Systemic Lupus Erythematosus: Symptoms and Signs at Initial Presentations

Clinical and laboratory characteristics of early-onset and delayed-onset lupus nephritis patients: A single-center retrospective study

BACKGROUND

Lupus nephritis (LN) manifests systemic lupus erythematosus (SLE) and is characterized by various clinical and laboratory features. This study aimed to comprehensively evaluate the characteristics of LN patients according to the time of LN diagnosis: early-onset (LN diagnosed within one year from SLE diagnosis) vs. delayed-onset (LN diagnosed more than one year after SLE diagnosis).

METHODS

We conducted a retrospective analysis of medical records from all SLE patients treated at the University Hospital in Kraków, Poland, from 2012 to 2022. We collected data on demographic, clinical, and laboratory characteristics, including histological findings, treatment modalities, and disease outcomes. Statistical analyses were performed to identify factors impacting LN development and prognosis.

RESULTS

Among 331 LN patients, early-onset was diagnosed in 207 (62.54%) and delayed-onset was documented in 122 cases (36.86%). In 2 (0.6%) LN cases, the time of first kidney manifestation in the SLE course was unknown. Delayed-onset LN had a higher female-to-male ratio and younger age at SLE diagnosis. This group was associated with more severe clinical manifestations. In turn, studied subgroups did not differ in internist comorbidities, kidney histopathology, and family history regarding autoimmune diseases. Delayed-onset LN exhibited a higher frequency of anti-dsDNA, anti-Smith, anti-Ro, anti-RNP, and anti-cardiolipin IgG autoantibodies. During a 14-year follow-up period, 16 patients died. Mortality rate and causes of death were comparable in both analyzed subgroups.

CONCLUSIONS

More severe clinical manifestations in delayed-onset LN prompt strict monitoring of non-LN SLE patients to diagnose and treat kidney involvement early. Also, recognizing the higher frequency of autoantibodies such as anti-dsDNA or anti-Smith in delayed-onset LN underscores the potential value of autoantibody profiling as a diagnostic and prognostic tool.

Superior Mesenteric Artery Syndrome in Systemic Lupus Erythematosus

Although the gastrointestinal (GI) manifestations of systemic lupus erythematosus (SLE) are relatively less reported, they are common and occur in approximately half of individuals with SLE. These symptoms vary and include, but are not limited to, oral ulceration, dysphagia, nausea, vomiting, diarrhea, abdominal pain, and intestinal perforation. Gastrointestinal manifestations are often triggered by an inciting event, such as an infection or the side effects of medication. This case report presents a rare GI-related SLE complication, namely superior mesenteric artery syndrome.

Serological and clinical associations of autoantibodies in Chinese patients with new-onset systemic lupus erythematosus

To study the clinical significance of autoantibodies in Chinese patients with new-onset systemic lupus erythematosus (SLE), we enrolled 526 new-onset patients who met the 1997 Updated American College of Rheumatology SLE Classification Criteria for a retrospective cohort study. Chi-square test and Wilcoxon rank-sum test were used to detect the relationship of autoantibodies with clinical manifestations and serological results respectively. Our results demonstrated that the positive rate of anti-ribosomal P protein (anti-P) antibody in female patients was higher than that in male patients (41.2% vs. 22%, P = 0.008). Patients with anti-SSB (43.95 ± 73.12 vs. 40.92 ± 75.75, P = 0.004; 63.93 ± 103.56 vs. 55.06 ± 120.84, P = 0.008 respectively) antibodies had higher levels of alanine aminotransferase (ALT) and aspartate transaminase (AST), whereas those with anti-P antibody (28.90 ± 25.70 vs. 50.08 ± 93.00, P = 0.014; 38.51 ± 48.19 vs. 69.95 ± 142.67, P = 0.047, respectively) had lower levels of them. Anti-dsDNA antibody (P = 0.021) was associated with pulmonary arterial hypertension (PAH). The patients with anti-Ro60 (P = 0.044), anti-P (P = 0.012) and anti-dsDNA (P = 0.013) antibodies were less likely to develop Interstitial lung disease. Anti-SmRNP antibody was correlated to lower prevalence of neuropsychiatric symptoms (P = 0.037), and patients with anti-centromere antibody (ACA) were more likely to develop serositis (P = 0.016).We identified five clusters of SLE-related autoantibodies, confirmed previously reported associations of autoantibodies, and discovered new associations.

