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Labouret M, Trebossen V, Ntorkou A, Bartoli S, Aubart M, Auvin S, Bader-Meunier B, Baudouin V, Corseri O, Dingulu G, Ducrocq C, Dumaine C, Elmaleh M, Fabien N, Faye A, Hau I, Hentgen V, Kwon T, Meinzer U, Ouldali N, Parmentier C, Pouletty M, Renaldo F, Savioz I, Benoist JF, Le Roux E, Ellul P, Melki I. Juvenile neuropsychiatric systemic lupus erythematosus: A specific clinical phenotype and proposal of a probability score. Lupus 2024; 33:328-339. [PMID: 38315109 DOI: 10.1177/09612033241229022] [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: 02/07/2024]
Abstract
OBJECTIVE Juvenile systemic lupus erythematosus (j-SLE) is a rare chronic auto-immune disease involving several organs. Neuropsychiatric (NP) SLE (NPSLE) is frequent in j-SLE and associated with increased morbidity/mortality. Although NPSLE classification criteria exist, attributing NP features to j-SLE remains a major challenge. The study objective is to thoroughly describe j-NPSLE patients and assist in their diagnosis. METHODS This is a 4-year retrospective monocentric study of j-SLE patients. NP events were attributed to j-SLE using standardised diagnostic criteria and multidisciplinary paediatric clinical expertise. Clinical features, brain magnetic resonance imaging (MRI)s and samples analysis including cerebrospinal fluid were assessed. A risk of j-NPSLE score was developed based on multivariable logistic regression analysis. RESULTS Of 39 patients included, 44% were identified as having j-NPSLE. J-NPSLE diagnosis was established at the onset of j-SLE in 59% of patients. In addition to frequent kidney involvement (76%) and chilblains (65%), all j-NPSLE patients displayed psychiatric features: cognitive symptoms (82%), hallucinations (76%), depressed mood (35%), acute confused state (18%) and catatonia (12%). Neurological involvement was often mild and nonspecific, with headache (53%) in about half of the patients. The main features reported on brain MRI were nonspecific T2/FLAIR white matter hyperintensities (65%), and cerebral atrophy (88%). Upon immunosuppressive treatment, clinical improvement of NP features was observed in all j-NPSLE patients. The score developed to attribute j-NPSLE probability, guide further investigations and appropriate treatments is based on hallucinations, memory, sleep and renal involvement (Sensitivity: 0.95 Specificity: 0.85). Cerebrospinal fluid (CSF) neopterin assessment increases the score sensitivity and specificity. CONCLUSION Physicians should carefully and systematically assess the presence of NP features at diagnosis and early stages of j-SLE. For j-NPSLE patients with predominant psychiatric features, a multidisciplinary collaboration, including psychiatrists, is essential for the diagnosis, management and follow-up.
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Affiliation(s)
- Mathilde Labouret
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Sorbonne Université, Paris, France
| | - Vincent Trebossen
- Department of Child and Adolescent Psychiatry, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
| | - Alexandra Ntorkou
- Department of Paediatric Radiology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Sophie Bartoli
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Mélodie Aubart
- Paediatric Neurology Department, Necker-Enfants Malades Hospital, University of Paris-Cité, AP-HP, Paris, France
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, French Institute of Health and Medical Research U1163, Imagine Institute, University of Paris-Cité, Paris, France
| | - Stéphane Auvin
- Department of Paediatric Neurology, Center for Rare Epilepsies & Epilepsy Unit, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Université Paris Cité, INSERM NeuroDiderot, Paris, France
- Institut Universitaire de France (IUF), Paris, France
| | - Brigitte Bader-Meunier
- Department of Paediatric Haematology-Immunology And Rheumatology, Necker-Enfants-Malades University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Laboratory of Immunogenetics of Paediatric Autoimmune Diseases, Imagine Institute, INSERM UMR 1163, Université Paris Cité, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Olivier Corseri
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Glory Dingulu
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Camille Ducrocq
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Cécile Dumaine
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Monique Elmaleh
- Department of Paediatric Radiology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Nicole Fabien
- Immunology Department, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Albert Faye
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
- UMR1123 Inserm, Université Paris Cité, Paris, France
| | - Isabelle Hau
- Department of General Paediatrics, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Véronique Hentgen
- Department of General Paediatrics, French Reference centre for Autoinflammatory diseases and amyloidosis (CEREMAIA), Versailles Hospital, Le Chesnay, France
| | - Théresa Kwon
- Department of Paediatric Nephrology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Ulrich Meinzer
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
- Center for Research on Inflammation, INSERM, Université Paris Cité, Paris, France
- Biology and Genetics of Bacterial Cell Wall Unit, Pasteur Institute, Paris, France
| | - Naim Ouldali
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
| | - Cyrielle Parmentier
- Department of Paediatric Nephrology, Armand-Trousseau Childrens' Hospital, AP-HP, Paris, France
| | - Marie Pouletty
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Florence Renaldo
- Department of Paediatric Neurology, Center for Neurogenetic Diseases, Armand-Trousseau Childrens' Hospital, AP-HP, Paris, France
| | - Isabelle Savioz
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Jean-François Benoist
- Metabolic Biochemistry Laboratory, Reference Centre for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, AP-HP, Paris, France
- Université Paris Saclay, UFR Pharmacie, France
| | - Enora Le Roux
- UMR1123 Inserm, Université Paris Cité, Paris, France
- Unité d'Épidémiologie Clinique, Inserm, CIC 1426, Robert Debré Mother-Child University Hospital, Nord-Université Paris Cité, AP-HP, Paris, France
| | - Pierre Ellul
- Department of Child and Adolescent Psychiatry, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Immunology-Immunopathology-Immunotherapy (i3), Sorbonne Université, Paris, France
| | - Isabelle Melki
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Department of Paediatric Haematology-Immunology And Rheumatology, Necker-Enfants-Malades University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Imagine Institute, Laboratory of Neurogenetics and Neuroinflammation, INSERM UMR 1163, Université Paris Cité, Paris, France
- Paediatrics, Rheumatology and Paediatric Internal Medicine, Children's Hospital, Bordeaux, France
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Geng W, Zhang S, Cao J, Zhu B, Duan Y, Hong X, Wei J. Antipsychotics reduces mortality in patients with neuropsychiatric systemic lupus erythematosus: a retrospective study of psychiatric consultation cases. Front Psychiatry 2023; 14:1189940. [PMID: 37583844 PMCID: PMC10424435 DOI: 10.3389/fpsyt.2023.1189940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/17/2023] [Indexed: 08/17/2023] Open
Abstract
Objective This study aimed to identify the presence of psychiatric comorbidities as well as investigate the relationship between psychiatric interventions for mental symptoms and mortality in patients with systemic lupus erythematosus (SLE). Method We retrospectively evaluated the records of 160 inpatients with SLE who required psychiatric consultation for further therapeutic intervention from 2013 to 2020 in a tertiary general hospital. We collected clinical data, including diagnoses, medications, and mortality rate. We compared clinical characteristics among the diagnosis groups and correlations between variables. Results A total of 138 (86.3%) patients met the diagnostic criteria for at least one mental disorder, with the most common being delirium (54.4%). The average Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score significantly differed among the diagnosis groups (p = 0.003). The mortality rate among patients with delirium was significantly higher than that in the other patient groups (x2 = 12.967, p = 0.024). SLEDAI-2K score was not significantly correlated with mortality (r = 0.123, p = 0.087). Antipsychotics use was associated with mortality (odds ratio 0.053, p = 0.021). Conclusion Antipsychotic use may decrease death risk for patients with NPSLE. Early psychiatric consultation is necessary for patients with SLE who have developed or have suspected psychiatric symptoms in order to establish a comprehensive intervention plan.
