sigal ML. Ischémie digitale aiguë : étude rétrospective de 13 cas. Ann Dermatol Venereol 2015; 142:332-9. [DOI: 10.1016/j.annder.2015.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 12/30/2014] [Accepted: 02/04/2015] [Indexed: 11/29/2022]
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24
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Levy O, Maslakov I, Vosco S, Markov A, Amit-Vazina M, Tishler M. Critical peripheral ischemia precipitated by severe episode of Raynaud's phenomenon in a patient with aPL-positive systemic lupus erythematosus, upon high titer anti-RNP seroconversion. Lupus 2014; 24:327-30. [PMID: 25467391 DOI: 10.1177/0961203314560427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 35-year-old female with long standing aPL-positive lupus without history of thromboembolic events, who has developed critical peripheral ischemia (CPI) is described. An episode of severe Raynaud's phenomenon rapidly progressed to an extensive digit-threatening ischemia, involving bilateral hands and feet. She was successfully treated with corticosteroids, anticoagulation, iloprost, sildenafil, and nifedipine. Her serological studies were remarkable for the emergence of high titer anti-RNP seroconversion and an increase in aPL titer, suggesting that these autoantibodies played a role in the pathogenesis of CPI. It is important to note that such observation should herald this potentially devastating complication of systemic lupus erythematosus.
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Affiliation(s)
- O Levy
- Assaf Harofeh Medical Center, Internal Medicine B, Rheumatology Unit; Tel Aviv University, Sackler School of Medicine
| | - I Maslakov
- Assaf Harofeh Medical Center, Internal Medicine B, Rheumatology Unit; Tel Aviv University, Sackler School of Medicine
| | - S Vosco
- Assaf Harofeh Medical Center, Internal Medicine B, Rheumatology Unit; Tel Aviv University, Sackler School of Medicine
| | - A Markov
- Assaf Harofeh Medical Center, Internal Medicine B, Rheumatology Unit; Tel Aviv University, Sackler School of Medicine
| | - M Amit-Vazina
- Assaf Harofeh Medical Center, Internal Medicine B, Rheumatology Unit; Tel Aviv University, Sackler School of Medicine
| | - M Tishler
- Assaf Harofeh Medical Center, Internal Medicine B, Rheumatology Unit; Tel Aviv University, Sackler School of Medicine
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25
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Response to rituximab in a case of lupus associated digital ischemia. Case Rep Rheumatol 2014; 2014:763608. [PMID: 25114828 PMCID: PMC4120793 DOI: 10.1155/2014/763608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/27/2014] [Accepted: 06/29/2014] [Indexed: 11/18/2022] Open
Abstract
We report the case of a 38-year-old female patient with systemic lupus erythematosus (SLE) and Jaccoud arthritis (JA) that sequentially developed digital ischemic lesions of the hands. In spite of follow-up treatment with glucocorticoids, immunosuppressant, antiaggregant, and potent vasodilatator agents, a serious progression to digital gangrene over a one-month period was observed. Surprisingly, her nonhealing digital lesions improved after two cycles of rituximab (RTX) administration.
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26
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Prete M, Fatone MC, Favoino E, Perosa F. Raynaud's phenomenon: from molecular pathogenesis to therapy. Autoimmun Rev 2014; 13:655-67. [PMID: 24418302 DOI: 10.1016/j.autrev.2013.12.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 12/24/2013] [Indexed: 01/01/2023]
Abstract
Raynaud's phenomenon (RP) is a well defined clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical/chemical or emotional stress. RP has been classified as primary or secondary, depending on whether it occurs as an isolated condition (pRP) or is associated to an underlying disease, mainly a connective tissue disease (CTD-RP). In both cases, it manifests with unique "triple" (pallor, cyanosis and erythema), or "double" color changes. pRP is usually a benign condition, while sRP can evolve and be complicated by acral digital ulcers and gangrene, which may require surgical treatment. The pathogenesis of RP has not yet been entirely clarified, nor is it known whether autoantibodies have a role in RP. Even so, recent advances in our understanding of the pathophysiology have highlighted novel potential therapeutic targets. The aim of this review is to discuss the etiology, epidemiology, risk factors, clinical manifestations, recently disclosed pathogenic mechanisms underlying RP and their correlation with the available therapeutic options, focusing primarily on pRP and CTD-RP.
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Affiliation(s)
- Marcella Prete
- Internal Medicine, University of Bari Medical School, I-70124 Bari, Italy
| | | | - Elvira Favoino
- Rheumatological and Autoimmune Systemic Diseases Units, University of Bari Medical School, I-70124 Bari, Italy
| | - Federico Perosa
- Rheumatological and Autoimmune Systemic Diseases Units, University of Bari Medical School, I-70124 Bari, Italy.
