1
|
Li GM, Li YF, Zeng QQ, Zhang XM, Liu HM, Feng JY, Shi Y, Wu BB, Xu H, Sun L. Lupus podocytopathy and antiphospholipid syndrome in a child with SLE: A case report and literature review. Front Pediatr 2022; 10:950576. [PMID: 36061375 PMCID: PMC9437347 DOI: 10.3389/fped.2022.950576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Lupus podocytopathy is a glomerular lesion in systemic lupus erythematosus (SLE) characterized by diffuse podocyte foot process effacement (FPE) without immune complex (IC) deposition or with only mesangial IC deposition. It is rarely seen in children with SLE. A 13-year-old girl met the 2019 European League Against Rheumatism (EULAR)/ American College of Rheumatology (ACR) Classification Criteria for SLE based on positive ANA; facial rash; thrombocytopenia; proteinuria; and positive antiphospholipid (aPL) antibodies, including lupus anticoagulant (LAC), anti-β2 glycoprotein-I antibody (anti-β2GPI), and anti-cardiolipin antibody (aCL). The renal lesion was characterized by 3+ proteinuria, a 4.2 mg/mg spot (random) urine protein to creatinine ratio, and hypoalbuminemia (26.2 g/l) at the beginning of the disease. Kidney biopsy findings displayed negative immunofluorescence (IF) for immunoglobulin A (IgA), IgM, fibrinogen (Fb), C3, and C1q, except faint IgG; a normal glomerular appearance under a light microscope; and diffuse podocyte foot process effacement (FPE) in the absence of subepithelial or subendothelial deposition by electron microscopy (EM). Histopathology of the epidermis and dermis of the pinna revealed a hyaline thrombus in small vessels. The patient met the APS classification criteria based on microvascular thrombogenesis and persistently positive aPL antibodies. She responded to a combination of glucocorticoids and immunosuppressive agents. Our study reinforces the need to consider the potential cooccurrence of LP and APS. Clinicians should be aware of the potential presence of APS in patients with a diagnosis of LP presenting with NS and positivity for aPL antibodies, especially triple aPL antibodies (LCA, anti-β2GPI, and aCL).
Collapse
Affiliation(s)
- Guo-Min Li
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yi-Fan Li
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Qiao-Qian Zeng
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Mei Zhang
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Hai-Mei Liu
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Jia-Yan Feng
- National Children's Medical Center, Shanghai, China.,Department of Pathology, Children's Hospital of Fudan University, Shanghai, China
| | - Yu Shi
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Bing-Bing Wu
- National Children's Medical Center, Shanghai, China.,Medical Transformation Centre, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- National Children's Medical Center, Shanghai, China.,Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Li Sun
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| |
Collapse
|
2
|
Liu L, Murray B, Tomaszewski JE. Lupus podocytopathy superimposed on diabetic glomerulosclerosis: A case report. Medicine (Baltimore) 2021; 100:e27077. [PMID: 34664831 PMCID: PMC8448049 DOI: 10.1097/md.0000000000027077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Lupus podocytopathy (LP) is an entity that is increasingly being reported in the literature on systemic lupus erythematosus (SLE). LP is characterized by nephrotic syndrome in SLE patients with diffuse glomerular podocyte foot process effacement and no immune complex deposits along the capillary loops. Histologically, LP typically mimics minimal change disease or primary focal segmental glomerulosclerosis (FSGS) on a background of ISN/RPS class I or II lupus nephritis. In situations where there are coexistent glomerular diseases, however, LP may be easily masked by background lesions and overlapping clinical symptoms. PATIENT CONCERNS We report the case of a 24-year-old woman with type I diabetes, hypertension, psoriasis/rash, and intermittent arthritis who presented with abrupt onset of severe nephrotic proteinuria and renal insufficiency. Renal biopsy revealed nodular glomerulosclerosis and FSGS. Immune deposits were not identified by immunofluorescence or electron microscopy. Ultrastructurally, there was diffuse glomerular basement membrane thickening and over 90% podocyte foot process effacement. With no prior established diagnosis of SLE, the patient was initially diagnosed with diabetic nephropathy with coexistent FSGS, and the patient was started on angiotensin-converting enzyme inhibitors (ACEI) and diuretics. However, nephrotic proteinuria persisted and renal function deteriorated. The patient concurrently developed hemolytic anemia with pancytopenia. DIAGNOSES Subsequent to the biopsy, serologic results showed positive autoantibodies against double strand DNA (dsDNA), Smith antigen, ribonucleoprotein (RNP), and Histone. A renal biopsy was repeated, revealing essentially similar findings to those of the previous biopsy. Integrating serology and clinical presentation, SLE was favored. The pathology findings were re-evaluated and considered to be most consistent with LP and coexistent diabetic nephropathy, with superimposed FSGS either as a component of LP or as a lesion secondary to diabetes or hypertension. INTERVENTIONS The patient was started on high-dose prednisone at 60 mg/day, with subsequent addition of mycophenolate mofetil and ACEI, while prednisone was gradually tapered. OUTCOMES The patient's proteinuria, serum creatinine, complete blood counts, skin rash, and arthritis were all significantly improved. CONCLUSION The diagnosis of LP when confounded by other glomerular diseases that may cause nephrotic syndrome can be challenging. Sufficient awareness of this condition is necessary for the appropriate diagnosis and treatment.
