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Nikolopoulos D, Cetrez N, Lindblom J, Parodis I. Neuropsychiatric involvement in systemic lupus erythematosus contributes to organ damage beyond the nervous system: a post-hoc analysis of 5 phase III randomized clinical trials. Rheumatol Int 2024; 44:1679-1689. [PMID: 39115551 PMCID: PMC11343782 DOI: 10.1007/s00296-024-05667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 07/20/2024] [Indexed: 08/25/2024]
Abstract
OBJECTIVE To investigate the association between neuropsychiatric systemic lupus erythematosus (NPSLE) and SLICC/ACR damage index (SDI) items, especially non-neuropsychiatric items. METHODS Baseline data from five phase III trials (BLISS-52, BLISS-76, BLISS-SC, BLISS-NEA, EMBRACE) were analysed. NPSLE involvement was defined as NP BILAG A/B/C/D (n = 272); NP BILAG E denoted non-neuropsychiatric SLE (n = 3273). We employed multivariable logistic regression analysis adjusting for age, sex, disease duration, and ethnicity. RESULTS The median (IQR) and mean ± SD SDI scores were 0 (0-1) and 0.62 ± 1.09. Compared with the non-neuropsychiatric SLE group, NPSLE patients were more likely to develop damage (adjusted (a)OR = 2.86; 95% CI = 2.28-3.59). This held true also after suppression of the NP SDI items (aOR = 1.70; 95% CI = 1.36-2.12). Beyond the neuropsychiatric domain, NPSLE was associated with damage in the cardiovascular (aOR = 2.63; 95% CI = 1.75-3.95), musculoskeletal (aOR = 1.90; 95% CI = 1.43-2.52), and skin (aOR = 1.54; 95% CI = 1.06-2.22) SDI domains. Dissecting domains into items, NPSLE was associated with coronary artery disease (aOR = 3.08; 95% CI = 1.44-6.58), myocardial infraction (aOR = 3.11; 95% CI = 1.54-6.27), muscle atrophy (aOR = 3.34; 2.16-5.16), scarring alopecia (aOR = 1.79; 95% CI = 1.19-2.70), bowel infarction (aOR = 1.98; 95% CI = 1.20-3.26), retinopathy (aOR = 2.23; 95% CI = 1.15-4.32), and premature gonadal failure (aOR = 2.10; 95% CI = 1.11-3.90). CONCLUSION The intricate association between NPSLE and damage accrual extends beyond the nervous system to also comprise the musculoskeletal, skin, and cardiovascular organ systems.
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Affiliation(s)
- Dionysis Nikolopoulos
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Nursen Cetrez
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Julius Lindblom
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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de Oliveira JL, Cordeiro RA, Guedes LKN, Pasoto SG. Shrinking lung syndrome in primary Sjögren's syndrome: a case-based review. Rheumatol Int 2024; 44:1795-1800. [PMID: 37735285 DOI: 10.1007/s00296-023-05447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/24/2023] [Indexed: 09/23/2023]
Abstract
Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease that affects exocrine glands, mainly the salivary and lacrimal glands, leading to the development of sicca symptoms. Patients with pSS may also present with extraglandular manifestations, including lung involvement, estimated to occur in 9-24% of cases. Shrinking lung syndrome (SLS) is an uncommon respiratory complication primarily associated with systemic lupus erythematosus, with a prevalence of approximately 1% in these patients. It typically manifests as dyspnea, pleuritic chest pain, lung volume reduction, and a restrictive pattern on respiratory function tests. Cases reporting SLS with other connective tissue diseases, including pSS, are even rarer. Herein, we describe a case of a 57-year-old woman with a 10-year history of pSS who presented with dyspnea and pleuritic chest pain. After evaluation, the patient was diagnosed with SLS based on clinical, radiologic, laboratorial, and electrophysiologic characteristics. In addition, we identified and analyzed previously published cases of SLS in pSS. Treatment includes corticosteroids, immunosuppressants, and respiratory muscle training. This study highlights the importance of considering SLS in the differential diagnosis of patients with pSS and respiratory symptoms.
