Lupus lung

Pulmonary vasculitis: diagnosis and endovascular therapy

Pulmonary vasculitides are caused by a heterogeneous group of diseases with different clinical features and etiologies. Radiologic manifestations depend on the predominant type of vessel involved, which are grouped into large, medium, or small-sized vessels. Diagnosing pulmonary vasculitides is a challenging task, and radiologists play an important role in their management by providing supportive evidence for diagnosis and opportunities for minimally invasive therapy. This paper aims to present a practical approach for understanding the vasculitides that can affect the pulmonary vessels and lungs. We will describe and illustrate the main radiologic findings, discussing opportunities for minimally invasive treatment.

Pulmonary Vasculitis: Spectrum of Imaging Appearances

Pulmonary vasculitis is a relatively uncommon disorder, usually manifesting as part of systemic vasculitis. Imaging, specifically computed tomography, is often performed in the initial diagnostic workup. Although the findings in vasculitis can be nonspecific, they can provide important clues in the diagnosis, and guide the clinical team toward the right diagnosis. Radiologists must have knowledge of common and uncommon imaging findings in various vasculitides. Also, radiologists should be able to integrate the clinical presentation and laboratory test findings together with imaging features, so as to provide a meaningful differential diagnosis.

Extrapulmonary Causes of Respiratory Failure

The causes of respiratory failure can be divided into two main groups: extrapulmonary and pulmonary. Extrapulmonary causes of respiratory failure include conditions that exclusively or primarily cause respiratory failure by their effect on structures other than the lungs (i.e., the extrapulmonary compartment). To place the topic of extrapulmonary respiratory failure into perspective, we briefly review normal and abnormal gas exchange and then examine how one can use this information to suspect or confirm the diagnosis of an extrapulmonary cause of respiratory failure. We then review the individual causes of extrapulmonary respiratory failure. These have been divided into two main functional categories: (1) those that involve a decrease in normal force generation, and (2) those that involve an increase in resistance to (bulk flow) ventilation. We then briefly consider the treatment of these disorders from a respiratory point of view.

Pulmonary involvement of systemic lupus erythematosus: analysis of 90 necropsies

Pleuropulmonary manifestations of systemic lupus erythematosus (SLE) have been reported to be of variable prevalence, depending on the diagnostic methods used. The objective of this study was to determine the anatomopathological prevalence and the nature of lung involvement associated with SLE and to define if there were differences in the grade and type of pulmonary involvement in patients who had died at different time periods, before or after 1996. Complete autopsy studies of 90 patients with SLE diagnosis carried out between 1958 and 2006 and their clinical records were studied. All patients fulfilled the American College of Rheumathology (ACR) diagnostic criteria for SLE. Two groups of patients were analyzed: patients who had died before 1996 and those deceased in 1996–2006. Some pleuropulmonary involvement was detected in 97.8% of the autopsies. The most frequent findings were pleuritis (77.8%), bacterial infections (57.8%), primary and secondary alveolar haemorrhages (25.6%), followed by distal airway alterations (21.1%), opportunistic infections (14.4%) and pulmonary thromboembolism (7.8%), both acute and chronic. No cases of acute or chronic lupus pneumonitis were found. Opportunistic lung infections were invasive aspergillosis, disseminated strongyloidiasis, mucormicosis and Pneumocystis carinii. Only three of 23 patients with alveolar haemorrhage showed capillaritis. The four patients with primary pulmonary hypertension (PHT) had plexiform lesions. Deceased patients’ age at death (46.09 ± 11.01 vs 30.3 ± 11.5 years, P < 0.0001) as well as survival time from diagnosis date (11.8 ± 11.2 vs 4.4 ± 4.9 years, P < 0.0001) in the second time period evaluated were significantly higher. However, there were no statistically significant differences in the prevalence of any of the pulmonary manifestations. Sepsis was considered the major cause of death without significant differences in both groups. Our results show that pulmonary manifestations directly caused by systemic lupus erythematosus are very uncommon and that their prevalence has not changed in the past 10 years. Pulmonary infection is still the most frequent affection, and it is an important cause of death in patients with lupus.