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Affiliation(s)
- Wenqi Geng
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jinya Cao
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Boheng Zhu
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yanping Duan
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xia Hong
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Wei
- Department of Psychological Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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Galoppini G, Marangoni A, Cirilli F, Ruffilli F, Garaffoni C, Govoni M, Scirè CA, Silvagni E, Bortoluzzi A. Optimizing Patient Care: A Systematic Review of Multidisciplinary Approaches for SLE Management. J Clin Med 2023; 12:4059. [PMID: 37373752 DOI: 10.3390/jcm12124059] [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: 05/08/2023] [Revised: 06/10/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is characterized by multisystemic clinical manifestations ranging from a relatively mild involvement to potentially life-threatening complications. Due to this complexity, a multidisciplinary (MD) approach is the best strategy for optimizing patients' care. The main aim of this systematic literature review (SLR) was to scrutinize the published data regarding the MD approach for the management of SLE patients. The secondary objective was to evaluate the outcomes of the MD approach in SLE patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used. We performed an SLR to retrieve articles available in English or Italian listed in PubMed, Embase, Cinahl, and Cochrane Library concerning the MD approach used in observational studies and clinical trials. Four independent reviewers performed the study selection and data collection. Of 5451 abstracts evaluated, 19 studies were included in the SLR. The MD approach was most frequently described in the context of SLE pregnancy, reported in 10 papers. MD teams were composed of a rheumatologist, except for one cohort study; a gynecologist; a psychologist; a nurse; and other health professionals. MD approaches had a positive impact on pregnancy-related complications and disease flares and improved SLE psychological impact. Although international recommendations advise an MD approach for managing SLE, our review highlighted the paucity of data supporting this strategy, with most of the available evidence on the management of SLE during pregnancy.
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Affiliation(s)
- Giorgio Galoppini
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - Antonio Marangoni
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - Francesca Cirilli
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - Francesca Ruffilli
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - Carlo Garaffoni
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - Marcello Govoni
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | | | - Ettore Silvagni
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - Alessandra Bortoluzzi
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
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Cocco C, Manca E, Corda G, Angioni MM, Noli B, Congia M, Loy F, Isola M, Chessa E, Floris A, Lorefice L, Saba L, Mathieu A, Ferri GL, Cauli A, Piga M. Brain-reactive autoantibodies in neuropsychiatric systemic lupus erythematosus. Front Immunol 2023; 14:1157149. [PMID: 37383228 PMCID: PMC10294074 DOI: 10.3389/fimmu.2023.1157149] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/19/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction The pathogenesis of neuropsychiatric systemic lupus erythematosus (NPSLE) is widely unknown, and the role of autoantibodies is still undetermined. Methods To identify brain-reactive autoantibodies possibly related to NPSLE, immunofluorescence (IF) and transmission electron microscopy (TEM) on rat and human brains were performed. ELISA was used to reveal the presence of known circulating autoantibodies, while western blot (WB) was applied to characterize potential unknown autoantigen(s). Results We enrolled 209 subjects, including patients affected by SLE (n=69), NPSLE (n=36), Multiple Sclerosis (MS, n=22), and 82 age- and gender-matched healthy donors (HD). Autoantibody reactivity by IF was observed in almost the entire rat brain (cortex, hippocampus, and cerebellum) using sera from NPSLE and SLE patients and was virtually negative in MS and HD. NPSLE showed higher prevalence (OR 2.4; p = 0.047), intensity, and titer of brain-reactive autoantibodies than SLE patients. Most of the patient sera with brain-reactive autoantibodies (75%) also stained human brains. Double staining experiments on rat brains mixing patients' sera with antibodies directed against neuronal (NeuN) or glial markers showed autoantibody reactivity restricted to NeuN-containing neurons. Using TEM, the targets of brain-reactive autoantibodies were located in the nuclei and, to a lesser extent, in the cytoplasm and mitochondria. Given the high degree of colocalization between NeuN and brain-reactive autoantibodies, we assumed NeuN was a possible autoantigen. However, WB analysis with HEK293T cell lysates expressing or not expressing the gene encoding for NeuN protein (RIBFOX3) showed that patients' sera carrying brain-reactive autoantibodies did not recognize the NeuN corresponding band size. Among the panel of NPSLE-associated autoantibodies (e.g., anti-NR2, anti-P-ribosomal protein, antiphospholipid) investigated by ELISA assay, only the anti-β2-glycoprotein-I (aβ2GPI) IgG was exclusively found in those sera containing brain-reactive autoantibodies. Conclusion In conclusion, SLE and NPSLE patients possess brain-reactive autoantibodies but with higher frequency and titers found in NPSLE patients. Although many target antigens of brain-reactive autoantibodies are still undetermined, they likely include β2GPI.
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Affiliation(s)
- Cristina Cocco
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Elias Manca
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Giulia Corda
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Maria Maddalena Angioni
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Barbara Noli
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Mattia Congia
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
| | - Francesco Loy
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Michela Isola
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | | | - Alberto Floris
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Center, Binaghi Hospital, ATS Sardegna, ASSL Cagliari, Cagliari, Italy
| | - Luca Saba
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
- Radiology Department, University Clinic, AOU Cagliari, Cagliari, Italy
| | - Alessandro Mathieu
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Gian Luca Ferri
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Alberto Cauli
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
| | - Matteo Piga
- Rheumatology Unit, University Clinic, AOU Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public health, University of Cagliari, Monserrato, Italy
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5
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Monahan RC, Beaart-van de Voorde LJJ, Fronczek R, de Bresser J, Eikenboom J, Kloppenburg M, Middelkoop HAM, Terwindt GM, van der Wee NJA, Huizinga TWJ, Steup-Beekman GM. Clinical outcome in patients with suspected inflammatory neuropsychiatric lupus treated with immunosuppression: an observational cohort study. Lupus Sci Med 2023; 10:10/1/e000850. [PMID: 36737098 PMCID: PMC9900068 DOI: 10.1136/lupus-2022-000850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The short-term and long-term outcome of inflammatory neuropsychiatric SLE (NPSLE) with immunosuppressive treatment is largely unknown. We used clinical data from our tertiary referral centre for NPSLE to investigate the type of inflammatory NPSLE manifestations, type of immunosuppressive treatment prescribed for these manifestations and clinical outcomes. METHODS All patients with SLE visiting the Leiden University Medical Centre NPSLE clinic between 2007 and 2021 receiving immunosuppressive therapy for neuropsychiatric symptoms were included. Clinical, immunological and radiological information was collected in as standardised way during a 1-day multidisciplinary assessment. In a multidisciplinary consensus meeting, the presence of NPSLE and the type of NPSLE manifestations and treatment were determined. For this study, short-term (0-6 months) and long-term outcomes (7-24 months) of the NP symptoms were assessed by two independent readers and scored on a 7-point Likert scale, ranging from death to resolved. RESULTS In total, 95 out of 398 (24%) patients visiting the NPSLE clinic between 2007 and 2021 received any form of immunosuppressive treatment for 101 separate NPSLE events. The most common NP manifestation was cognitive dysfunction (50%) as identified by formal cognitive assessment, often present in combination with other NPSLE manifestations. Treatment modalities were induction (24%), induction and maintenance (73%) and other therapy (3%). The treatments mostly consisted of (combinations of) prednisone (97%), methylprednisolone (53%), azathioprine (generally 2 mg/kg daily) (49%) and cyclophosphamide (generally induction 750 mg/m2 every 4 weeks for 24 weeks or 500mg biweekly for 12 weeks) (42%). Short-term outcome showed improvement on the Likert scale in 73% (improved: 22%, much improved: 29%, resolved: 22%), no change in 21% and worsening in 6% of patients. Long-term outcome was available for 78 out of 101 events and showed improvement in 70% (improved: 14%, much improved: 28%, resolved: 28%), no change in 17%, worsening in 10% and death in 3% of patients (none directly NPSLE-related). CONCLUSION The outcome of inflammatory NPSLE after immunosuppressive treatment is generally good, with improvement of neuropsychiatric symptoms occuring in approximately 70% of events.
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Affiliation(s)
- Rory C Monahan
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | | | - Rolf Fronczek
- Department of Neurology, LUMC, Leiden, The Netherlands,SEIN, Hoofddorp, The Netherlands
| | | | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, LUMC, Leiden, The Netherlands
| | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Huub A M Middelkoop
- Department of Neurology, LUMC, Leiden, The Netherlands,Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
| | | | - Nic J A van der Wee
- Department of Psychiatry, LUMC, Leiden, The Netherlands,Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands,Department of Rheumatology, Haaglanden Medical Centre, the Hague, The Netherlands
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Tract-based white matter hyperintensity patterns in patients with systemic lupus erythematosus using an unsupervised machine learning approach. Sci Rep 2022; 12:21376. [PMID: 36494508 PMCID: PMC9734118 DOI: 10.1038/s41598-022-25990-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Currently, little is known about the spatial distribution of white matter hyperintensities (WMH) in the brain of patients with Systemic Lupus erythematosus (SLE). Previous lesion markers, such as number and volume, ignore the strategic location of WMH. The goal of this work was to develop a fully-automated method to identify predominant patterns of WMH across WM tracts based on cluster analysis. A total of 221 SLE patients with and without neuropsychiatric symptoms from two different sites were included in this study. WMH segmentations and lesion locations were acquired automatically. Cluster analysis was performed on the WMH distribution in 20 WM tracts. Our pipeline identified five distinct clusters with predominant involvement of the forceps major, forceps minor, as well as right and left anterior thalamic radiations and the right inferior fronto-occipital fasciculus. The patterns of the affected WM tracts were consistent over the SLE subtypes and sites. Our approach revealed distinct and robust tract-based WMH patterns within SLE patients. This method could provide a basis, to link the location of WMH with clinical symptoms. Furthermore, it could be used for other diseases characterized by presence of WMH to investigate both the clinical relevance of WMH and underlying pathomechanism in the brain.