Primary Healthcare Practitioners' Knowledge, Attitude, and Practice Toward Systemic Lupus Erythematosus in the Qassim Region, Saudi Arabia

Objective The study aims to evaluate the primary healthcare practitioner's (PHCP) knowledge, attitude, and practice toward systemic lupus erythematosus (SLE) and to explore the difficulties of early referral to specialized clinics. Method This is a cross-sectional study conducted between February and March 2022 targeting the PHCP among the primary healthcare centers in Qassim, Saudi Arabia. The study was conducted among 203 participants who enrolled via a cluster random sampling technique depending on the survey. Qualitative categorical variables are expressed as frequencies and percentages, while continuous variables are reported as means and standard deviations (SD). The one-way analysis of variance (ANOVA) test and the independent T-test have been used to explore the relationship between participants' knowledge scores and their socio-demographic characteristics. A P-value ≤0.05 was considered statistically significant. Result The study found that only 4.4% of participating PHCPs had good knowledge related to SLE, while 45.8% of them had fair knowledge, and nearly half of them (49.8%) had poor knowledge. It was noted that GPs who specialized in family medicine or saw more than 40 patients each week had comparably better knowledge than others, which was statistically significant (p<0.05). The difficulty in diagnosing SLE patients was mentioned by 48.3% of the PHCPs. Family medicine consultants (p<0.001), those who worked in a tertiary care facility for more than six months (p<0.001) and those who worked in a rheumatology department (p<0.05), reported considerably better levels of comfort when treating SLE patients. Conclusion This study found that included participants' understanding of SLE, its diagnosis, and management was inadequate. Coordination between rheumatologists and experts from many disciplines at the primary, secondary, and tertiary levels of care is critical for overcoming ambiguities and obstacles in the diagnosis and therapy of SLE patients.

An evaluation of anifrolumab for use in adults with systemic lupus erythematosus

INTRODUCTION

Type 1 interferons play a key role in the pathogenesis of systemic lupus erythematosus (SLE). An important clinical question is whether inhibiting the type 1 interferon pathway reduce the disease activity in SLE patients. This review evaluates the safety and efficacy of the monoclonal antibody against the type 1 interferon alpha receptor, anifrolumab, in patients with SLE.

AREAS COVERED

Key terms (SLE, type 1 interferon, anifrolumab) were used to query the PubMed database for phase 1, 2 and 3 clinical trials of anifrolumab for SLE patients. Phase 1 studies showed anifrolumab has non-linear pharmacokinetics and the optimal safe dose is 300 mg given intravenously every four weeks. The MUSE (phase 2) and the TULIP-2 (phase 3) trials showed that anifrolumab when added to standard therapy significantly reduced disease activity in SLE patients. Common adverse events associated with anifrolumab were upper respiratory and urinary infections as well as shingles.

EXPERT OPINION

Anifrolumab is an exciting new therapeutic for SLE patients. Additional analyses of the combined TULIP-1 and TULIP-2 datasets as well as future studies with anifrolumab will generate yet more data in SLE. No doubt anifrolumab will be studied in other diseases where type I interferons play an important role.

Novel immunoprofiling method for diagnosing SLE and evaluating therapeutic response

Objective

Diagnosis of SLE is based on clinical manifestations but is heterogeneous in early onset. Hence, we aimed to evaluate the feature of the immunoprofiling in patients with SLE and apply it to develop an immune signature algorithm for supporting SLE diagnosis.

Methods

We enrolled 13 newly diagnosed patients with SLE and 9 healthy controls (HCs) followed by analysing their immunoprofilings within their peripheral blood mononuclear cells (PBMCs) through flow cytometry. The immunoprofiling from the patients with SLE and HCs were ranked and formed an immune signature score. Besides, we enrolled four patients with SLE and monitored the changes in their immunoprofilings after immunosuppressant treatment.

Results

Among 93 immune cell subsets, 29 differed significantly between patients with SLE and HCs, and lower dendritic and natural killer cell percentages and a higher CD8⁺ T-cell percentage were identified in patients with SLE. In an investigation of immune-tolerant-related cell subsets, higher concentrations of CD8⁺ regulatory natural killer T cells, programmed cell death 1 (PD-1)⁺ T cells, and lower concentrations of programmed cell death ligand 1 (PD-L1)⁺ PBMCs were observed in the SLE group. The immune signature score from patients with SLE was significantly different from that from the HCs. After treatment, the disease activity of the four patients were tended to stable and percentages of PD-L1⁺ monocytes, PD-1⁺ CD4 T and CD8 T cells in patients with SLE exhibited positively and negatively correlation with the SLEDAI-2K (Systemic Lupus Erythematosus Disease Activity Index 2000) score, which might associate with the remission of SLE.