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Affiliation(s)
- Jobson Lopes de Oliveira
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, sala 3192, São Paulo, SP, ZIP Code: 01246-903, Brazil
| | - Rafael Alves Cordeiro
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, sala 3192, São Paulo, SP, ZIP Code: 01246-903, Brazil
| | - Lissiane Karine Noronha Guedes
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, sala 3192, São Paulo, SP, ZIP Code: 01246-903, Brazil
| | - Sandra Gofinet Pasoto
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, sala 3192, São Paulo, SP, ZIP Code: 01246-903, Brazil.
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Synthetic Pharmacotherapy for Systemic Lupus Erythematosus: Potential Mechanisms of Action, Efficacy, and Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010056. [PMID: 36676680 PMCID: PMC9866503 DOI: 10.3390/medicina59010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
The pharmacological treatment of systemic lupus erythematosus (SLE) aims to decrease disease activity, progression, systemic compromise, and mortality. Among the pharmacological alternatives, there are chemically synthesized drugs whose efficacy has been evaluated, but which have the potential to generate adverse events that may compromise adherence and response to treatment. Therapy selection and monitoring will depend on patient characteristics and the safety profile of each drug. The aim of this review is to provide a comprehensive understanding of the most important synthetic drugs used in the treatment of SLE, including the current treatment options (mycophenolate mofetil, azathioprine, and cyclophosphamide), review their mechanism of action, efficacy, safety, and, most importantly, provide monitoring parameters that should be considered while the patient is receiving the pharmacotherapy.
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Ciaffi J, Gegenava M, Ninaber MK, Huizinga TWJ. Shrinking Lung Syndrome: Diagnostic and Therapeutic Challenges in 3 Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2021; 27:S525-S529. [PMID: 31483349 DOI: 10.1097/rhu.0000000000001132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Depascale R, Del Frate G, Gasparotto M, Manfrè V, Gatto M, Iaccarino L, Quartuccio L, De Vita S, Doria A. Diagnosis and management of lung involvement in systemic lupus erythematosus and Sjögren's syndrome: a literature review. Ther Adv Musculoskelet Dis 2021; 13:1759720X211040696. [PMID: 34616495 PMCID: PMC8488521 DOI: 10.1177/1759720x211040696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/03/2021] [Indexed: 12/20/2022] Open
Abstract
Lung involvement in systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (pSS) has extensively been outlined with a multiplicity of different manifestations. In SLE, the most frequent finding is pleural effusion, while in pSS, airway disease and parenchymal disorders prevail. In both cases, there is an increased risk of pre-capillary and post-capillary pulmonary arterial hypertension (PAH) and pulmonary venous thromboembolism (VTE). The risk of VTE is in part due to an increased thrombophilic status secondary to systemic inflammation or to the well-established association with antiphospholipid antibody syndrome (APS). The lung can also be the site of an organ-specific complication due to the aberrant pathologic immune-hyperactivation as occurs in the development of lymphoma or amyloidosis in pSS. Respiratory infections are a major issue to be addressed when approaching the differential diagnosis, and their exclusion is required to safely start an immunosuppressive therapy. Treatment strategy is mainly based on glucocorticoids (GCs) and immunosuppressants, with a variable response according to the primary pathologic process. Anticoagulation is recommended in case of VTE and multi-targeted treatment regimens including different drugs are the mainstay for PAH management. Antibiotics and respiratory physiotherapy can be considered relevant complement therapeutic measures. In this article, we reviewed lung manifestations in SLE and pSS with the aim to provide a comprehensive overview of their diagnosis and management to physicians taking care of patients with connective tissue diseases.
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Affiliation(s)
- Roberto Depascale
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Giulia Del Frate
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Michela Gasparotto
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Valeria Manfrè
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Quartuccio
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Salvatore De Vita
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
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Di Bartolomeo S, Alunno A, Carubbi F. Respiratory Manifestations in Systemic Lupus Erythematosus. Pharmaceuticals (Basel) 2021; 14:276. [PMID: 33803847 PMCID: PMC8003168 DOI: 10.3390/ph14030276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by a wide spectrum of clinical manifestations. The respiratory system can be involved in up to 50-70% of patients and be the presenting manifestation of the disease in 4-5% of cases. Every part of the respiratory part can be involved, and the severity can vary from mild self-limiting to life threatening forms. Respiratory involvement can be primary (caused by SLE itself) or secondary (e.g., infections or drug toxicity), acute or chronic. The course, treatment and prognosis vary greatly depending on the specific pattern of the disease. This review article aims at providing an overview of respiratory manifestations in SLE along with an update about therapeutic approaches including novel biologic therapies.