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7
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Neuropsichiatric Manifestations of Systemic Lupus Erythematosus: Diagnosis and Treatment Approach. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2017-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Neuropsychiatric involvement in systemic lupus erythematosus includes heterogeneous manifestations involving both the central and peripheral nervous system. A major issue in clinical evaluation is the attribution of neuropsychiatric symptoms to systemic lupus erithematosus. Antiphospholipid antibodies, immune complex, microangiopathy, early and accelerated arteriosclerosis are factors that have the main role in pathogenesis of neuropsychiatric manifestations of systemic lupus erithematosus. There are no neurological symptoms specific to systemic lupus erithematosus, but they can also occur very commonly in the general population. Lesions of nervous system can be focal or diffuse and may be due to systemic lupus erithematosus itself (primary lesions), but it also may be caused by other diseases or disbalances. Therapy of the neuropsychiatric manifestations depends on the nature of the pathological process (dominant inflammation or thrombosis). If it is result of an inflammatory neurotoxic process and in the presence of an increased activity of systemic lupus erithematosus, therapy includes glycocorticoids independently or in combination with immunosuppressives. Focal neuropsychiatric syndrome with antiphospholipid antibodies positivity should be treated with anticoagulant and/or antiplatelet therapy. In addition, control of classical cardiovascular risk factors, stop smoking, and treatment with hydroxychloroquine is recommended.
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8
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Su L, Zhuo Z, Duan Y, Huang J, Qiu X, Li M, Liu Y, Zeng X. Structural and Functional Characterization of Gray Matter Alterations in Female Patients With Neuropsychiatric Systemic Lupus. Front Neurosci 2022; 16:839194. [PMID: 35585919 PMCID: PMC9108669 DOI: 10.3389/fnins.2022.839194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate morphological and functional alterations within gray matter (GM) in female patients with neuropsychiatric systemic lupus (NPSLE) and to explore their clinical significance. Methods 54 female patients with SLE (30 NPSLE and 24 non-NPSLE) and 32 matched healthy controls were recruited. All subjects received a quantitative MRI scan (FLAIR, 3DT1, resting-state functional MRI). GM volume (GMV), fractional amplitude of low-frequency fluctuation (fALFF), regional homogeneity (ReHo), and degree of centrality (DC) were obtained. Between-group comparison, clinical correlation, and discrimination of NPSLE from non-NPSLE were achieved by voxel-based analysis, cerebellar seed-based functional connectivity analysis, regression analysis, and support vector machine (SVM), respectively. Results Patients with NPSLE showed overt subcortical GM atrophy without significantly abnormal brain functions in the same region compared with controls. The dysfunction within the left superior temporal gyri (L-STG) was found precede the GM volumetric loss. The function of the nodes in default mode network (DMN) and salience network (SN) were weakened in NPSLE patients compared to controls. The function of the cerebellar posterior lobes was significantly activated in non-NPSLE patients but attenuated along with GM atrophy and presented higher connectivity with L-STG and DMN in NPSLE patients, while the variation of the functional activities in the sensorimotor network (SMN) was the opposite. These structural and functional alterations were mainly correlated with disease burden and anti-phospholipid antibodies (aPLs) (r ranges from -1.53 to 1.29). The ReHos in the bilateral cerebellar posterior lobes showed high discriminative power in identifying patients with NPSLE with accuracy of 87%. Conclusion Patients with NPSLE exhibit both structural and functional alterations in the GM of the brain, which especially involved the deep GM, the cognitive, and sensorimotor regions, reflecting a reorganization to compensate for the disease damage to the brain which was attenuated along with pathologic burden and cerebral vascular risk factors. The GM within the left temporal lobe may be one of the direct targets of lupus-related inflammatory attack. The function of the cerebellar posterior lobes might play an essential role in compensating for cortical functional disturbances and may contribute to identifying patients with suspected NPSLE in clinical practice.
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Affiliation(s)
- Li Su
- Department of Rheumatology and Clinical Immunology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Education, Beijing, China
| | - Zhizheng Zhuo
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Huang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaolu Qiu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Education, Beijing, China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Education, Beijing, China
- *Correspondence: Xiaofeng Zeng,
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9
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Monahan RC, Middelkoop HAM, Beaart-van de Voorde LJJ, Fronczek R, Groenwold RHH, Kloppenburg M, Huizinga TWJ, Steup-Beekman GM. High Prevalence but Low Impact of Cognitive Dysfunction on Quality of Life in Patients With Lupus and Neuropsychiatric Symptoms. Arthritis Care Res (Hoboken) 2022; 75:1017-1025. [PMID: 35470979 DOI: 10.1002/acr.24904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/09/2022] [Accepted: 04/21/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the prevalence and impact of cognitive impairment on health-related-quality of life (HRQoL) in patients with systemic lupus erythematosus (SLE) and neuropsychiatric (NP) symptoms. METHODS Patients with SLE and NP symptoms referred to the Leiden NPSLE clinic (2007-2019) were included. In a multidisciplinary evaluation, NP symptoms were attributed to SLE (NPSLE: inflammatory, ischemic, or both combined) or other causes. Four cognitive domains were determined: global cognitive function (score 0-30), learning and memory, executive function and complex attention, and psychomotor speed (all T scores). HRQoL was determined using the mental component score and physical component score of the Short Form 36 health survey. The associations between cognition and NPSLE phenotype and cognition and HRQoL were assessed with multiple regression analyses and linear mixed models corrected for confounding and expressed in SDs. RESULTS A total of 357 patients (86% female, mean age 44 years) were included. Of those 357 patients, 169 had a follow-up visit (median follow-up 11 months). Impairment in global cognitive function was present in 8% of patients, and in all other cognitive domains in ±50%. The most severe impairment (all domains) was seen in patients with a combined NPSLE phenotype. Diffuse cognitive impairment (learning and memory, executive function and complex attention, and psychomotor speed) was most common and was present more often in patients with an inflammatory phenotype. A weak association between cognition and HRQoL was found both cross-sectionally and longitudinally. In general, 1 SD lower scores on the cognitive domains were associated with at most one-fifth SD lower HRQoL. CONCLUSION Objective cognitive impairment is common in SLE patients with NP symptoms, but may have a limited influence on HRQoL.
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Affiliation(s)
- Rory C Monahan
- Leiden University Medical Center, Leiden, The Netherlands
| | - Huub A M Middelkoop
- Leiden University Medical Center and Leiden University, Leiden, The Netherlands
| | | | | | | | | | | | - Gerda M Steup-Beekman
- Leiden University Medical Center, Leiden, and Haaglanden Medical Center, The Hague, The Netherlands
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10
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Monahan RC, van den Beukel MD, Borggreven NV, Fronczek R, Huizinga TWJ, Kloppenburg M, Steup-Beekman GM, Trouw LA. Autoantibodies against specific post-translationally modified proteins are present in patients with lupus and associate with major neuropsychiatric manifestations. RMD Open 2022; 8:rmdopen-2021-002079. [PMID: 35450955 PMCID: PMC9024229 DOI: 10.1136/rmdopen-2021-002079] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/27/2022] [Indexed: 11/08/2022] Open
Abstract
Background Although autoantibodies are an important hallmark of systemic lupus erythematosus (SLE), most are not specific for SLE or any of its clinical manifestations. Autoantibodies against post-translationally modified (PTM) proteins have been studied extensively in rheumatoid arthritis and associate with disease progression. While PTMs have also been detected in patients with SLE, studies on anti-PTM antibodies remain scarce. We studied the presence of anti-PTM antibodies in SLE and neuropsychiatric SLE (NPSLE), a manifestation that lacks serological markers. Methods IgG antibody responses against six PTMs (malondialdehyde–acetaldehyde adducts (MAA), advanced glycation end-products (AGE), carbamylation (CarP), citrullination, acetylation and nitration) were tested using ELISA in sera of 349 patients with SLE (mean age 44±13 years; 87% female) and compared with 108 healthy controls. Levels and positivity were correlated with clinical features and SLE manifestations. Results Anti-MAA, anti-AGE and anti-CarP antibodies were more prevalent in SLE compared with controls (MAA: 29% vs 3%, AGE: 18% vs 4%, CarP: 14% vs 5%, all p≤0.0001). Anti-MAA and anti-AGE antibodies correlated with clinical manifestations and serological inflammatory markers. Patients with major NPSLE showed higher positivity of anti-MAA (39% vs 24%, p=0.01) and anti-CarP antibodies (20% vs 11%, p=0.04) than patients without major NPSLE. In addition, anti-PTM antibody levels correlated with brain volumes, an objective measure of nervous system involvement. Conclusions In our NPSLE cohort, a subset of patients with SLE have anti-PTM antibodies against MAA, AGE and CarP modified proteins. Interestingly, anti-MAA and anti-CarP were more prevalent in NPSLE, a manifestation for which no biomarkers exist.