Collagen Vascular Diseases and Disorders of Connective Tissue

The collagen vascular diseases, also referred to as connective tissue diseases, are a diverse group of systemic inflammatory disorders thought to be immunologically mediated. The concept of collagen vascular disease began to take shape in the 1930s, when it was recognized that rheumatic fever and rheumatoid arthritis can affect connective tissues throughout the body.1,2 During the following decade, as conditions such as systemic lupus erythematosus (SLE) and scleroderma came to be viewed as systemic diseases of connective tissue, the terms diffuse connective disease and diffuse collagen disease were proposed.3,4 During the same period, the designation of diffuse vascular disease was proposed for diseases such as scleroderma, polymyositis, SLE, and polyarteritis nodosa, which featured widespread vascular involvement.5 With the realization that many of these entities can exhibit both systemic connective tissue manifestations and vascular abnormalities, the unifying designation of collagen vascular disease was introduced.6

Pulmonale Manifestationen bei Erkrankungen des rheumatischen Formenkreises

Collagen based vascular diseases with pulmonary involvement comprise rheumatoid arthritis, systemic lupus erythematosus, progressive systemic sclerosis, dermatomyositis and polymyositis, ankylosing spondylitis, Sjögren's syndrome, and mixed connective tissue diseases. The different characteristics of pulmonary involvement are described. In such circumstances, early recognition of lung involvement is of considerable significance and the relationship to the corresponding disease has to be made. Frequently unrecognised pulmonary involvement ends up as fibrosis with irreversible deficits in respiratory function.

Genetic basis of the complex pathological manifestations of collagen disease: lessons from MRL/lpr and related mouse models

The pathological findings in collagen disease including systemic lupus erythematosus show complex lesions such as glomerulonephritis, systemic vasculitis, polyarthritis, sialoadenitis, etc. Moreover, some cases of collagen disease are categorized into overlapping syndromes. It is still controversial whether such diversity and similarity of pathological manifestations among the collagen disease depends on ambiguity in diagnosis or is an intrinsic quality of the collagen diseases themselves. In this paper, we reviewed this subject focusing on a series of our genetic studies of murine models of collagen disease, MRL strains of mice with a deficit in Fas-mediated apoptosis, which spontaneously develop glomerulonephritis, systemic vasculitis, polyarthritis and sialoadenitis. We observed that each lesion was controlled by a different set of genes and they appeared to act in an additive manner on the development of each lesion. We conclude that various disease categories in collagen disease will be a result of the combination of polygenes.

Fibrose pulmonar grave: achado incomum em lúpus eritematoso sistêmico: relato de um caso

Os autores relatam o caso de uma paciente do sexo feminino, 51 anos de idade, branca, com diagnóstico estabelecido de lúpus eritematoso sistêmico associado a evidência radiológica de fibrose pulmonar grave. A epidemiologia das manifestações pleuropulmonares do lúpus eritematoso sistêmico, dando ênfase à fibrose pulmonar, é discutida.

Alveolar hemorrhage in systemic lupus erythematosus: presentation and management

AIM

To describe our experience with alveolar hemorrhage (AH) in systemic lupus erythematosus (SLE).

METHODS

Review of medical records and pertinent medical literature using MEDLINE and reference lists from retrieved publications.

PATIENTS

Seven patients with SLE admitted with episodes of AH (n = 11).

RESULTS

Six patients were female, and one was male. Mean age at the time of AH was 31.1 years. Mean duration of SLE was 4.5 years. AH occurred within 3 weeks of SLE onset in two patients. Recurrent AH was observed in four patients. Six patients were already receiving treatment for SLE at the time of AH. All patients presented with dyspnea and new pulmonary infiltrates. Hemoptysis occurred in only 54%. All patients had BAL within 48 h of presentation. Temperature > or =39 degrees C (102.2 degrees F) accompanied 82% of episodes. Glomerulonephritis was the most common nonpulmonary SLE manifestation (74%). Treatment with empiric IV antibiotics was initiated in 10 episodes. Initial treatment included high-dose corticosteroids (prednisone, 1 to 3 mg/kg/d [n = 2]; or IV methylprednisolone, 1 g/d [n = 9], with or without oral cyclophosphamide, 2 to 3 mg/kg/d [n = 7]). Plasmapheresis (three to four sessions) was added in five episodes for persistent AH. All patients survived.

CONCLUSIONS

AH may mimic pneumonia. Hemoptysis may not be evident. Infection must be aggressively excluded, especially since many patients with AH are already receiving immunosuppressive therapy. AH frequently recurs despite ongoing immunosuppression. Although high mortality rates have been reported with AH in SLE, we observed 100% survival.

