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Celis-Andrade M, Rojas M, Rodríguez Y, Calderon JB, Rodríguez-Jiménez M, Monsalve DM, Acosta-Ampudia Y, Ramírez-Santana C. Performance of the Systemic Lupus Erythematosus Risk Probability Index (SLERPI) in a cohort of Colombian population. Clin Rheumatol 2024; 43:3313-3322. [PMID: 39243279 DOI: 10.1007/s10067-024-07108-x] [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: 05/02/2024] [Revised: 07/21/2024] [Accepted: 08/09/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVE To evaluate the performance of the Systemic Lupus Erythematosus Risk Probability Index (SLERPI) in Colombian patients with systemic lupus erythematosus (SLE). METHODS The Colombian cohort included 435 SLE patients and 430 controls with other autoimmune diseases (ADs). Clinical and serological data were collected, and SLE was indicated by SLERPI scores > 7. The American College of Rheumatology (ACR)-1997, Systemic Lupus International Collaborating Clinics (SLICC)-2012, and European League Against Rheumatism (EULAR)/ACR-2019 criteria were used as reference standards. The impact of overt polyautoimmunity (PolyA) on SLERPI performance was assessed. Additionally, multivariate lineal regression analysis was performed to evaluate the contribution of SLERPI features to the overall SLERPI score. RESULTS SLE patients had higher SLERPI scores (P < 0.0001), with almost 90% meeting "definite" lupus criteria. Main factors influencing SLERPI included immunological disorder (β:44.75, P < 0.0001), malar/maculopapular rash (β:18.43, P < 0.0001), and anti-nuclear antibody positivity (β:15.65, P < 0.0001). In contrast, subacute cutaneous lupus erythematosus/discoid lupus erythematosus (β:2.40, P > 0.05) and interstitial lung disease (β:-21.58, P > 0.05) were not significant factors to the overall SLERPI score. SLERPI demonstrated high sensitivity for SLE, both for the overall SLE group and for those without overt PolyA (95.4% and 94.6%, respectively), but had relatively low specificity (92.8% and 93.7%, respectively). The model showed high sensitivity for hematological lupus (98.8%) and lupus nephritis (96.0%), but low sensitivity for neuropsychiatric lupus (93.2%). Compared to the ACR-1997, SLICC-2012 and EULAR/ACR-2019 criteria, SLERPI yielded the highest sensitivity and lowest specificity. CONCLUSION SLERPI efficiently identified SLE patients in a Colombian cohort, showing high sensitivity but low specificity. The model effectively distinguishes SLE patients, even in the presence of concurrent overt PolyA. Key Points •SLERPI has a high sensitivity, but low specificity compared to ACR-1997, SLICC-2012 and EULAR/ACR-2019 criteria in the Colombian population. •Within the SLERPI score, immunological disorder, malar/maculopapular rash, and anti-nuclear antibody positivity are the strongest predictors of SLE. •SLERPI model can efficiently distinguish patients with SLE, regardless of concomitant overt PolyA. •SLERPI demonstrates high sensitivity in identifying hematological and nephritic subphenotypes of SLE.
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Affiliation(s)
- Mariana Celis-Andrade
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
| | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, USA
| | - Yhojan Rodríguez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
- Department of Internal Medicine, University Hospital, Fundación Santa Fe de Bogota, Bogota, D.C, Colombia
| | - Juan Benjamín Calderon
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
| | - Mónica Rodríguez-Jiménez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
| | - Diana M Monsalve
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
| | - Yeny Acosta-Ampudia
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia
| | - Carolina Ramírez-Santana
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C- 69, 110010, Bogota, D.C, Colombia.