Collapse
Affiliation(s)
- Lin Liu
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Brian Murray
- Department of Internal Medicine, Jacobs School of Medicine, University at Buffalo, State University of New York, Buffalo, NY
| | - John E. Tomaszewski
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| |
Collapse
|
3
|
Abdelnabi HH. Is podocytopathy another image of renal affection in p-SLE? Pediatr Rheumatol Online J 2021; 19:57. [PMID: 33902643 PMCID: PMC8077747 DOI: 10.1186/s12969-021-00547-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 04/14/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Lupus podocytopathy (LP) is a renal affection described in systemic lupus erythematosus (SLE) patients with nephrotic range proteinuria, characterized by diffuse foot process effacement without immune deposits and glomerular proliferation. This study describes LP, its pathological features and outcomes of pediatric (p-SLE) patients in comparison to the usual lupus nephritis (LN) cases. METHODOLOGY A retrospective cohort study conducted on a 10-year registration (2010-2019) of 140 p-SLE patients at the Pediatric Department, Tanta University. Histopathological analysis with light microscopy (LM) and immunofluorescence (IF) of all renal biopsies were evaluated according to the International Society of Nephrology Renal Pathology Society (ISN/RPS) grading system. In addition, some biopsies were examined with electron microscopy (EM). RESULTS Eighty-six p-SLE cases (61.4%) had renal involvement; seventy-nine biopsies (91.86%) of them met the classification criteria of LN as defined by ISN/RPS system. Five biopsies were normal (MCD) and two showed focal segmental sclerosis (FSGN) that did not meet any known classification of LN. Hence, they were reevaluated using EM that revealed diffuse effaced podocytes without glomerular sub-epithelial, endocapillary or basement membrane immune deposits, and were classified as having lupus podocytopathy, representing (8.14%) of all LN biopsies. Those seven cases showed good response to steroids with a complete remission duration of 3.40 ± 1.95 weeks. However, some case had 1-3 relapses during the duration of follow up. CONCLUSIONS LP is a spectrum of p-SLE, not an association as it is related to disease activity and its initial presentation.
Collapse
Affiliation(s)
- Hend H. Abdelnabi
- grid.412258.80000 0000 9477 7793Nephrology Unit, Pediatric Department, Tanta University, El-Geesh Street, Tanta, Egypt
| |
Collapse
|
4
|
Yan HB, Li YM. Atrial thrombus as a complication of SLE and APS in an 8-year-old child. Pediatr Rheumatol Online J 2020; 18:90. [PMID: 33203428 PMCID: PMC7672915 DOI: 10.1186/s12969-020-00484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/01/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is an autoimmune disease involving multiple systems with various clinical manifestations. Renal involvement is common, but intracardiac thrombus is rarely reported as a complication of antiphospholipid syndrome (APS, also known as anticardiolipin syndrome). Anticoagulant therapy is the first-line treatment, and surgery is performed in severe cases. We report a case to improve clinicians' understanding of disease diagnosis. CASE PRESENTATION An 8-year-old girl was admitted to our hospital because of left costal pain, hematuria and fever. She had obvious edema occult blood 3+, urinary protein 3.2 g/24 h, albumin 17.6 g/L, and total cholesterol 7.21 mmol/L, consistent with a diagnosis of nephrotic syndrome. We continued to track the etiology of nephrotic syndrome and performed a renal biopsy, showing dsDNA 1:10 positivity, low C3, low platelets and hemoglobin, anticardiolipin IgM 12 U/ml, anti-β2-glycoprotein I (β2GPI) 223 U/ml; renal pathology suggested lupus nephritis (LN), and the patient was ultimately diagnosed with SLE, secondary APS and LN. The patient was treated with hormones and immunosuppressants. Sixteen weeks later, her urinary protein was 1+, and the quantity of urine protein was less than 0.5 g/d. Echocardiography showed that the mass in the right atrium was thrombotic. Heparin anticoagulant therapy was effective. CONCLUSION SLE can involve multiple systems and various complications. Thrombus in the right atrium is a rare complication of APS. Early diagnosis and treatment are key to improving the prognosis of children.