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Affiliation(s)
- Rory C Monahan
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Rolf Fronczek
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom W J Huizinga
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Margreet Kloppenburg
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Leendert A Trouw
- Immunology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Inglese F, Kim M, Steup-Beekman GM, Huizinga TWJ, van Buchem MA, de Bresser J, Kim DS, Ronen I. MRI-Based Classification of Neuropsychiatric Systemic Lupus Erythematosus Patients With Self-Supervised Contrastive Learning. Front Neurosci 2022; 16:695888. [PMID: 35250439 PMCID: PMC8889016 DOI: 10.3389/fnins.2022.695888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction/PurposeSystemic lupus erythematosus (SLE) is a chronic auto-immune disease with a broad spectrum of clinical presentations, including heterogeneous neuropsychiatric (NP) syndromes. Structural brain abnormalities are commonly found in SLE and NPSLE, but their role in diagnosis is limited, and their usefulness in distinguishing between NPSLE patients and patients in which the NP symptoms are not primarily attributed to SLE (non-NPSLE) is non-existent. Self-supervised contrastive learning algorithms proved to be useful in classification tasks in rare diseases with limited number of datasets. Our aim was to apply self-supervised contrastive learning on T1-weighted images acquired from a well-defined cohort of SLE patients, aiming to distinguish between NPSLE and non-NPSLE patients.Subjects and MethodsWe used 3T MRI T1-weighted images of 163 patients. The training set comprised 68 non-NPSLE and 34 NPSLE patients. We applied random geometric transformations between iterations to augment our data sets. The ML pipeline consisted of convolutional base encoder and linear projector. To test the classification task, the projector was removed and one linear layer was measured. Validation of the method consisted of 6 repeated random sub-samplings, each using a random selection of a small group of patients of both subtypes.ResultsIn the 6 trials, between 79% and 83% of the patients were correctly classified as NPSLE or non-NPSLE. For a qualitative evaluation of spatial distribution of the common features found in both groups, Gradient-weighted Class Activation Maps (Grad-CAM) were examined. Thresholded Grad-CAM maps show areas of common features identified for the NPSLE cohort, while no such communality was found for the non-NPSLE group.Discussion/ConclusionThe self-supervised contrastive learning model was effective in capturing common brain MRI features from a limited but well-defined cohort of SLE patients with NP symptoms. The interpretation of the Grad-CAM results is not straightforward, but indicates involvement of the lateral and third ventricles, periventricular white matter and basal cisterns. We believe that the common features found in the NPSLE population in this study indicate a combination of tissue loss, local atrophy and to some extent that of periventricular white matter lesions, which are commonly found in NPSLE patients and appear hypointense on T1-weighted images.
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Affiliation(s)
- Francesca Inglese
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Minseon Kim
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | | | - Tom W. J. Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark A. van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Dae-Shik Kim
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Itamar Ronen,
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12
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Monahan RC, Blonk AME, Huizinga TW, Kloppenburg M, Middelkoop HAM, van der Wee NJA, Steup-Beekman GM. To treat or not to treat with immunosuppressive therapy: psychiatric disorders in patients with systemic lupus erythematosus. Lupus Sci Med 2022; 9:9/1/e000629. [PMID: 34996858 PMCID: PMC8739443 DOI: 10.1136/lupus-2021-000629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/22/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Rory C Monahan
- Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Anne M E Blonk
- Psychiatry, LUMC, Leiden, The Netherlands.,Ministry of Defense, Military Mental Health Services, Amsterdam, The Netherlands
| | - Tom Wj Huizinga
- Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Margreet Kloppenburg
- Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands.,Epidemiology, LUMC, Leiden, The Netherlands
| | - Huub A M Middelkoop
- Neurology, LUMC, Leiden, The Netherlands.,Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
| | - Nic J A van der Wee
- Psychiatry, LUMC, Leiden, The Netherlands.,Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands.,Rheumatology, Haaglanden Medical Center, The Hague, The Netherlands
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13
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Inglese F, Jaarsma-Coes MG, Steup-Beekman GM, Monahan R, Huizinga T, van Buchem MA, Ronen I, de Bresser J. Neuropsychiatric systemic lupus erythematosus is associated with a distinct type and shape of cerebral white matter hyperintensities. Rheumatology (Oxford) 2021; 61:2663-2671. [PMID: 34730801 PMCID: PMC9157072 DOI: 10.1093/rheumatology/keab823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/27/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives Advanced white matter hyperintensity (WMH) markers on brain MRI may help reveal underlying mechanisms and aid in the diagnosis of different phenotypes of SLE patients experiencing neuropsychiatric (NP) manifestations. Methods In this prospective cohort study, we included a clinically well-defined cohort of 155 patients consisting of 38 patients with NPSLE (26 inflammatory and 12 ischaemic phenotype) and 117 non-NPSLE patients. Differences in 3 T MRI WMH markers (volume, type and shape) were compared between patients with NPSLE and non-NPSLE and between patients with inflammatory and ischaemic NPSLE by linear and logistic regression analyses corrected for age, sex and intracranial volume. Results Compared with non-NPSLE [92% female; mean age 42 (13) years], patients with NPSLE [87% female; mean age 40 (14) years] showed a higher total WMH volume [B (95%-CI)]: 0.46 (0.0 7 ↔ 0.86); P = 0.021], a higher periventricular/confluent WMH volume [0.46 (0.0 6 ↔ 0.86); P = 0.024], a higher occurrence of periventricular with deep WMH type [0.32 (0.1 3 ↔ 0.77); P = 0.011], a higher number of deep WMH lesions [3.06 (1.2 1 ↔ 4.90); P = 0.001] and a more complex WMH shape [convexity: ‒0.07 (‒0.12 ↔ ‒0.02); P = 0.011, concavity index: 0.05 (0.0 1 ↔ 0.08); P = 0.007]. WMH shape was more complex in inflammatory NPSLE patients [89% female; mean age 39 (15) years] compared with patients with the ischaemic phenotype [83% female; mean age 41 (11) years] [concavity index: 0.08 (0.0 1 ↔ 0.15); P = 0.034]. Conclusion We demonstrated that patients with NPSLE showed a higher periventricular/confluent WMH volume and more complex shape of WMH compared with non-NPSLE patients. This finding was particularly significant in inflammatory NPLSE patients, suggesting different or more severe underlying pathophysiological abnormalities.
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Affiliation(s)
- Francesca Inglese
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Rory Monahan
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
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14
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Meier AL, Bodmer NS, Wirth C, Bachmann LM, Ribi C, Pröbstel AK, Waeber D, Jelcic I, Steiner UC. Neuro-psychiatric manifestations in patients with systemic lupus erythematosus: A systematic review and results from the Swiss lupus cohort study. Lupus 2021; 30:1565-1576. [PMID: 34152246 PMCID: PMC8489688 DOI: 10.1177/09612033211025636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objectives Systemic lupus erythematosus (SLE) is a systemic autoimmune disease associated with neuro-psychiatric (NP) manifestations. Frequency and patterns of neuro-psychiatric systemic lupus erythematosus (NPSLE) vary substantially between patients. We conducted a systematic review (SR) of the literature and examined prevalence and characteristics of NPSLE in the Swiss SLE cohort study (SSCS). Methods The SR search was performed between January 1999 and January 2020. We included prospective/cross-sectional studies focusing on NPSLE. We secured study characteristics, cohort compositions and frequencies of NP manifestations, assessed heterogeneity across reports and investigated sources of variation using meta-regression models. Regarding the SSCS, we reviewed all patients included and classified NP manifestations. Results The SR searches identified 530 studies. We included 22 studies in our meta-analysis, the mean frequency of NPSLE ranged from 10.6% to 96.4%. The frequency of NPSLE in the SSCS was 28.1%. Severe events including cerebrovascular insults, seizures and psychosis appeared in 7.1%, 5.3% and 6.5% respectively. There was a linear relationship between duration of SLE and cumulative incidence of NPSLE. Conclusions The spectrum of NPSLE is very broad. The diagnostic work-up and rates of reported manifestations varied substantially across studies. We call for concerted efforts and consensus regarding definitions of NPSLE that will facilitate accurate diagnosis and attribution to SLE, particularly with a view to timely intervention and patient outcomes.