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Kapsala N, Nikolopoulos D, Fanouriakis A. The Multiple Faces of Systemic Lupus Erythematosus: Pearls and Pitfalls for Diagnosis. Mediterr J Rheumatol 2024; 35:319-327. [PMID: 39193185 PMCID: PMC11345601 DOI: 10.31138/mjr.130124.ppa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 08/29/2024] Open
Abstract
Systemic lupus erythematosus is the prototype multisystem autoimmune disorder characterised by a broad spectrum of organ involvement and a multitude of laboratory abnormalities. Clinical heterogeneity, unpredictable course and lack of pathognomonic clinical and serological features pose a considerable challenge in the diagnosis of SLE. The latter remains largely clinical, typically accompanied however by features of serologic autoimmunity, which are characteristic for the disease. Despite significant improvements in treatment strategies, an early diagnosis often continues to be an unmet need, as the median reported delay from symptom onset to SLE diagnosis is approximately 2 years. Classification criteria are usually used to support the diagnosis, yet with significant caveats. In this article, we provide an updated review of the clinical presentation of lupus and give clues for an accurate diagnosis.
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Affiliation(s)
- Noemin Kapsala
- ”Attikon” University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dionysis Nikolopoulos
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Antonis Fanouriakis
- ”Attikon” University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Csóka DL, Kovács KT, Kumánovics G. A Clinical Picture of Unselected Patients with Systemic Lupus Erythematosus in a Tertiary Hungarian Center-A Spectrum Ranging from Pure Lupus to Overlap Syndromes. J Clin Med 2024; 13:3251. [PMID: 38892962 PMCID: PMC11172817 DOI: 10.3390/jcm13113251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/11/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction: Systemic lupus erythematosus (SLE) is a multidimensional disease; however, the association of another systemic autoimmune disease further complicates its clinical presentation. Aim: We decided to investigate whether the association of overlap syndromes is linked with a different clinical picture compared to pure lupus and whether this association changes the sensitivity of the following commonly used criteria: the 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR), the ACR-1997 and the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria. Method: We performed a retrospective observational study among 382 patients afflicted with lupus: we measured as much of the full clinical and laboratory picture as possible in an unselected cohort. The diagnosis of SLE and other systemic autoimmune diseases was established by the rheumatologist in routine care and then the authors compared the characteristics of patients with pure lupus and those with overlapping pathologies. The diagnosis rates were compared to those that were determined based on the three classification criteria in order to identify various sensitivities and whether the existence of an overlap affects their rates. The fulfillment of each set of criteria was calculated using an Excel-based automatic calculation. Results: Among the patients, the ACR 1997's sensitivity was 81.2% (310 patients), and the SLICC 2012 criteria achieved 94.5% sensitivity (361 patients). The 2019 EULAR/ACR classification criteria resulted in a slightly lower sensitivity (90.3%-345 patients) when compared to the original publication (96%) due to the lower sensitivity of our anti-nuclear antibody (ANA) test (measured via enzyme-linked immunosorbent assay (ELISA)). Nearly all ANA-negative (21/22-95%) patients showed a positive lupus-associated antibody test. The proportion of ANA-negative cases showed no significant difference among pure and overlap patients. No significant difference was found between patients with overlap (138 patients-36%) and pure SLE (244 patients-64%) through the use of these criteria, with the exception of the SLICC criteria (ACR: 80.4% vs. 81.6%; SLICC: 97.4% vs. 92.6%, p = 0.035; EULAR/ACR 2019: 91.4% vs. 89.6%). Patients with an overlap syndrome were significantly older (55 vs. 50 years, p = 0.001), more likely to suffer from interstitial lung disease (ILD: 20% vs. 11%, p = 0.0343) and less frequently showed class III/IV lupus nephritis (7% vs. 14%, p = 0.029) when compared with their pure lupus counterparts. Conclusion: All investigated criteria regarding sensitivity were similar to the original publication's findings. The sensitivity of the EULAR/ACR 2019 classification criterion in cases with overlap syndrome proved excellent, with results very similar to patients afflicted with pure SLE. In the presence of an overlap syndrome, we found significantly fewer patients with lupus nephritis III/IV but no differences in other typical lupus organ manifestation beyond the kidney, whereas we found a higher proportion of ILD in patients with an overlap, indicating that the presence of an overlap syndrome significantly influences the observed clinical picture in real-world conditions.