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Affiliation(s)
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, 06123 Perugia, Italy;
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L’Aquila and Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, 67100 L’Aquila, Italy
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Amarnani R, Yeoh SA, Denneny EK, Wincup C. Lupus and the Lungs: The Assessment and Management of Pulmonary Manifestations of Systemic Lupus Erythematosus. Front Med (Lausanne) 2021; 7:610257. [PMID: 33537331 PMCID: PMC7847931 DOI: 10.3389/fmed.2020.610257] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022] Open
Abstract
Pulmonary manifestations of systemic lupus erythematosus (SLE) are wide-ranging and debilitating in nature. Previous studies suggest that anywhere between 20 and 90% of patients with SLE will be troubled by some form of respiratory involvement throughout the course of their disease. This can include disorders of the lung parenchyma (such as interstitial lung disease and acute pneumonitis), pleura (resulting in pleurisy and pleural effusion), and pulmonary vasculature [including pulmonary arterial hypertension (PAH), pulmonary embolic disease, and pulmonary vasculitis], whilst shrinking lung syndrome is a rare complication of the disease. Furthermore, the risks of respiratory infection (which often mimic acute pulmonary manifestations of SLE) are increased by the immunosuppressive treatment that is routinely used in the management of lupus. Although these conditions commonly present with a combination of dyspnea, cough and chest pain, it is important to consider that some patients may be asymptomatic with the only suggestion of the respiratory disorder being found incidentally on thoracic imaging or pulmonary function tests. Treatment decisions are often based upon evidence from case reports or small cases series given the paucity of clinical trial data specifically focused on pulmonary manifestations of SLE. Many therapeutic options are often initiated based on studies in severe manifestations of SLE affecting other organ systems or from experience drawn from the use of these therapeutics in the pulmonary manifestations of other systemic autoimmune rheumatic diseases. In this review, we describe the key features of the pulmonary manifestations of SLE and approaches to investigation and management in clinical practice.
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Affiliation(s)
- Raj Amarnani
- Department of Rheumatology, University College London Hospital, London, United Kingdom
| | - Su-Ann Yeoh
- Department of Rheumatology, University College London Hospital, London, United Kingdom
- Division of Medicine, Department of Rheumatology, University College London, London, United Kingdom
| | - Emma K. Denneny
- Department of Respiratory Medicine, University College London Hospital, London, United Kingdom
- Leukocyte Trafficking Laboratory, Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, United Kingdom
| | - Chris Wincup
- Department of Rheumatology, University College London Hospital, London, United Kingdom
- Division of Medicine, Department of Rheumatology, University College London, London, United Kingdom
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Affiliation(s)
- Sadettin Uslu
- Clinic of Rheumatology, Ömer Halisdemir University Bor Physical Medicine and Rehabilitation Training and Research Hospital, Niğde, Turkey
| | - Aydan Köken Avşar
- Department of Rheumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Yeşim Erez
- Department of Rheumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - İsmail Sarı
- Department of Rheumatology, Dokuz Eylül University School of Medicine, İzmir, Turkey
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Abstract
Sjögren syndrome (SS) is a progressive autoimmune disease characterized by dryness, predominantly of the eyes and mouth, caused by chronic lymphocytic infiltration of the lacrimal and salivary glands. Extraglandular inflammation can lead to systemic manifestations, many of which involve the lungs. Studies in which lung involvement is defined as requiring the presence of respiratory symptoms and either radiograph or pulmonary function test abnormalities quote prevalence estimates of 9% to 22%. The most common lung diseases that occur in relation to SS are airways disease and interstitial lung disease. Evidence-based guidelines to inform treatment recommendations for lung involvement are largely lacking.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 836 W. Gates Building, Philadelphia, PA 19104, USA
| | - Chadwick Johr
- Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 3737 Market Street, 8th floor, Philadelphia, PA 19104, USA
| | - Maryl Kreider
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 836 W. Gates Building, Philadelphia, PA 19104, USA.