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Affiliation(s)
- Aline L Meier
- Department of Immunology, University Hospital of Zurich, Zurich, Switzerland
| | | | - Carla Wirth
- Medignition Healthcare Innovations, Zurich, Switzerland
| | | | - Camillo Ribi
- Division of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Katrin Pröbstel
- Neurologic Clinic and Policlinic, Departments of Medicine and Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Waeber
- Departement of Psychiatry, University Hospital of Zurich, Zurich, Switzerland
| | - Ilijas Jelcic
- Departement of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Urs C Steiner
- Department of Immunology, University Hospital of Zurich, Zurich, Switzerland
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15
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Yuen K, Green R, Bingham K, Ruttan L, Lee-Kim V, Tartaglia MC, Anderson M, Zandy M, Choi MY, Fritzler MJ, Wither JE, Beaton DE, Katz P, Touma Z. Metrics and definitions used in the assessment of cognitive impairment in systemic lupus erythematosus: A systematic review. Semin Arthritis Rheum 2021; 51:819-830. [PMID: 34157577 DOI: 10.1016/j.semarthrit.2021.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/03/2021] [Accepted: 05/31/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To review: 1) degree of conformity to the American College of Rheumatology neuropsychological battery (ACR-NB) among studies that used a NB, 2) review definitions of cognitive impairment (CI) from studies that used a NB, and 3) characterize measurement tools used to assess CI in systemic lupus erythematosus (SLE). METHODS The literature search was conducted in Ovid Medline, Embase, and PsycINFO for articles on CI in adult SLE patients. We reviewed studies that used a NB and compared their tests to the ACR-NB to assess the degree of conformity. Definitions of CI from studies that used a NB were reviewed when sufficient information was available. We reviewed and categorized CI measurement tools into four broad categories: NB, screening, incomplete/mixed batteries, and computerized batteries. RESULTS Of 8727 references, 118 were selected for detailed review and 97 were included in the final analysis. Of 43 studies that used a NB, none of the studies used the ACR-NB exactly as published. Many studies supplemented with other tests. Overall, there was inconsistent use of ACR-NB tests. Definitions for CI varied, with cut-offs ranging from 1 to 3 standard deviations below normative values on domains/tests varying in type and number. The most frequently used measurement tool for assessing CI in SLE was a NB. Use of screening tests and computerized batteries have also increased over the last decade. CONCLUSION The assessment and definition of CI in SLE remains heterogeneous. A consensus meeting to address existing inconsistencies should be considered to harmonize the field of CI in SLE.
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Affiliation(s)
- Kimberley Yuen
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto Lupus Clinic, EW, 1-412, 399 Bathurst Street, Toronto, Ontario, Canada; Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Robin Green
- University Health Network- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Kathleen Bingham
- University Health Network Centre for Mental Health, Toronto, Ontario, Canada
| | - Lesley Ruttan
- University Health Network- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Victoria Lee-Kim
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | | | - Melanie Anderson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Moe Zandy
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto Lupus Clinic, EW, 1-412, 399 Bathurst Street, Toronto, Ontario, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joan E Wither
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Patricia Katz
- University of California at San Francisco, San Francisco, California, USA
| | - Zahi Touma
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto Lupus Clinic, EW, 1-412, 399 Bathurst Street, Toronto, Ontario, Canada.
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16
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Donnellan C, Cohen H, Werring DJ. Cognitive dysfunction and associated neuroimaging biomarkers in antiphospholipid syndrome: a systematic review. Rheumatology (Oxford) 2021; 61:24-41. [PMID: 34003972 PMCID: PMC8742819 DOI: 10.1093/rheumatology/keab452] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives Cognitive dysfunction is common in patients with aPL (including primary APS or APS associated with SLE). Neuroimaging biomarkers may contribute to our understanding of mechanisms of cognitive dysfunction in these cohorts. This review aimed to investigate: (i) the prevalence of cognitive dysfunction in studies including neuroimaging biomarkers; and (ii) associations between cognition and neuroimaging biomarkers in patients with APS/aPL. Methods We conducted a systematic search of electronic databases PubMed, Science Direct, Scopus and PsycINFO, and included studies with descriptions of neuroimaging findings, cognitive dysfunction or both, in patients with aPL positivity (LA, IgG and IgM aCL and anti-β2 glycoprotein-I antibodies). Results Of 120 search results we included 20 eligible studies (6 APS, 4 SLE with APS/aPL and 10 NPSLE). We identified a medium risk of bias in 6/11 (54%) of cohort studies and 44% of case–control studies, as well as marked heterogeneity in cognitive assessment batteries, APS and aPL definitions, and neuroimaging modalities and protocols. The prevalence of cognitive dysfunction ranged between 11 and 60.5%. Structural MRI was the most common imaging modality, reporting cognitive dysfunction to be associated with white matter hyperintensities, ischaemic lesions and cortical atrophy (four with cerebral atrophy, two with white matter hyperintensities and two with cerebral infarcts). Conclusion Our findings confirm that cognitive impairment is commonly found in patients with aPL (including APS, SLE and NPSLE). The risk of bias, and heterogeneity in the cognitive and neuroimaging biomarkers reported does not allow for definitive conclusions.
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Affiliation(s)
- Claire Donnellan
- School of Nursing and Midwifery, Faculty of Health Sciences, University of Dublin, Trinity College Dublin, Dublin, Ireland
- Correspondence to: Claire Donnellan, School of Nursing and Midwifery, Faculty of Health Sciences, University of Dublin Trinity College, 2 Clare Street, Dublin 2, Ireland. E-mail:
| | - Hannah Cohen
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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17
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Inglese F, Kant IMJ, Monahan RC, Steup-Beekman GM, Huizinga TWJ, van Buchem MA, Magro-Checa C, Ronen I, de Bresser J. Different phenotypes of neuropsychiatric systemic lupus erythematosus are related to a distinct pattern of structural changes on brain MRI. Eur Radiol 2021; 31:8208-8217. [PMID: 33929569 PMCID: PMC8523434 DOI: 10.1007/s00330-021-07970-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 12/14/2022]
Abstract
Objectives The underlying structural brain correlates of neuropsychiatric involvement in systemic lupus erythematosus (NPSLE) remain unclear, thus hindering correct diagnosis. We compared brain tissue volumes between a clinically well-defined cohort of patients with NPSLE and SLE patients with neuropsychiatric syndromes not attributed to SLE (non-NPSLE). Within the NPSLE patients, we also examined differences between patients with two distinct disease phenotypes: ischemic and inflammatory. Methods In this prospective (May 2007 to April 2015) cohort study, we included 38 NPSLE patients (26 inflammatory and 12 ischemic) and 117 non-NPSLE patients. All patients underwent a 3-T brain MRI scan that was used to automatically determine white matter, grey matter, white matter hyperintensities (WMH) and total brain volumes. Group differences in brain tissue volumes were studied with linear regression analyses corrected for age, gender, and total intracranial volume and expressed as B values and 95% confidence intervals. Results NPSLE patients showed higher WMH volume compared to non-NPSLE patients (p = 0.004). NPSLE inflammatory patients showed lower total brain (p = 0.014) and white matter volumes (p = 0.020), and higher WMH volume (p = 0.002) compared to non-NPSLE patients. Additionally, NPSLE inflammatory patients showed lower white matter (p = 0.020) and total brain volumes (p = 0.038) compared to NPSLE ischemic patients. Conclusion We showed that different phenotypes of NPSLE were related to distinct patterns of underlying structural brain MRI changes. Especially the inflammatory phenotype of NPSLE was associated with the most pronounced brain volume changes, which might facilitate the diagnostic process in SLE patients with neuropsychiatric symptoms. Key Points • Neuropsychiatric systemic lupus erythematosus (NPSLE) patients showed a higher WMH volume compared to SLE patients with neuropsychiatric syndromes not attributed to SLE (non-NPSLE). • NPSLE patients with inflammatory phenotype showed a lower total brain and white matter volume, and a higher volume of white matter hyperintensities, compared to non-NPSLE patients. • NPSLE patients with inflammatory phenotype showed lower white matter and total brain volumes compared to NPSLE patients with ischemic phenotype. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07970-2.