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Affiliation(s)
| | | | - Gábor Kumánovics
- Department of Rheumatology and Immunology, Medical School, University of Pécs, 7632 Pécs, Hungary; (D.L.C.); (K.T.K.)
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Babgi E, Al Marri M, Al-Mayouf SM, Shehata R, Majeed M, Alsufyani K, Batouk E, Bakri R, AlE'ed A, Yateem M, Akbar L, Gari S, Alghamdi W, Asiri A, Al Rowais A. Comparison of systemic lupus international collaborating clinics 2012 classification criteria and European league against rheumatism/American college of rheumatology 2019 classification criteria for early detection of childhood onset systemic lupus erythematosus (multi-center study). Lupus 2024; 33:629-637. [PMID: 38533912 DOI: 10.1177/09612033241240830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To assess the performance of the new EULAR/ACR criteria, particularly for early detection of cSLE, in comparison to the SLICC criteria among the pediatric population in multiple centers in Saudi Arabia. METHODS We conducted a retrospective study that enrolled pediatric patients up to the age of 14 years who've been diagnosed with SLE and followed in pediatric rheumatology clinics at 9 multi-tertiary hospitals in Saudi Arabia from 2010 to 2021 as a case group and were compared to a similar group of pediatric patients who've had defined rheumatological diseases other than SLE with a positive ANA titer (≥1:80) as controls. In total, 245 patients were included and distributed as 129 cases (diagnosed by expert pediatric rheumatologists) versus 116 patients in the control group. All relevant clinical information, including history, physical examination findings, and laboratory tests, was documented at the initial presentations. Then, the two sets of SLE classification criteria were applied to both groups to define who's going to meet both or either one of them. The exclusion criteria included those who had insufficient data or had overlapping or undifferentiated diseases. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), receiver operating curve (ROC), and accuracy were calculated for SLICC 2012 and EULAR/ACR 2019 criteria (total scores≥ 10 and ≥ 13). We performed a Chi-squared test to compare sensitivity and specificity of SLICC 2012 and EULAR/ACR 2019. RESULTS For SLICC (cut-off ≥4 criteria), the sensitivity was found to be 96.9% (95% CI 92.6%-99.4%) and the specificity was 94.8% (95% CI 89.6%-98.32%), with PPV and NPV of 95.4% and 96.5%, respectively. The ROC for it was 0.96 (95% CI 0.93-0.99), and this criterion had an accuracy of 95%. Regarding EULAR/ACR (total score ≥ 10), the performance measure showed a sensitivity of 99.2% and a specificity of 86.2%. Similarly, PPV was 88.9%; while NPV was a little higher (99.0%) than SLICC. The ROC for EULAR/ACR (total score ≥ 10) was 0.93 (95% CI 0.89-0.96), and this criterion had an accuracy of 93%. However, there was no statistically significant difference between the sensitivity and specificity of either using SLICC or EULAR/ACR (total score ≥ 10), as reflected by a p-value of 0.86 using the Chi-squared test. Although applying the EULAR/ACR with a total score of ≥ 13 revealed lower sensitivity (93.8%) than both the SLICC and the EULAR/ACR (total score ≥ 10), the specificity for it was found to increase up to 91.4% (85.7-96.2%) compared to the (86.2%) specificity of the EULAR/ACR (total score ≥ 10). CONCLUSION In this cohort among the Saudi population with childhood-onset SLE, the new EULAR/ACR 2019 criteria efficiently enable early detection of SLE, although a more frequent rate of false positives was observed with them. Escalating the total score from ≥ 10 to ≥ 13 in the cSLE population improved the specificity close to that of SLICC 2012. Further prospective studies in pediatrics need to be done for the validation of a cut- off score of ≥ 13 in cSLE rather than the traditional score of ≥ 10 in aSLE.