Radiologic manifestations of the systemic autoimmune diseases

Advances in thoracic imaging during the past two decades, such as CT scans and MR imaging, have enhanced our understanding of the pleuropulmonary abnormalities that develop in the systemic autoimmune diseases. In this article, the thoracic radiologic manifestations of several connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome, polymyositis/dermatomyositis, progressive systemic sclerosis, and anklyosing spondylitis), two granulomatous vasculitides, (Wegener's Granulomatosis and Churg-Strauss syndrome), and antiglomerular basement membrane disease are reviewed.

Pulmonary manifestations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. The respiratory system is more commonly involved in SLE than in any other collagen vascular disease. SLE may affect virtually all components of the respiratory system, including the upper airway, lung parenchyma, pulmonary vasculature, pleura, and respiratory muscles. Respiratory system involvement ranges from symptomatic to fulminant and life threatening. This article reviews the pulmonary manifestations of SLE, including drug-induced SLE.

Intercellular adhesion molecule-1 deficiency prolongs survival and protects against the development of pulmonary inflammation during murine lupus

One of the characteristic features of the lupus syndrome in humans and mice is the organ-specific accumulation of leukocytes within a variety of different tissues; however, the etiology of this phenomenon remains unclear. The work presented here determined the role of intercellular adhesion molecule (ICAM)-1 in the development of pulmonary leukocyte accumulation by generating MRL/MpJ-Faslpr mice that are genetically deficient in this critical adhesion molecule. Interestingly, these MRL/MpJ-Faslpr ICAM-1 knockout mice exhibit prolonged survival times compared to littermates expressing ICAM-1. We have determined that lack of ICAM-1 completely abrogates the development of pulmonary inflammation but does not prevent the development of autoantibodies, lymphadenopathy, and glomerulonephritis. Furthermore, the lack of pulmonary inflammation was found to be due to decreased migration of leukocytes to the lung rather than decreased in situ proliferation of cells.

Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome

Diffuse alveolar hemorrhage (DAH) complicating systemic lupus erythematosus (SLE) remains a devastating pulmonary complication of this systemic disease. We conducted this study to review the clinicopathologic presentation and the effects of prior treatment, presence of infection, and current treatment on the survival and outcome of patients with DAH and SLE. We reviewed the records of 15 SLE patients who experienced 19 episodes of DAH over a 10-year period in a single tertiary care hospital. These patients were compared with 57 previously reported cases. The 19 episodes of DAH represented 3.7% of the 510 admissions occasioned by various complications of SLE. As previously reported, the majority (66%) were women with a median age of 27 years. The onset was often abrupt: < 3 days in 12 of the episodes. In 3 patients (20%), DAH was the initial manifestation of SLE, compared with 11% in the literature series. In the other patients in the present series, DAH appeared a median of 31 months following the diagnosis of SLE, versus 35 months in the literature series. In only 42% of the episodes in the present series, compared with 66% in the literature series, was hemoptysis present at the time of admission. However, hemoptysis eventually appeared in all 19 episodes. Temperature elevation (> 38 degrees C) was another inconsistent finding, found in only 5 episodes (26%) in the present series. The most constant concurrent systemic finding was lupus nephritis (14/15 patients). This represents a significant increase when compared with the literature series (29/48 patients). In 8 of 10 patients in whom lung tissue was available, pulmonary capillaritis accompanied the DAH. This represents a marked difference in the underlying histologic pattern when compared with the literature series. In those patients, 72% (31/43 patients) had bland pulmonary hemorrhage, and capillaritis was described in only 6 patients. The overall patient mortality rate was 53% in the current series and 50% in the literature series. Factors associated with an increased mortality in the present series include the following: mechanical ventilation (62%) versus no mechanical ventilation (0%); infection (78%) versus no infection (20%); and cyclophosphamide therapy for the acute DAH episode (70%) versus no cyclophosphamide therapy (20%). The incidence of infection in DAH and SLE (9/19 episodes) is far greater than previously reported (7/ 57 episodes). One possible explanation for this difference is the increased use of outpatient immunosuppressive therapy with monthly intravenous cyclophosphamide therapy for lupus nephritis. Eighteen DAH episodes in the present series were treated with intravenous methylprednisolone. When one combines both the current and literature series experience (16 episodes), the use of plasmapheresis does not improve survival. Of the 7 patients in the present series who survived all episodes of DAH, 6 remain alive a median of 50 months post episode and without recurrence of DAH. Diffuse alveolar hemorrhage is an uncommon but lethal complication of SLE. The survival rate remains unchanged from previous reports. The absence of hemoptysis should not exclude this diagnosis, particularly in those patients who experience an acute pulmonary syndrome with new radiographic infiltrates accompanied by falling hematocrit and the presence of a hemorrhagic bronchoalveolar lavage. Evidence for lupus nephritis is present in the great majority of cases. Most cases demonstrate the histologic pattern of pulmonary capillaritis. The mortality is adversely affected by the need for mechanical ventilation, either the presence of infection at the time of admission or the development of infection in the hospital, and the use of cyclophosphamide for treatment of the acute event.