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10
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Shrinking lung syndrome and pleural effusion as an initial manifestation of primary Sjögren's syndrome. ACTA ACUST UNITED AC 2018; 16:65-68. [PMID: 29472172 DOI: 10.1016/j.reuma.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 11/20/2022]
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Tseng HJ, Henry TS, Veeraraghavan S, Mittal PK, Little BP. Pulmonary Function Tests for the Radiologist. Radiographics 2017; 37:1037-1058. [DOI: 10.1148/rg.2017160174] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Hsiang-Jer Tseng
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Travis S. Henry
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Srihari Veeraraghavan
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Pardeep K. Mittal
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Brent P. Little
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
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Borrell H, Narváez J, Alegre JJ, Castellví I, Mitjavila F, Aparicio M, Armengol E, Molina-Molina M, Nolla JM. Shrinking lung syndrome in systemic lupus erythematosus: A case series and review of the literature. Medicine (Baltimore) 2016; 95:e4626. [PMID: 27537601 PMCID: PMC5370827 DOI: 10.1097/md.0000000000004626] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Shrinking lung syndrome (SLS) is a rare and less known complication mainly associated with systemic lupus erythematosus (SLE). In this study, we analyze the clinical features, investigation findings, approaches to management, and outcome in a case series of 9 adult patients with SLE and SLS diagnosed during a 35-year period in 3 referral tertiary care hospitals in Spain. Additionally, we reviewed 80 additional cases previously reported (PubMed 1965-2015). These 80 cases, together with our 9 patients, form the basis of the present analysis.The overall SLS prevalence in our SLE population was 1.1% (9/829). SLS may complicate SLE at any time over its course, and it usually occurs in patients without previous or concomitant major organ involvement. More than half of the patients had inactive lupus according to SELENA-systemic lupus erythematosus disease activity index (SLEDAI) scores. Typically, it presents with progressive exertional dyspnea of variable severity, accompanied by pleuritic chest pain in 76% of the cases.An important diagnostic delay is common. The diagnostic tools that showed better yield for SLS detection are the imaging techniques (chest x-ray and high-resolution computed tomography) along with pulmonary and diaphragmatic function tests. Evaluation of diaphragm dome motion by M-mode ultrasonography and phrenic nerve conduction studies are less useful.There are no standardized guidelines for the treatment of SLS in SLE. The majority of patients were treated with medium or high doses of glucocorticoids. Several immunosuppressive agents have been used in conjunction with steroids either if the patient fails to improve or since the beginning of the treatment. Theophylline and beta-agonists, alone or in combination with glucocorticoids, have been suggested with the intent to increase diaphragmatic strength.The overall long-term prognosis was good. The great majority of patients had significant clinical improvement and stabilization, or mild to moderate improvement on pulmonary function tests. The mortality rate was very low.
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Affiliation(s)
- Helena Borrell
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Javier Narváez
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
- Correspondence: Dr Francisco Javier Narváez García, Department of Rheumatology (Planta 10–2), Hospital Universitario de Bellvitge, Feixa Llarga, s/n, Hospitalet de Llobregat, Barcelona 08907, Spain (e-mail: )
| | - Juan José Alegre
- Department of Rheumatology, Hospital Universitario Dr. Peset, Valencia
| | | | | | - María Aparicio
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Eulàlia Armengol
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - María Molina-Molina
- Department of Pneumology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Joan M. Nolla
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
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Papiris SA, Manali ED, Kolilekas L, Kagouridis K, Maniati M, Filippatos G, Bouros D. Acute Respiratory Events in Connective Tissue Disorders. Respiration 2016; 91:181-201. [PMID: 26938462 DOI: 10.1159/000444535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.