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Affiliation(s)
- Esraa Babgi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Munira Al Marri
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sulaiman M Al-Mayouf
- Pediatric Rheumatology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Rawia Shehata
- Department of Pediatrics, King Abdulaziz Hospital, Jeddah, Saudi Arabia
| | - Mahmoud Majeed
- Department of Pediatrics, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Khayriah Alsufyani
- Department of Pediatrics, Maternity and Children Hospital, Makkah, Saudi Arabia
| | - Entesar Batouk
- Department of Pediatrics, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Reema Bakri
- Department of Pediatrics, East Jeddah Hospital, Jeddah, Saudi Arabia
| | - Ashwaq AlE'ed
- Department of Pediatrics, College of Medicine, Qassim University, Buraydah, Saudi Arabia
| | - Mada Yateem
- Department of Pediatrics, King Fahad Central Hospital, Jazan, Saudi Arabia
| | - Lujayn Akbar
- Pediatric Rheumatology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Shahad Gari
- Department of Pediatrics, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Wafa Alghamdi
- Department of Pediatrics, East Jeddah Hospital, Jeddah, Saudi Arabia
| | - Abdularahman Asiri
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz Al Rowais
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Zhong Y, Liu Z, Ma J, Zhang L, Xue L. Tumour-associated antigens in systemic lupus erythematosus: association with clinical manifestations and serological indicators. Rheumatology (Oxford) 2024; 63:235-241. [PMID: 37184876 DOI: 10.1093/rheumatology/kead224] [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: 01/31/2023] [Revised: 04/09/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES To explore the relationship of tumour-associated antigens (TAAs) with the clinical manifestations and serological markers of SLE. METHODS This was a retrospective study. Clinical data of SLE patients were extracted from the electronic medical records, including serum levels of TAAs such as alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9, CA125, CA15-3 and cytokeratin 19-fragments (CYFRA21-1). TAA positivity was defined as serum level exceeding the upper limit of the corresponding reference range. RESULTS A total of 149 SLE patients (SLE group) and 149 age- and sex-matched healthy subjects (control group) were enrolled. Compared with healthy controls, the SLE group had higher positivity rates for CA19-9 and CYFRA21-1, and elevated serum levels of CA125, CA15-3 and CYFRA21-1. SLE patients with TAA positivity were older, had a higher prevalence of serous effusion, pericardial effusion, albuminuria and thrombocytopenia, and lower positivity rate for anti-dsDNA than patients without TAA positivity. The levels of serum creatinine (SCR), blood urea nitrogen, glutamic oxalate transaminase and 24-h urinary protein were also higher in SLE patients with TAA positivity, but platelet count and serum albumin levels were lower. On logistic regression, thrombocytopenia and SCR levels were identified as independent risk factors for TAA positivity. CA125 positivity rate and serum levels of CA125 were associated with SLE disease activity. CONCLUSION The positivity rates and serum levels of some TAAs were elevated in SLE, and thrombocytopenia and SCR levels were independent risk factors for TAA positivity.