Conclusions

The comparison of immunprofiling between patients with SLE and HCs exhibited a distinct pattern. This difference and its application to immune signature algorithm shed light on the studies of SLE pathogenesis and immune-based diagnostic tool development in the future.

Association between Toxoplasma gondii and systemic lupus erythematosus: A systematic review and meta-analysis

Infecting approximately one-third of the world's population, the intraneuronal parasite Toxoplasma gondii has been associated with several autoimmune diseases. While Toxoplasma gondii may be protective against multiple sclerosis, other findings have negatively associated Toxoplasma gondii with different autoimmune diseases, including systemic lupus erythematosus. To further characterize the association between Toxoplasma gondii and systemic lupus erythematosus, we completed a systematic review and meta-analysis of published studies looking at the association between Toxoplasma gondii and systemic lupus erythematosus. The primary results of a random-effects model showed an odds ratio of 2.34 (95% confidence interval 1.17–4.69, P = 0.017), indicating the odds of Toxoplasma gondii seropositivity were 2.34 times higher in the group with systemic lupus erythematosus than in the healthy control group. Few available source studies, an overall lack of information about immunosuppressive status, and little information about sex composition and assays limit this finding and indicate the need for additional research to further characterize the association between systemic lupus erythematosus and Toxoplasma gondii.

Systemic Lupus Erythematosus Presenting as Pulmonary Embolism After Liposuction: A Clinical Conundrum

Systemic lupus erythematosus (SLE) is an autoimmune disorder with a wide array of presentations and a predilection to affect women of certain ethnic backgrounds. The hallmark of the disease is multisystem involvement, dispersed in time and severity. Usual pulmonary involvement includes pleuritis, pleural effusions, pneumonitis, shrinking lung syndrome, pulmonary hypertension, and alveolar hemorrhage. Pulmonary embolism (PE) is a relatively unusual presentation of SLE. We present the case of a 28-year-old Hispanic female who presented with shortness of breath and chest pain after liposuction and was found to have a PE. Fat embolism was ruled out. The absence of overt signs and symptoms and traditional risk factors prompted a fragmentary workup. This led to the detection of antibodies sensitive and specific for SLE, in the absence of overt signs and symptoms. We revive the concept of latent lupus, a condition construed as early lupus. Since our patient was lost to follow up, we were unable to complete workup for SLE, but firmly suspect direct causation between SLE and PE. Further studies are needed to establish pathogenesis in order to facilitate early diagnosis and prevent morbidity and mortality from PE.

Celiac disease in patients with systemic lupus erythematosus

Objectives

Celiac disease (CD) is one of the most common chronic diseases. Celiac disease has been associated with several autoimmune disorders, but the association with systemic lupus erythematosus (SLE) as a systemic autoimmune disease is still controversial. In this study, we aimed to determine the prevalence of biopsy-proven CD in patients with SLE, and to determine the clinical symptoms and laboratory data in these patients.

Material and methods

In a cross-sectional study, SLE patients at a referral clinic were evaluated for gastrointestinal symptoms between March and December 2016. Patients were evaluated by a gastroenterologist, and upper gastrointestinal endoscopy with intestinal biopsy was performed if deemed necessary. The clinical symptoms, laboratory data, and endoscopy results were recorded and compared between groups.

Results

In total, 130 patients were evaluated in this study. Gastrointestinal symptoms were present in 40% of the patients. Endoscopy was performed in all SLE patients with gastrointestinal symptoms. Four patients (3%) were diagnosed as having CD based on biopsy results and response to a gluten-free diet. Anti-endomysium antibody (AEA) was found to be 100% sensitive and 99.2% specific for the diagnosis of CD in SLE patients, and anti-gliadin antibody (AGA) had a 50% sensitivity and 98% specificity. Patients with comorbid CD and SLE were significantly more likely to have diarrhea, abdominal pain, nausea/vomiting, recurrent oral aphthosis, and anemia.

Conclusions

The results of this study suggest that a significant association is present between CD and SLE. We found a prevalence of 3% for biopsy-proven CD in patients with SLE, which is five times the prevalence of CD in the general population.

Systemic lupus erythematosus presenting with holocord myelitis

This is a report of a case of a 25-year-old woman, who presented with a rapidly progressive sensory-motor flaccid quadriparesis which had developed over a few days along with bladder and bowel involvement. She had a past history of photosensitive rash and joint pains along with mild-to-moderate grade fever; for which she had never been evaluated. Serological markers for systemic lupus erythematosus (SLE) were strongly positive and helped in establishing the diagnosis of SLE-related holocord myelitis. High-dose intravenous glucocorticoid followed by intravenous pulse cyclophosphamide was used to treat her and there was a significant improvement. In this case report, the diagnosis of SLE was made for the first time in a patient presenting with holocord myelitis.