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Affiliation(s)
- Spyros A Papiris
- 2nd Department of Pneumonology, x2018;Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
The lung is a common site of complications of systemic connective tissue disease (CTD), and lung involvement can present in several ways. Interstitial lung disease (ILD) and pulmonary hypertension are the most common lung manifestations in CTD. Although it is generally thought that interstitial lung disease develops later on in CTD it is often the initial presentation ("lung dominant" CTD). ILD can be present in most types of CTD, including rheumatoid arthritis, scleroderma, systemic lupus erythematosus, polymyositis or dermatomyositis, Sjögren's syndrome, and mixed connective tissue disease. Despite similarities in clinical and pathologic presentation, the prognosis and treatment of CTD associated ILD (CTD-ILD) can differ greatly from that of other forms of ILD, such as idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) can present as a primary vasculopathy in pulmonary arterial hypertension or in association with ILD (PH-ILD). Therefore, detailed history, physical examination, targeted serologic testing, and, occasionally, lung biopsy are needed to diagnose CTD-ILD, whereas both non-invasive and invasive assessments of pulmonary hemodynamics are needed to diagnose pulmonary hypertension. Immunosuppression is the mainstay of treatment for ILD, although data from randomized controlled trials (RCTs) to support specific treatments are lacking. Furthermore, treatment strategies vary according to the clinical situation-for example, the treatment of a patient newly diagnosed as having CTD-ILD differs from that of someone with an acute exacerbation of the disease. Immunosuppression is indicated only in select cases of pulmonary arterial hypertension related to CTD; more commonly, selective pulmonary vasodilators are used. For both diseases, comorbidities such as sleep disordered breathing, symptoms of dyspnea, and cough should be evaluated and treated. Lung transplantation should be considered in patients with advanced disease but is not always feasible because of other manifestations of CTD and comorbidities. Clinical trials of novel therapies including immunosuppressive therapies are needed to inform best treatment strategies.
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Affiliation(s)
- Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sonye K Danoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Robles-Perez A, Molina-Molina M. Treatment Considerations of Lung Involvement in Rheumatologic Disease. Respiration 2015; 90:265-74. [DOI: 10.1159/000441238] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Blanco Pérez JJ, Pérez González A, Guerra Vales JL, Melero Gonzalez R, Pego Reigosa JM. Síndrome del pulmón encogido en el síndrome de Sjögren primario tratado con éxito con rituximab. Arch Bronconeumol 2015; 51:475-6. [DOI: 10.1016/j.arbres.2014.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 11/15/2014] [Accepted: 11/21/2014] [Indexed: 11/26/2022]
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17
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Rice AD, Wakefield LB, Patterson K, Reed ED, Wurn BF, King CR, Wurn LJ. Decreasing adhesions and avoiding further surgery in a pediatric patient involved in a severe pedestrian versus motor vehicle accident. Pediatr Rep 2014; 6:5126. [PMID: 24711912 PMCID: PMC3977160 DOI: 10.4081/pr.2014.5126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 01/16/2014] [Indexed: 12/18/2022] Open
Abstract
In this case study, we report the use of manual physical therapy in a pediatric patient experiencing complications from a life-threatening motor vehicle accident that necessitated 19 surgeries over the course of 12 months. Post-surgical adhesions decreased the patient's quality of life. He developed multiple medical conditions including recurrent partial bowel obstructions and an ascending testicle. In an effort to avoid further surgery for bowel obstruction and the ascending testicle, the patient was effectively treated with a manual physical therapy regimen focused on decreasing adhesions. The therapy allowed return to an improved quality of life, significant decrease in subjective reports of pain and dysfunction, and apparent decreases in adhesive processes without further surgery, which are important goals for all patients, but especially for pediatric patients.
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Affiliation(s)
- Amanda D Rice
- Clear Passage Physical Therapy , Gainesville, FL, USA
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Peñacoba Toribio P, Córica Albani ME, Mayos Pérez M, Rodríguez de la Serna A. Rituximab in the treatment of shrinking lung syndrome in systemic lupus erythematosus. ACTA ACUST UNITED AC 2013; 10:325-7. [PMID: 24315464 DOI: 10.1016/j.reuma.2013.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 09/18/2013] [Accepted: 09/26/2013] [Indexed: 11/27/2022]
Abstract
Shrinking lung syndrome (SLS) is a rare manifestation of systemic lupus erythematosus. We report the case of a patient with non-responding SLS (neither to glucocorticoids nor immunosupresors), who showed remarkable improvement after the onset of treatment with rituximab. Although there is a little evidence, treatment with rituximab could be proposed in SLS when classical treatment fails.