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Affiliation(s)
- Ying Zhong
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhichun Liu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinlu Ma
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Lin Zhang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Leixi Xue
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
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Zhang L, Lu W, Yan D, Liu Z, Xue L. Systemic Lupus Erythematosus Risk Probability Index: ready for routine use? Results from a Chinese cohort. Lupus Sci Med 2023; 10:e000988. [PMID: 37696613 PMCID: PMC10496657 DOI: 10.1136/lupus-2023-000988] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/25/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES To evaluate the performance of Systemic Lupus Erythematosus Risk Probability Index (SLERPI) in patients with SLE using a Chinese cohort. METHODS The Chinese cohort included 352 patients with and 385 without SLE (control group). The clinical data of patients, including demographic data, clinical findings and serological profiles, were collected. Patients with an SLERPI score >7 were classified as SLE. The performance of the American College of Rheumatology (ACR)-1997, Systemic Lupus International Collaborating Clinics (SLICC)-2012 and European League Against Rheumatism (EULAR)/ACR-2019 criteria were used as references. RESULTS Of these four classification criteria, SLERPI has the highest sensitivity (98.3% (95% CI 96.3% to 99.4%)), but lowest specificity (89.4% (95% CI 85.8% to 92.2%)). In the control group, patients eligible for the classification criteria for SLE were mainly those with primary Sjogren's syndrome (pSS) and undifferentiated connective tissue disease (UCTD), which adversely affected the specificity of the classification criteria. Moreover, significantly more patients with pSS and UCTD met SLERPI than those who met other classification criteria. After excluding patients with pSS and UCTD from the control group, the specificity and accuracy of SLERPI improved to 94.3% (95% CI 91.0% to 96.6%) and 96.5% (95% CI 95.0% to 97.9%), respectively, and both outperformed the EULAR/ACR-2019 criteria. The time to SLERPI classification was the same as their clinical time to diagnosis in 261 patients, earlier than the clinical diagnosis in 23 patients and later than the clinical diagnosis in 9 patients. A total of 280 patients had the same time to SLERPI classification as EULAR/ACR-2019, 8 patients had earlier than EULAR/ACR-2019 and 1 patient had later than EULAR/ACR-2019. CONCLUSION SLERPI performed well in patients with SLE, particularly for the earlier diagnosis of SLE.
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Affiliation(s)
- Lin Zhang
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wentian Lu
- Department of Hematology, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Dong Yan
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhichun Liu
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Leixi Xue
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Emerson JS, Gruenewald SM, Gomes L, Lin MW, Swaminathan S. The conundrum of neuropsychiatric systemic lupus erythematosus: Current and novel approaches to diagnosis. Front Neurol 2023; 14:1111769. [PMID: 37025200 PMCID: PMC10070984 DOI: 10.3389/fneur.2023.1111769] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/07/2023] [Indexed: 04/08/2023] Open
Abstract
Recognising neuropsychiatric involvement by systemic lupus erythematosus (SLE) is of growing importance, however many barriers to this exist at multiple levels of our currently available diagnostic algorithms that may ultimately delay its diagnosis and subsequent treatment. The heterogeneous and non-specific clinical syndromes, serological and cerebrospinal fluid (CSF) markers and neuroimaging findings that often do not mirror disease activity, highlight important research gaps in the diagnosis of neuropsychiatric SLE (NPSLE). Formal neuropsychological assessments or the more accessible screening metrics may also help improve objective recognition of cognitive or mood disorders. Novel serum and CSF markers, including autoantibodies, cytokines and chemokines have also shown increasing utility as part of diagnosis and monitoring, as well as in distinguishing NPSLE from SLE patients without SLE-related neuropsychiatric manifestations. Novel neuroimaging studies also expand upon our existing strategy by quantifying parameters that indicate microarchitectural integrity or provide an assessment of neuronal function. Some of these novel markers have shown associations with specific neuropsychiatric syndromes, suggesting that future research move away from considering NPSLE as a single entity but rather into its individually recognized neuropsychiatric manifestations. Nevertheless, it is likely that a composite panel of these investigations will be needed to better address the gaps impeding recognition of neuropsychiatric involvement by SLE.
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Affiliation(s)
- Jonathan S. Emerson
- Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Centre for Immunology and Allergy Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia
- *Correspondence: Jonathan S. Emerson,
| | - Simon M. Gruenewald
- Department of Nuclear Medicine, PET and Ultrasound, Westmead Hospital, Sydney, NSW, Australia
| | - Lavier Gomes
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Radiology, Westmead Hospital, Sydney, NSW, Australia
| | - Ming-Wei Lin
- Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sanjay Swaminathan
- Department of Clinical Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Clinical Immunology, Blacktown Hospital, Sydney, NSW, Australia
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
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