Collapse
Affiliation(s)
- Hai-bo Yan
- grid.430605.4Department of Pediatric Critical Medicine, The First Hospital of Jilin University, 71 Xin Min Street, Changchun, 130000 China
| | - Yu-mei Li
- grid.430605.4Department of Pediatric Critical Medicine, The First Hospital of Jilin University, 71 Xin Min Street, Changchun, 130000 China
| |
Collapse
|
5
|
Wu H, Chang C, Lu Q. The Epigenetics of Lupus Erythematosus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1253:185-207. [PMID: 32445096 DOI: 10.1007/978-981-15-3449-2_7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a life-threatening autoimmune disease that is characterized by dysregulated dendritic cells, T and B cells, and abundant autoantibodies. The pathogenesis of lupus remains unclear. However, increasing evidence has shown that environment factors, genetic susceptibilities, and epigenetic regulation contribute to abnormalities in the immune system. In the past decades, several risk gene loci have been identified, such as MHC and C1q. However, genetics cannot explain the high discordance of lupus incidence in homozygous twins. Environmental factor-induced epigenetic modifications on immune cells may provide some insight. Epigenetics refers to inheritable changes in a chromosome without altering DNA sequence. The primary mechanisms of epigenetics include DNA methylation, histone modifications, and non-coding RNA regulations. Increasing evidence has shown the importance of dysregulated epigenetic modifications in immune cells in pathogenesis of lupus, and has identified epigenetic changes as potential biomarkers and therapeutic targets. Environmental factors, such as drugs, diet, and pollution, may also be the triggers of epigenetic changes. Therefore, this chapter will summarize the up-to-date progress on epigenetics regulation in lupus, in order to broaden our understanding of lupus and discuss the potential roles of epigenetic regulations for clinical applications.
Collapse
Affiliation(s)
- Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Christopher Chang
- Division of Pediatric Immunology and Allergy, Joe DiMaggio Children's Hospital, Hollywood, FL, 33021, USA.,Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, Davis, CA, 95616, USA
| | - Qianjin Lu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
| |
Collapse
|
6
|
Wu H, Liao J, Li Q, Yang M, Zhao M, Lu Q. Epigenetics as biomarkers in autoimmune diseases. Clin Immunol 2018; 196:34-39. [PMID: 29574040 DOI: 10.1016/j.clim.2018.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 12/21/2022]
Abstract
Autoimmune diseases are immune system disorders in which immune cells cannot distinguish self-antigens from foreign ones. The current criteria for autoimmune disease diagnosis are based on clinical manifestations and laboratory tests. However, none of these markers shows both high sensitivity and specificity. In addition, some autoimmune diseases, for example, systemic lupus erythematosus (SLE), are highly heterogeneous and often exhibit various manifestations. On the other hand, certain autoimmune diseases, such as Sjogren's syndrome versus SLE, share similar symptoms and autoantibodies, which also causes difficulties in diagnosis. Therefore, biomarkers that have both high sensitivity and high specificity for diagnosis, reflect disease activity and predict drug response are necessary. An increasing number of publications have proposed the abnormal epigenetic modifications as biomarkers of autoimmune diseases. Therefore, this review will comprehensively summarize the epigenetic progress in the pathogenesis of autoimmune disorders and unearth potential biomarkers that might be appropriate for disease diagnosis and prediction.
Collapse
Affiliation(s)
- Haijing Wu
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Jieyue Liao
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Qianwen Li
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Ming Yang
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Ming Zhao
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Qianjin Lu
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China.
| |
Collapse
|
7
|
Abstract
Systemic lupus erythematosus (SLE) is a complex and highly heterogeneous disease. By now, no novel drug has been approved by the US FDA in the past 50 years, except Belimumab, a monoclonal antibody to inhibit B-cell activating factor. The stagnating drug development of lupus may be due to our limited understanding of disease etiopathogenesis and the extreme heterogeneity of patient population. Thus, the individualized treatment for SLE becomes necessary. Recently, biomarkers have shown potential in individualized treatment. This review comprehensively summarizes novel potential biomarkers, discusses their current status in preclinical studies and clinical use, sensitivity to treatments and correlation with the disease activity, and provides an insight into the possibility of biomarkers in the utilization of individualized treatment for SLE.