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Affiliation(s)
- Francesca Inglese
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.
| | - Ilse M J Kant
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Cesar Magro-Checa
- Department of Rheumatology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419, PC, Heerlen, The Netherlands
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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18
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Monahan RC, Beaart-van de Voorde LJ, Eikenboom J, Fronczek R, Kloppenburg M, Middelkoop HA, Terwindt GM, van der Wee NJ, Huizinga TW, Steup-Beekman GM. Fatigue in patients with systemic lupus erythematosus and neuropsychiatric symptoms is associated with anxiety and depression rather than inflammatory disease activity. Lupus 2021; 30:1124-1132. [PMID: 33779389 PMCID: PMC8120630 DOI: 10.1177/09612033211005014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION We aimed to investigate risk factors for fatigue in patients with systemic lupus erythematosus (SLE) and neuropsychiatric symptoms in order to identify potential interventional strategies. METHODS Patients visiting the neuropsychiatric SLE (NPSLE) clinic of the Leiden University Medical Center between 2007-2019 were included. In a multidisciplinary consensus meeting, SLE patients were classified as having neuropsychiatric symptoms of inflammatory origin (inflammatory phenotype) or other origin (non-inflammatory phenotype). Fatigue was assessed with the SF-36 vitality domain (VT) since 2007 and the multidimensional fatigue inventory (MFI) and visual analogue scale (VAS) since 2011. Patients with a score on the SF-36 VT ≥1 standard deviation (SD) away from the mean of age-related controls of the general population were classified as fatigued; patients ≥2 SD away were classified as extremely fatigued. Disease activity was measured using the SLE disease activity index-2000. The influence of the presence of an inflammatory phenotype, disease activity and symptoms of depression and anxiety as measured by the hospital anxiety and depression scale (HADS) was analyzed using multiple regression analyses corrected for age, sex and education. RESULTS 348 out of 371 eligible patients filled in questionnaires and were included in this study . The majority was female (87%) and the mean age was 43 ± 14 years. 72 patients (21%) had neuropsychiatric symptoms of an inflammatory origin. Fatigue was present in 78% of all patients and extreme fatigue was present in 50% of patients with an inflammatory phenotype vs 46% in the non-inflammatory phenotype. Fatigue was similar in patients with an inflammatory phenotype compared to patients with a non-inflammatory phenotype on the SF-36 VT (β: 0.8 (95% CI -4.8; 6.1) and there was less fatigue in patients with an inflammatory phenotype on the MFI and VAS (β: -3.7 (95% CI: -6.9; -0.5) and β: -1.0 (95% CI -1.6; -0.3)). There was no association between disease activity and fatigue, but symptoms of anxiety and depression (HADS) associated strongly with all fatigue measurements. CONCLUSION This study suggests that intervention strategies to target fatigue in (NP)SLE patients may need to focus on symptoms of anxiety and depression rather than immunosuppressive treatment.
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Affiliation(s)
- Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Sleep-Wake Center SEIN, Heemstede, the Netherlands
| | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Huub Am Middelkoop
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nic Ja van der Wee
- Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom Wj Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Haaglanden Medical Center, the Hague, the Netherlands
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19
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Bulk M, van Harten T, Kenkhuis B, Inglese F, Hegeman I, van Duinen S, Ercan E, Magro-Checa C, Goeman J, Mawrin C, van Buchem M, Steup-Beekman G, Huizinga T, van der Weerd L, Ronen I. Quantitative susceptibility mapping in the thalamus and basal ganglia of systemic lupus erythematosus patients with neuropsychiatric complaints. Neuroimage Clin 2021; 30:102637. [PMID: 33812303 PMCID: PMC8053812 DOI: 10.1016/j.nicl.2021.102637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
Systemic lupus erythematosus (SLE) is an auto-immune disease characterized by multi-organ involvement. Although uncommon, central nervous system involvement in SLE, termed neuropsychiatric SLE (NPSLE), is not an exception. Current knowledge on underlying pathogenic mechanisms is incomplete, however, neuroinflammation is thought to play a critical role. Evidence from neurodegenerative diseases and multiple sclerosis suggests that neuroinflammation is correlated with brain iron accumulation, making quantitative susceptibility mapping (QSM) a potential hallmark for neuroinflammation in vivo. This study assessed susceptibility values of the thalamus and basal ganglia in (NP)SLE patients and further investigated the in vivo findings with histological analyses of postmortem brain tissue derived from SLE patients. We used a 3T MRI scanner to acquire single-echo T2*-weighted images of 44 SLE patients and 20 age-matched healthy controls. Of the 44 patients with SLE, all had neuropsychiatric complaints, of which 29 were classified as non-NPSLE and 15 as NPSLE (seven as inflammatory NPSLE and eight as ischemic NPSLE). Mean susceptibility values of the thalamus, caudate nucleus, putamen, and globus pallidus were calculated. Formalin-fixed paraffin-embedded post-mortem brain tissue including the putamen and globus pallidus of three additional SLE patients was obtained and stained for iron, microglia and astrocytes. Susceptibility values of SLE patients and age-matched controls showed that iron levels in the thalamus and basal ganglia were not changed due to the disease. No subgroup of SLE showed higher susceptibility values. No correlation was found with disease activity or damage due to SLE. Histological examination of the post-mortem brain showed no increased iron accumulation. Our results suggest that neuroinflammation in NPSLE does not necessarily go hand in hand with iron accumulation, and that the inflammatory pathomechanism in SLE may differ from the one observed in neurodegenerative diseases and in multiple sclerosis.
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Affiliation(s)
- Marjolein Bulk
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thijs van Harten
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Boyd Kenkhuis
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Francesca Inglese
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingrid Hegeman
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sjoerd van Duinen
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ece Ercan
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands; Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jelle Goeman
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian Mawrin
- Department of Neuropathology, Otto-von-Guericke University, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany
| | - Mark van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerda Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Louise van der Weerd
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Itamar Ronen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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20
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Monahan RC, Fronczek R, Eikenboom J, Middelkoop HAM, Beaart-van de Voorde LJJ, Terwindt GM, van der Wee NJA, Rosendaal FR, Huizinga TWJ, Kloppenburg M, Steup-Beekman GM. Mortality in patients with systemic lupus erythematosus and neuropsychiatric involvement: A retrospective analysis from a tertiary referral center in the Netherlands. Lupus 2020; 29:1892-1901. [PMID: 33079617 PMCID: PMC7684795 DOI: 10.1177/0961203320963815] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective We aimed to evaluate all-cause and cause-specific mortality in patients with systemic lupus erythematosus (SLE) and neuropsychiatric (NP) symptoms in the Netherlands between 2007–2018. Methods Patients visiting the tertiary referral NPSLE clinic of the Leiden University Medical Center were included. NP symptoms were attributed to SLE requiring treatment (major NPSLE) or to other and mild causes (minor/non-NPSLE). Municipal registries were checked for current status (alive/deceased). Standardized mortality ratios (SMRs) and 95% confidence intervals (CI) were calculated using data from the Dutch population. Rate ratio (RR) and 95% CI were calculated using direct standardization to compare mortality between major NPSLE and minor/non-NPSLE. Results 351 patients were included and 149 patients were classified as major NPSLE (42.5%). Compared with the general population, mortality was increased in major NPSLE (SMR 5.0 (95% CI: 2.6–8.5)) and minor/non-NPSLE patients (SMR 3.7 (95% CI: 2.2–6.0)). Compared with minor/non-NPSLE, mortality was similar in major NPSLE patients (RR: 1.0 (95% CI: 0.5–2.0)). Cause-specific mortality rates demonstrated an increased risk of death due to infections in both groups, whereas death due to cardiovascular disease was only increased in minor/non-NPSLE patients. Conclusion Mortality was increased in both major NPSLE and minor/non-NPSLE patients in comparison with the general population. There was no difference in mortality between major NPSLE and minor/non-NPSLE patients.