Diagnosis of alveolitis in interstitial lung manifestation in connective tissue diseases: importance of late inspiratory crackles, 67 gallium scan and bronchoalveolar lavage

The diagnostic relevance of bronchoalveolar lavage (BAL) and associated non-invasive findings in connective tissue diseases (CTD) has not been established regarding alveolitis so far. The goal of the study was to determine the relations between BAL cell differential count and findings of non-invasive diagnostic procedures for alveolitis to predict the clinical value of BAL in CTD. One hundred-five patients (92 non-smokers; 13 smokers) with CTD (73 patients with systemic sclerosis, 19 with systemic lupus erythematosus, 13 with primary Sjögren's syndrome) had symptoms or signs of lung involvement and were further examined (lung function test, chest radiography, thoracic computed tomography, 67 gallium scintigraphy and BAL). The relations between BAL in middle lobe and cell count differentiation to non-invasive investigations were analyzed by logistic regression. In all CTD patients investigated a pulmonal involvement occurred based on non-invasive methods. Regarding non-invasive methods, alveolitis determined by BAL cell differential count was significantly associated with an increased 67-gallium uptake and late inspiratory crackles (P < 0.01), and to a lesser extent with an abnormal interstitial pattern in CT (P < 0.055). Parameters of lung function and laboratory parameters were related to alveolitis using multivariate testing. Considering the alveolitis subtype (granulo- or lymphocytosis), only a reduced FEV1 showed a relationship to granulocytic alveolitis (P < 0.01). Late inspiratory crackles and increased 67 gallium uptake as non-invasive diagnostic findings point out alveolitis in CTD remarkably. Therapeutic and prognostic aspects necessitate BAL to specify the type of alveolitis (lymphocytosis or granulocytosis or mixed forms) in CTD patients with lung manifestation. Non-invasive diagnostic procedures cannot predict the type of alveolitis sufficiently.

False positive pleural biopsy and high CA125 levels in serum and pleural effusion in systemic lupus erythematosus

A 23-year-old female with systemic lupus erythematosus is reported. The clinical features included fever, shortness of breath, lymphadenopathies, hepatosplenomegaly, pleural and pericardial fluids, ANA and Anti-DNA positivity. Pleural biopsy was false positive for malignancy on two occasions. High CA125 levels were detected in both serum and pleural fluid. Following prednisolone treatment, clinical and laboratory findings returned to normal.

False positive pleural biopsy and high CA125 levels in serum and pleural effusion in systemic lupus erythematosus

A 23-year-old female with systemic lupus erythematosus is reported. The clinical features included fever, shortness of breath, lymphadenopathies, hepatosplenomegaly, pleural and pericardial fluids, ANA and Anti-DNA positivity. Pleural biopsy was false positive for malignancy on two occasions. High CA125 levels were detected in both serum and pleural fluid. Following prednisolone treatment, clinical and laboratory findings returned to normal.

Phrenic nerve function in patients with diaphragmatic weakness and systemic lupus erythematosus

Diaphragmatic weakness has been identified as one of the pulmonary manifestations of systemic lupus erythematosus. Whether this weakness results from a neuropathic or myopathic process has not been established. Thirty patients with SLE were screened for the presence of inspiratory muscle (IM) weakness. Detailed studies were performed in nine with IM weakness. All nine were found to have diaphragmatic weakness (mean +/- SD, maximal transdiaphragmatic pressure 50 +/- 12 cmH2O). Phrenic nerve latencies, evaluated using transcutaneous stimulation, were normal in all individuals excluding a demyelinating neuropathy. Compound diaphragm action potential (CDAP) with phrenic nerve stimulation was normal in six of these nine patients. Reduced CDAP in three of nine patients was consistent either with axonal degeneration of the phrenic nerve or diaphragm myopathy. Nerve conduction and electromyographic studies on peripheral nerves and muscles respectively failed to demonstrate an associated generalized neuropathy or myopathy. We conclude that diaphragmatic weakness in patients with SLE is both common and is very unlikely to be caused by a phrenic neuropathy.