Rare Initial Manifestation of Lupus as Lobular Panniculitis of the Breast-A Case Report and Review of the Literature

ABSTRACT

Lupus mastitis is a rare complication of systemic or discoid lupus erythematosus with an uncommon initial presentation when limited to the breast. In this article, we report a 42-year-old woman who presented with constant pain and tenderness in her breasts. Ultrasound imaging of the left breast revealed a 14-mm oval mass, suspicious for malignancy; a needle core biopsy was performed. Sections showed necrosis of the fat lobules with associated mixed nodular lymphoplasmacytic aggregates. Karyorrhectic debris, fibrinoid necrosis of small vessels, and microcalcifications were all present while the background breast parenchyma was unremarkable. The diagnosis of lupus mastitis was rendered. Subsequent serology showed negative dsDNA but positive antinuclear antibodies, C4, and anti -Sjögren';s-syndrome-related antigen A antibodies. Clinical features of active systemic disease were not identified at the patient's follow-up dermatology appointment 1 month after the biopsy, and she elected management for her nodules with steroids. To the best of our knowledge, only 40 other cases of lupus mastitis have been reported in the English literature, of which 25 presented as a mass and only in 6 lupus mastitis of the breast was the initial presentation. In conclusion, we bring much needed awareness to lupus mastitis as the first presentation of disease.

Association of microRNA 17 host gene variant (rs4284505) with susceptibility and severity of systemic lupus erythematosus

Objective

MicroRNAs are large family clusters of small noncoding RNAs that implicated in genetic and epigenetic regulation of several immunological processes and pathways. As an epigenetic modifier, the microRNA 17‐92 cluster host gene (MIR17HG) has been shown to regulate the expression of genes involved in systemic lupus erythematosus (SLE) pathway. This study aimed to explore the association of MIR17HG (rs4284505; A>G) variant with SLE development and phenotype in a sample of the Eastern Mediterranean population.

Methods

A total of 326 participants (163 patients with SLE and 163 healthy controls) were enrolled in this study. The different genotypes of the MIR17HG (rs4284505) variant were characterized using the TaqMan real‐time polymerase chain reaction technique. Association with the available clinical and laboratory data, including the systemic lupus erythematosus disease activity index (SLEDAI), was also executed.

Results

The MIR17HG (rs4284505) variant showed a protective effect against developing SLE under heterozygote (A/G vs A/A; odds ratio [OR] = 0.10, 95% confidence interval [CI] = 0.05‐0.20, P < 0.001) and dominant (A/G+G/G vs A/A; OR = 0.39, 95% CI = 0.25‐0.61, P < .001) models. This association was consistent even after SLE stratified by lupus nephritis. In contrast, rs4284505 (G/G) genotype conferred increased susceptibility to SLE (G/G vs A/A+A/G; OR = 2.15, 95% CI = 1.31‐3.53, P = .002). Moreover, the rs4284505 variant showed a statistically significant association with mucocutaneous lesions and SLEDAI scores (all P < .05).

Conclusion

This study is the first one to explore that the MIR17HG rs4284505 is associated with SLE risk; (A/G) genotype conferred a protective effect, while the (G/G) genotype showed increased susceptibility to SLE and association with the disease severity in the study population.

Mechanistic Paradigms of Natural Plant Metabolites as Remedial Candidates for Systemic Lupus Erythromatosus

Systemic lupus erythematosus (SLE) is a complex autoimmune disorder involving a dysregulated immune response which ultimately leads to multiple organ failure. Several immunological and cellular checkpoints are available as drug targets. However, the available chemosynthetic drugs such as non-steroidal anti-inflammatory drugs and corticosteroids provide limited therapy with extreme toxicities. Moreover, the disease heterogeneity in SLE is very difficult to manage by a single drug component. Hence, it is imperative to utilize the holistic capabilities of natural plant products as immunomodulators and intracellular signaling regulators, thereby providing an auxiliary option of treatment. Additionally, the herbal drugs also serve as symptomatic relief providers, thereby serving as a prophylactic remedy in case of cerebrovascular, hepatic, nephropathological, hematological, cardiopulmonary, mucocutaneous and musculoskeletal manifestations of SLE. The present review attempts to showcase the current state of knowledge regarding the utility of plant-derived phyto-metabolites with their probable mechanistic roles in treating SLE, by means of targeting the signaling cascade, proinflammatory cytokine production and B–T cell co-stimulation. It is hoped that further preclinical and clinical studies will be embarked upon in order to understand the underlying therapeutic and mechanistic aspects of these medicinal herbs.