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Affiliation(s)
| | - María Emilia Córica Albani
- Unidad de Reumatología, Servicio de Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Mercedes Mayos Pérez
- Unidad de Trastornos Respiratorios del Sueño, Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CibeRes), Universidad Autónoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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Lethrosne C, Pernot B, Diot P, Diot E. [Cardio-respiratory involvement in adult-onset Still's disease]. Rev Mal Respir 2013; 30:262-71. [PMID: 23664285 DOI: 10.1016/j.rmr.2012.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 12/04/2012] [Indexed: 10/27/2022]
Abstract
Cardiopulmonary involvement in adult-onset Still's disease is not as common as cutaneous and articular involvement. Pleuropericarditis is the most frequent thoracic manifestation. Although difficult, diagnosis of other thoracic manifestations, which may reveal the disease, is crucial, due to the high risk to life and the efficacy of new immunosuppressive agents. The pathophysiology involves essentially immunological factors, Still's disease being increasingly seen as an autoimmune inflammatory disease. Pro-inflammatory cytokines such as interleukine (IL) 1, 6 and 18 play a crucial role in macrophage activation, which is central in the pathophysiology of adult Still's disease. The classification of cardiopulmonary manifestations is based on anatomy. Cardiac lesions may involve all the tissues of the heart and the pulmonary arteries. Respiratory lesions may involve the pleura, the lung parenchyma (organizing pneumonitis, infiltrative lung disease, alveolar damage, amyloidosis), and the respiratory muscles, including the diaphragm. Finally, some manifestations may be provoked by the treatment itself. Steroids, the first-line treatment, are very effective in pleuropericarditis. Methotrexate used to be prescribed when steroids failed, but biotherapies such as IL1 and IL6 inhibitors have transformed the prognosis of forms resistant to these drugs.
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Affiliation(s)
- C Lethrosne
- Inserm U1100/EA6305, service de pneumologie, hôpital Bretonneau, CHRU et université François-Rabelais de Tours, centre d'étude des pathologies respiratoires, 37044 Tours, France
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Gheita TA, El-Mofty S, Fawzy SM, El-Fishawy H. Shrinking lung syndrome in systemic lupus erythematosus patients with dyspnea. EGYPTIAN RHEUMATOLOGIST 2012. [DOI: 10.1016/j.ejr.2012.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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Shrinking lung syndrome masked by pleuropericarditis: a case report and review of the literature. Clin Rheumatol 2012; 31:1741-4. [PMID: 22923179 DOI: 10.1007/s10067-012-2061-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 08/09/2012] [Indexed: 10/28/2022]
Abstract
The purpose of this article is to present an unusual case of shrinking lung syndrome (SLS) masked by pleuropericarditis with a review of the literature. We report a case of SLS in a 44-year-old woman in which the diagnosis was initially confounded by concurrent pleuropericarditis. The English medical literature was comprehensively reviewed for SLS for its presentation, clinical findings, diagnosis, treatment, with specific focus on its pathogenesis. SLS is a rare respiratory complication associated with systemic lupus erythematosus (SLE). The main manifestation of the disease is unexplained dyspnea, chest pain, and orthopnea. Lung volume reduction without parenchymal abnormalities along with restrictive ventilatory defect on pulmonary function test (PFT) is the hallmarks of this condition. Pathogenesis, treatment, and prognosis of SLS are not well described due to the small number of reported cases. The diagnosis of SLS in our patient was made based on imaging, PFT, and the exclusion of other respiratory diseases associated with SLE. Treatment with corticosteroid and intravenous cyclophosphamide was initiated due to simultaneously diagnosed renal involvement. Our case demonstrates the salient features of SLS. It emphasizes that although SLS is a rare disease limited to small subset of patients with SLE, it should be considered in patients with SLE with unexplained dyspnea. Moreover, symptoms of pleuropericarditis can mask and delay the diagnosis of SLS. Prompt diagnosis and treatment can lead to a decrease in morbidity and stabilization of pulmonary function test abnormalities.