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Affiliation(s)
- Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Huub A M Middelkoop
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nic J A van der Wee
- Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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21
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Balajkova V, Olejarova M, Moravcova R, Kozelek P, Posmurova M, Hulejova H, Senolt L. Is serum TWEAK a useful biomarker of neuropsychiatric systemic lupus erythematosus? Physiol Res 2020; 69:339-346. [PMID: 32199014 DOI: 10.33549/physiolres.934308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to determine the role of the tumor necrosis factor like weak inducer of apoptosis (TWEAK) as a serum biomarker of neuropsychiatric involvement in systemic lupus erythematosus (NPSLE). Levels of TWEAK levels were measured in sera of 92 patients with systemic lupus erythematosus (SLE), including 28 patients with neuropsychiatric lupus, and in 59 healthy controls using ELISA. All SLE patients underwent rheumatological, neurological and psychiatric assessment. We found no significant differences in TWEAK levels, between SLE patients and the healthy controls (p=0.2411). Similarly, no difference was observed between subgroup of NPSLE and healthy controls (p=0.7658). The mean SLE disease activity (SLEDAI) was 13.25. No correlations between TWEAK levels with disease activity (SLEDAI, r=0.2113, p=0.2805) or the most common NPSLE manifestations such as headache (r=0.2079), seizures (r=0.1101), cerebrovascular disease (r= 0.2347), cognitive dysfunction (r=0.1597) and anxiety (r=0.1397) were observed. Our data do not support the use of serum TWEAK as a discriminating biomarker for NPSLE. The role of the TWEAK in NPSLE remains to be investigated.
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Affiliation(s)
- V Balajkova
- Department of Rheumatology, First Faculty of Medicine Charles University, Prague, Czech Republic.
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22
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Monahan RC, Beaart HJL, Fronczek R, Terwindt GM, Beaart-van de Voorde LJJ, de Bresser J, Kloppenburg M, van der Wee NJA, Huizinga TWJ, Steup-Beekman GM. Suspected Transverse Myelitis with Normal MRI and CSF Findings in a Patient with Lupus: What to Do? A Case Series and Systematic Review. Neuropsychiatr Dis Treat 2020; 16:3173-3186. [PMID: 33376333 PMCID: PMC7764958 DOI: 10.2147/ndt.s267000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/27/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate the use of immunosuppressive treatment, clinical outcome and diagnostic strategy in patients with systemic lupus erythematosus (SLE) presenting with clinical features of transverse myelitis (TM), but normal MRI of the spinal cord (sMRI) and normal cerebrospinal fluid (CSF) assessment, and to suggest a clinical guideline. PATIENTS AND METHODS All patients with SLE and clinical features compatible with (sub)acute TM visiting the NPSLE clinic of the LUMC between 2007 and 2020 were included. Information on baseline characteristics, investigations, treatment and outcomes was collected from electronic medical records. In addition, a systematic review of individual participant data was performed up to April 2020 in PubMed, Embase and Web of Science, identifying all patients with TM, SLE and sMRI assessment. Data regarding sMRI, CSF analysis, treatment and outcome were extracted, and outcome was compared between patients with normal sMRI and CSF (sMRI-/CSF-) and patients with abnormalities. RESULTS Twelve SLE patients with a clinical diagnosis of TM were identified: four sMRI-/CSF- and one sMRI- with CSF not available. All patients received immunosuppressive treatment, but outcome in sMRI-/CSF- patients was worse: no recovery (n=1) or partial recovery (n=3) compared to partial recovery (n=4) and (nearly) complete recovery (n=3) in MRI+ patients. The systematic literature review yielded 146 articles eligible for inclusion, 90% case reports. A total of 427 SLE patients with TM were identified, of which only four cases were sMRI-/CSF- (1%), showing no improvement (n=1), partial improvement (n=2) and complete recovery (n=1) after immunosuppressive treatment. CONCLUSION Outcome in SLE patients presenting with clinically suspected TM with normal sMRI and CSF is less favorable, despite treatment with immunosuppressive therapy. Taking a functional neurological disorder into consideration may be helpful in order to start other therapeutic strategies. We suggest prescribing immunosuppressive treatment for a restricted period of time to evaluate its effect in cases where a functional disorder initially is considered unlikely.
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Affiliation(s)
- Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Hannelore J L Beaart
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, LUMC, Leiden, the Netherlands.,Sleep-Wake Center SEIN, Heemstede, the Netherlands
| | | | | | | | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands.,Department of Clinical Epidemiology, LUMC, Leiden, the Netherlands
| | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, the Netherlands.,Department of Rheumatology, Haaglanden Medical Center, The Hague, the Netherlands
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23
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Neuronal BC RNA Transport Impairments Caused by Systemic Lupus Erythematosus Autoantibodies. J Neurosci 2019; 39:7759-7777. [PMID: 31405929 DOI: 10.1523/jneurosci.1657-18.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 05/02/2019] [Accepted: 06/24/2019] [Indexed: 12/27/2022] Open
Abstract
The etiology of the autoimmune disorder systemic lupus erythematosus (SLE) remains poorly understood. In neuropsychiatric SLE (NPSLE), autoimmune responses against neural self-antigens find expression in neurological and cognitive alterations. SLE autoantibodies often target nucleic acids, including RNAs and specifically RNA domains with higher-order structural content. We report that autoantibodies directed against neuronal regulatory brain cytoplasmic (BC) RNAs were generated in a subset of SLE patients. By contrast, anti-BC RNA autoantibodies (anti-BC abs) were not detected in sera from patients with autoimmune diseases other than SLE (e.g., rheumatoid arthritis or multiple sclerosis) or in sera from healthy subjects with no evidence of disease. SLE anti-BC abs belong to the IgG class of immunoglobulins and target both primate BC200 RNA and rodent BC1 RNA. They are specifically directed at architectural motifs in BC RNA 5' stem-loop domains that serve as dendritic targeting elements (DTEs). SLE anti-BC abs effectively compete with RNA transport factor heterogeneous nuclear ribonucleoprotein A2 (hnRNP A2) for DTE access and significantly diminish BC RNA delivery to synapto-dendritic sites of function. In vivo experiments with male BALB/c mice indicate that, upon lipopolysaccharide-induced opening of the blood-brain barrier, SLE anti-BC abs are taken up by CNS neurons where they significantly impede localization of endogenous BC1 RNA to synapto-dendritic domains. Lack of BC1 RNA causes phenotypic abnormalities including epileptogenic responses and cognitive dysfunction. The combined data indicate a role for anti-BC RNA autoimmunity in SLE and its neuropsychiatric manifestations.SIGNIFICANCE STATEMENT Although clinical manifestations of neuropsychiatric lupus are well recognized, the underlying molecular-cellular alterations have been difficult to determine. We report that sera of a subset of lupus patients contain autoantibodies directed at regulatory brain cytoplasmic (BC) RNAs. These antibodies, which we call anti-BC abs, target the BC RNA 5' domain noncanonical motif structures that specify dendritic delivery. Lupus anti-BC abs effectively compete with RNA transport factor heterogeneous nuclear ribonucleoprotein A2 (hnRNP A2) for access to BC RNAs. As a result, hnRNP A2 is displaced, and BC RNAs are impaired in their ability to reach synapto-dendritic sites of function. The results reveal an unexpected link between BC RNA autoantibody recognition and dendritic RNA targeting. Cellular RNA dysregulation may thus be a contributing factor in the pathogenesis of neuropsychiatric lupus.
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24
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Lubbers R, Beaart-van de Voorde LJJ, van Leeuwen K, de Boer M, Gelderman KA, van den Berg MJ, Ketel AG, Simon A, de Ree J, Huizinga TWJ, Steup-Beekman GM, Trouw LA. Complex medical history of a patient with a compound heterozygous mutation in C1QC. Lupus 2019; 28:1255-1260. [PMID: 31357913 PMCID: PMC6710612 DOI: 10.1177/0961203319865029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction C1q is an essential part of the classical pathway of complement activation. Genetic deficiencies, caused by homozygous mutations in one of the C1q genes, are rare and are strongly associated with development of systemic lupus erythematosus (SLE). Here we describe a C1q-deficient patient with a compound heterozygous mutation. Material and methods Serum was analysed with enzyme-linked immunosorbent assay (ELISA) and Western blot for the presence of C1q, and DNA and RNA sequencing was performed to identify the mutations and confirm that these were located on different chromosomes. Results The medical history of the patient includes SLE diagnosis at age 11 years with cerebral involvement at age 13, various infections, osteonecrosis and hemophagocytic syndrome. Using ELISA and Western blot, we confirmed the absence of C1q in the serum of the patient. Using DNA sequencing, two mutations in the C1QC gene were identified: c.100G > A p.(Gly34Arg) and c.205C > T p.(Arg69X). With RNA sequencing we confirmed that the mutations are located on different chromosomes. Discussion The patient described in this case report has a compound heterozygous mutation in C1QC resulting in C1q deficiency.