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27
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Williams AE, Crofts G, Teh LS. 'Focus on feet'--the effects of systemic lupus erythematosus: a narrative review of the literature. Lupus 2013; 22:1017-23. [PMID: 23877874 DOI: 10.1177/0961203313498805] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The manifestations of systemic lupus erythematosus (SLE) vary between individuals, from the severe and life-threatening renal and central nervous system involvement, to the involvement of skin, musculoskeletal and vascular system, and the complications of infection influencing the quality of life. However, as specific manifestations affecting the lower limb are perceived as receiving little focus, the purpose of this narrative literature review is to identify the specific factors associated with SLE that may have implications for lower limb and foot morbidity. METHOD A structured search of databases was conducted. The inclusion was restricted to publications in the English language, those that specifically investigate the feet as affected with SLE. No restriction on year of publication was imposed to reduce publication bias and to capture as many publication in relation to feet. RESULTS Eleven papers fulfilled the inclusion criteria. There were seven additional papers that made observations related to the articular or vascular complications of the feet. This narrative review provides some information on how SLE affects the lower limb and foot in relation to the musculoskeletal and vascular systems. However, there is a lack of literature that specifically focuses on all the manifestations of SLE and the complications associated with its management. DISCUSSION There are indications that SLE affects lower limb and foot morbidity but the scale of these problems is unclear and this is partly because of the absence of research and the lack of a 'gold standard' framework for the assessment of the lower limb and foot. In addition to clinical foot health assessment, ultrasonography may be a useful alternative to plain film radiography or magnetic resonance imaging (MRI) in capturing the extent of articular and extra-articular manifestations. Further, the Ankle Brachial Pressure Index (ABPI) may be useful in identifying those with atherosclerosis and ischaemia. CONCLUSION There are indications that SLE affects lower limb and foot morbidity but the scale of these problems and effective management of them is unclear. Therefore, further research is warranted in order to better understand the impact of SLE on the foot and lower limb and its impact on quality of life.
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Affiliation(s)
- A E Williams
- Directorate of Prosthetics, Orthotics and Podiatry, University of Salford, Manchester, UK.
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28
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Landry GJ, McClary A, Liem TK, Mitchell EL, Azarbal AF, Moneta GL. Factors affecting healing and survival after finger amputations in patients with digital artery occlusive disease. Am J Surg 2013; 205:566-9; discussion 569-70. [DOI: 10.1016/j.amjsurg.2013.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/10/2013] [Accepted: 01/14/2013] [Indexed: 10/27/2022]
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29
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Luijten RK, Fritsch-Stork RD, Bijlsma JW, Derksen RH. The use of glucocorticoids in Systemic Lupus Erythematosus. After 60years still more an art than science. Autoimmun Rev 2013; 12:617-28. [DOI: 10.1016/j.autrev.2012.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/02/2012] [Indexed: 01/18/2023]
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30
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Adelowo O, Olaosebikan H, Ajani W, Omosebi DT. Digital gangrene as the initial presentation of systemic lupus erythematosus. BMJ Case Rep 2012; 2012:bcr2012006259. [PMID: 23125294 PMCID: PMC4543316 DOI: 10.1136/bcr-2012-006259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Systemic lupus erythematosus (SLE) has rarely been reported among African blacks. However, recent reports may indicate otherwise. Digital gangrene in lupus patients has been reported in different populations and has mostly been seen in patients with long-standing lupus. Digital gangrene as the initial presentation of SLE has rarely been reported, even among African blacks. Two cases of digital gangrene as the initial presentation in Nigerian lupus patients are hereby presented. The medical and surgical managements, as well as relevant literature are hereby discussed.
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Affiliation(s)
- Olufemi Adelowo
- Department of Medicine, Lagos State University Teaching Hospital, Nigeria.
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31
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Omair MA, Bookman A, Mittoo S. Digital gangrene in a patient with systemic lupus erythematosus and systemic sclerosis. J Rheumatol 2012; 39:1895-7. [PMID: 22942305 DOI: 10.3899/jrheum.120123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Mohammed A Omair
- Department of Medicine, University of Toronto, Mount Sinai Hospital, Level 2, Room 003, 60 Murray Street, Toronto, Ontario M5T 3L9, Canada
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32
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Life-Threatening Complications of Systemic Lupus Erythematosus. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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33
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Rosato E, Molinaro I, Pisarri S, Salsano F. Digital ulcers as an initial manifestation of systemic lupus erythematosus. Intern Med 2011; 50:767-9. [PMID: 21467714 DOI: 10.2169/internalmedicine.50.4617] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Digital ulcers (DUs) and gangrene are common skin manifestations of connective tissue diseases, especially systemic sclerosis. Raynaud's phenomenon (RP) is an almost universal manifestation of systemic sclerosis, with 95% of all patients being affected, and resulting in DUs in approximately 30% of the patients each year. Although RP may be present in approximately 25-50% of the patients, DUs are relatively rare in systemic lupus erythematosus (SLE) and never present as an initial manifestation of disease. In this case report DUs appear as the initial manifestation of SLE in a young woman with a capillaroscopic scleroderma pattern and elevated systolic pulmonary arterial pressure.
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Affiliation(s)
- Edoardo Rosato
- Department of Clinical Medicine, Sapienza University of Rome, Italy
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