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Allen D, Fischer A, Bshouty Z, Robinson DB, Peschken CA, Hitchon C, El-Gabalawy H, Meyers M, Mittoo S. Evaluating systemic lupus erythematosus patients for lung involvement. Lupus 2012; 21:1316-25. [DOI: 10.1177/0961203312454343] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: We set out to determine the frequency of respiratory symptoms, abnormal lung function, and shrinking lung syndrome (SLS) among patients with systemic lupus erythematosus (SLE) and to determine correlates of SLS. Methods: Consecutive adult patients who fulfilled the American College of Rheumatology classification criteria for SLE were enrolled. Demographics, clinical, and serologic characteristics were recorded; all patients underwent pulmonary function tests (PFT) and had either a chest X-ray or computed tomography scan. SLS was defined as dyspnea with restrictive lung physiology (defined as a forced vital capacity (FVC) <80% predicted in the absence of obstruction) who did not have any evidence of interstitial lung disease on chest imaging; controls were symptomatic patients with no restrictive physiology and the absence of interstitial changes on chest imaging. Results: Sixty-nine out of 110 (63%) patients had respiratory symptoms, 73 (66%) patients had abnormal lung function, and 11 (10%) patients met the definition for SLS. In a multivariate model controlling for disease duration, a history of pleuritis, modified American College of Rheumatology total score, seropositivity for dsDNA and RNP antibodies, increased disease duration (odds ratio (OR) = 1.2; 95% confidence interval (CI) of 1.0–1.3, p = 0.04), seropositivity for anti-RNP (OR = 24.4; 95% CI of 1.6–384.0, p = 0.02), and a history of serositis were significantly associated with SLS when compared with symptomatic controls. Conclusion: Respiratory symptoms, abnormal lung function, and SLS are common in SLE. Clinicians should consider evaluation for SLS among symptomatic patients with long-standing disease and a history of pleuritis.
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Affiliation(s)
- D Allen
- Department of Medicine, University of Manitoba, Canada
| | - A Fischer
- Autoimmune Lung Center, University of Colorado, USA
| | - Z Bshouty
- Department of Medicine, University of Manitoba, Canada
| | - DB Robinson
- Department of Rheumatology, University of Manitoba, Canada
| | - CA Peschken
- Department of Rheumatology, University of Manitoba, Canada
| | - C Hitchon
- Department of Rheumatology, University of Manitoba, Canada
| | - H El-Gabalawy
- Department of Rheumatology, University of Manitoba, Canada
| | - M Meyers
- Department of Radiology University of Manitoba, Canada
| | - S Mittoo
- Department of Rheumatology, University of Toronto, Canada
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Trad S, Huong DLT, Frances C, Wechsler B, Cacoub P, Costedoat N, Haroche J, Piette JC, Hanslik T, Amoura Z. Impaired carbon monoxide diffusing capacity as a marker of limited systemic sclerosis. Eur J Intern Med 2011; 22:e80-6. [PMID: 22075318 DOI: 10.1016/j.ejim.2011.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 04/19/2011] [Accepted: 05/13/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND As impairment of diffusing capacity for carbon monoxide (DLCO) likely reflects underlying pulmonary vasculopathy in limited systemic sclerosis (lSSc), we examined whether DLCO could help to distinguish secondary from idiopathic Raynaud's phenomenon (iRP). METHODS We compared pulmonary function test (PFT) results in 145 lSSc patients and 24 age- and sex-matched iRP patients. RP duration at time of PFT was similar in the two groups. RESULTS DLCO values were low (<80% of predicted) in 106 (73%) of the 145 lSSc patients, and in 69 (71%) of the 97 patients with early lSSc. Interstitial lung disease (ILD) was found in 10% of lSSc patients. DLCO was significantly lower in lSSc than in iRP (72±15% versus 89±9%, p<0.0001). When evaluated, alveolar capillary membrane conductance (Dm) was markedly lower in lSSc patients without ILD than in iRP patients (45±12% versus 71±2.5%, p=0.003), although capillary blood volume was not different. DLCO was low in 3 iRP patients (12.5%). The sensitivity and specificity of low DLCO values for early lSSc diagnosis in patients with Raynaud's phenomenon were 71% and 87.5%, respectively. Sensitivity was similar to that of anti-centromere-antibodies (75%) and nailfold capillary abnormalities (81%). A DLCO cutoff of <70% had a sensitivity and specificity of 41% and 100%, respectively. In multivariable analysis, age and low DLCO were the only independent predictors of death; the hazard ratio for DLCO ≤50% was 7.9 (95% CI 2.3-26, p=0.0007). CONCLUSION Isolated DLCO impairment is significantly more frequent in patients with lSSc than in patients with idiopathic iRP. DLCO measurement could be a useful diagnostic tool for lSSc.
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Affiliation(s)
- Salim Trad
- Service de Médecine Interne, CHU Ambroise Paré, 9 av Charles de Gaulle 92100 Boulogne, France.
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