Collapse
Affiliation(s)
- Jinrong Zeng
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Ming Zhao
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Qianjin Lu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| |
Collapse
|
8
|
Nasri A, Bedoui I, Mrissa R, Riahi A, Derbali H, Zaouali J, Messelmani M, Mansour M. Recurrent status epilepticus in posterior reversible encephalopathy syndrome as initial feature of pediatric lupus: A newly diagnosed case and literature review. Brain Dev 2016; 38:835-41. [PMID: 27068876 DOI: 10.1016/j.braindev.2016.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/25/2016] [Accepted: 03/28/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Posterior reversible encephalopathy syndrome (PRES) is a recently described clinico-neuroradiological syndrome with several predisposing conditions. Systemic lupus erythematosus (SLE), beginning in 15-20% in childhood, is considered as a potential underlying etiology of PRES. In children, status epilepticus (SE) rarely complicates PRES, and exceptionally occurs in SLE. METHODS We report on an illustrative case of PRES complicating pediatric lupus revealed by recurrent SE, and we further review through a Pubmed search the previously reported cases of pediatric SLE, PRES and SE. RESULTS We describe the case of a 12-year old girl who presented with recurrent status epilepticus associated to high blood pressure and renal involvement. Brain imaging showed classical aspects of PRES. Immunological tests including antinuclear, anti-DNA, and anticardiolipin antibodies were positive. The diagnosis of SLE was established. The Pubmed search identified a total number of 9 children with SE in SLE, and 26 with PRES, including our patient. CONCLUSIONS We discussed the clinical and paraclinical features of PRES in SLE with epilepsy, their underlying pathophysiological aspects, and their management challenges. PRES should be considered in initial recurrent SE in children, justifying a battery of tests comprising immunological testing. Anticardiolipin antibodies seem to play a crucial role in epilepsy, PRES and renal involvement in pediatric SLE. Further studies are needed to clarify whether PRES should be considered one of the neuropsychiatric manifestations of SLE or a consequence of active disease in other organ systems or its treatment.
Collapse
Affiliation(s)
- Amina Nasri
- Department of Neurology, Military Hospital, Tunisia.
| | - Ines Bedoui
- Department of Neurology, Military Hospital, Tunisia
| | - Ridha Mrissa
- Department of Neurology, Military Hospital, Tunisia
| | - Anis Riahi
- Department of Neurology, Military Hospital, Tunisia
| | | | | | | | | |
Collapse
|
9
|
Hu WX, Chen YH, Bao H, Liu ZZ, Wang SF, Zhang HT, Liu ZH. Glucocorticoid with or without additional immunosuppressant therapy for patients with lupus podocytopathy: a retrospective single-center study. Lupus 2015; 24:1067-75. [PMID: 25819933 DOI: 10.1177/0961203315578766] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/02/2015] [Indexed: 01/22/2023]
Abstract
Lupus podocytopathy is a newly recognized class of lupus nephritis characterized by extensive glomerular foot process effacement without capillary wall immune deposits. The treatment response and relapse of glucocorticoid with or without additional immunosuppressive agents has not been well investigated. In this study, 50 patients with lupus podocytopathy were included and received glucocorticoid alone (glucocorticoid monotherapy) or glucocorticoid plus additional immunosuppressive agents (combination therapy) for their induction or maintenance treatment regimens. The treatment response and relapse rate in the two groups were respectively analyzed. We found that the induction treatment with glucocorticoid monotherapy and combination therapy led to remission in 47 patients (94.0%) at 12 weeks treatment, with complete remission (CR) occurring in 38 patients (76.0%). The CR rate compared between glucocorticoid monotherapy and combination therapy showed no difference (76.7% vs 75.0%, p = 0.9), the median time to CR was four weeks (range: 2.0-6.0 weeks) in glucocorticoid monotherapy and 8.0 weeks (range: 3.7-12.0 weeks) in combination therapy (p = 0.076). Twenty-seven of 47 patients (57.4%) relapsed during maintenance, the relapse rate was much higher in the glucocorticoid monotherapy group than in the combination therapy group (89.5% vs 35.7%, p < 0.001), regardless of the induction regimens being glucocorticoid monotherapy or combination therapy. No patient developed end stage renal disease or died during follow-up for 6-125 months (median 62 months). In conclusion, the remission of lupus podocytopathy could be induced by glucocorticoid monotherapy or glucocorticoid plus other immunosuppressive agents, while the remission should be maintained by the combination regimen.
Collapse
Affiliation(s)
- W X Hu
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Y H Chen
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - H Bao
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Z Z Liu
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - S F Wang
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - H T Zhang
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Z H Liu
- National Clinical Research Center of Kidney Diseases Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| |
Collapse
|