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Affiliation(s)
- R Lubbers
- 1 Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - K van Leeuwen
- 2 Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - M de Boer
- 2 Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - K A Gelderman
- 2 Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - M J van den Berg
- 3 Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Rheumatology and Immunology, Amsterdam, the Netherlands
| | - A G Ketel
- 4 Spaarnegasthuis, Hoofddorp, the Netherlands
| | - A Simon
- 5 Radboud University Medical Center, Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Nijmegen, the Netherlands
| | - J de Ree
- 4 Spaarnegasthuis, Hoofddorp, the Netherlands
| | - T W J Huizinga
- 1 Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - G M Steup-Beekman
- 1 Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - L A Trouw
- 1 Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,6 Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
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25
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Gegenava M, Beaart HJL, Monahan RC, Brilman E, Beaart-van de Voorde LJJ, Magro-Checa C, Huizinga TWJ, Steup-Beekman GM. Performance of the proposed ACR-EULAR classification criteria for systemic lupus erythematosus (SLE) in a cohort of patients with SLE with neuropsychiatric symptoms. RMD Open 2019; 5:e000895. [PMID: 31245049 PMCID: PMC6560656 DOI: 10.1136/rmdopen-2019-000895] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/09/2019] [Accepted: 05/16/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- Maka Gegenava
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Rory Caitlin Monahan
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Elisabeth Brilman
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Cesar Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Haaglanden Medical Center, The Hague, the Netherlands
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26
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Magro-Checa C, Kumar S, Ramiro S, Beaart-van de Voorde L, Eikenboom J, Ronen I, de Bresser J, van Buchem M, Huizinga T, Steup-Beekman G. Are serum autoantibodies associated with brain changes in systemic lupus erythematosus? MRI data from the Leiden NP-SLE cohort. Lupus 2019; 28:94-103. [PMID: 30526327 PMCID: PMC6304692 DOI: 10.1177/0961203318816819] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/09/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The effect of serum autoantibodies on the brain of systemic lupus erythematosus (SLE) patients remains unclear. We investigated whether serum autoantibodies, individually and assessed in groups, are associated with specific brain-MRI abnormalities or whether these structural changes are associated with other SLE-related or traditional cardiovascular disease risk factors. METHODS All patients underwent brain 3Tesla-MRI. White matter hyperintensities (WMHs), ischemic lesions, inflammatory-like lesions and cerebral atrophy were scored. Serum autoantibodies analyzed included lupus anticoagulant (LAC), anticardiolipine (aCL) IgG and IgM (first 3 also grouped into antiphospholipid autoantibodies (aPL)), anti-dsDNA, anti-SSA, anti-SSB, anti-RNP, and anti-Sm (the latter 5 grouped into SLE-related autoantibodies). Associations were assessed using logistic regression analysis adjusted for potential confounders. Furthermore, a sensitivity analysis including anti-Beta2 glycoprotein-1 antibodies (anti-β2GP1) in the aPL group was performed and the potential modification role of the neuropsychiatric clinical status in the model was assessed. RESULTS 325 patients (mean age 42 years (SD 14), 89% female) were included. The following MRI-brain abnormalities were found: WMHs (71%), lacunar infarcts (21%), gliosis (11%), micro-hemorrhages (5%), large hemorrhages (2%), inflammatory-like lesions (6%) and atrophy (14%). No associations were found between individual or total SLE-related autoantibodies and inflammatory-like lesions. A higher number of positive aPL was associated with lacunar infarcts (OR 1.37 (95%CI 1.02-1.99) and gliosis (OR 2.15 (1.37-3.37)). LAC was associated with lacunar infarcts in white matter (OR 3.38 (1.32-8.68)) and atrophy (OR 2.49 (1.01-6.15)), and aCL IgG with gliosis (OR 2.71 (1.05-7.02)). Among other variables, SLE patients with hypertension presented a higher chance for WMHs (OR 5.61 (2.52-12.48)) and lacunar infarcts in WM (OR 2.52 (1.10-5.74)) and basal ganglia (OR 8.34 (2.19-31.70)), while cumulative SLE-damage was correlated with lacunar infarcts in WM (OR 1.43 (1.07-1.90)), basal ganglia (OR 1.72 (1.18-2.51)) and cerebellum (OR 1.79 (1.33-2.41)). These associations were confirmed in the sensitivity analysis. CONCLUSIONS Brain abnormalities in SLE represent different underlying pathogenic mechanisms. aPL are associated with ischemic brain changes in SLE, while the presence of SLE-related serum autoantibodies is not related to inflammatory-like lesions. Hypertension and cumulative SLE-damage associate with ischemic MRI-brain changes in SLE, suggesting the importance of accelerated atherosclerosis in this process.
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Affiliation(s)
- C. Magro-Checa
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
- Department of Rheumatology, Zuyderland
Medical Center, Heerlen, the Netherlands
| | - S. Kumar
- Department of Neuroradiology,
National
Neuroscience Institute, Singapore
| | - S. Ramiro
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
- Department of Rheumatology, Zuyderland
Medical Center, Heerlen, the Netherlands
| | | | - J. Eikenboom
- Department of Thrombosis and Hemostasis,
Leiden University Medical Center, Leiden, the Netherlands
| | - I. Ronen
- CJ Gorter Center for High Field MRI,
Department of Radiology, Leiden University Medical Center, Leiden, the
Netherlands
| | - J de Bresser
- Department of Radiology, Leiden
University Medical Center, Leiden, The Netherlands
| | - M.A van Buchem
- Department of Radiology, Leiden
University Medical Center, Leiden, The Netherlands
| | - T.W. Huizinga
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
| | - G.M. Steup-Beekman
- Department of Rheumatology, Leiden
University Medical Center, Leiden, the Netherlands
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Rayes HA, Tani C, Kwan A, Marzouk S, Colosimo K, Medina-Rosas J, Mustafa A, Su J, Lambiris P, Mosca M, Touma Z. What is the prevalence of cognitive impairment in lupus and which instruments are used to measure it? A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 48:240-255. [DOI: 10.1016/j.semarthrit.2018.02.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 01/10/2018] [Accepted: 02/16/2018] [Indexed: 11/30/2022]
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Lucic AT. Neuropsichyatric Manifestations of Systemic Lupus Erythematosus: Diagnosis and Treatment Approach. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2017. [DOI: 10.1515/sjecr-2017-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Neuropsychiatric involvement in systemic lupus erythematosus includes heterogeneous manifestations involving both the central and peripheral nervous system. A major issue in clinical evaluation is the attribution of neuropsychiatric symptoms to systemic lupus erithematosus. Antiphospholipid antibodies, immune complex, microangiopathy, early and accelerated arteriosclerosis are factors that have the main role in pathogenesis of neuropsychiatric manifestations of systemic lupus erithematosus. Th ere are no neurological symptoms specific to systemic lupus erithematosus, but they can also occur very commonly in the general population. Lesions of nervous system can be focal or diff use and may be due to systemic lupus erithematosus itself (primary lesions), but it also may be caused by other diseases or disbalances. Therapy of the neuropsychiatric manifestations depends on the nature of the pathological process (dominant inflammation or thrombosis). If it is result of an inflammatory neurotoxic process and in the presence of an increased activity of systemic lupus erithematosus, therapy includes glycocorticoids independently or in combination with immunosuppressives. Focal neuropsychiatric syndrome with antiphospholipid antibodies positivity should be treated with anticoagulant and/ or antiplatelet therapy. In addition, control of classical cardiovascular risk factors, stop smoking, and treatment with hydroxychloroquine is recommended.
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Affiliation(s)
- Alesandra Tomic Lucic
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Serbia Internal Clinic, Department of Rheumathology, Clinical Center “ Kragujevac ”, Serbia
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Papadaki E, Fanouriakis A, Kavroulakis E, Karageorgou D, Sidiropoulos P, Bertsias G, Simos P, Boumpas DT. Neuropsychiatric lupus or not? Cerebral hypoperfusion by perfusion-weighted MRI in normal-appearing white matter in primary neuropsychiatric lupus erythematosus. Ann Rheum Dis 2017; 77:441-448. [DOI: 10.1136/annrheumdis-2017-212285] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/16/2017] [Accepted: 12/01/2017] [Indexed: 11/03/2022]
Abstract
ObjectivesCerebral perfusion abnormalities have been reported in systemic lupus erythematosus (SLE) but their value in distinguishing lupus from non-lupus-related neuropsychiatric events remains elusive. We examined whether dynamic susceptibility contrast-enhanced perfusion MRI (DSC-MRI), a minimally invasive and widely available method of cerebral perfusion assessment, may assist neuropsychiatric SLE (NPSLE) diagnosis.MethodsIn total, 76patients with SLE (37 primary NPSLE, 16 secondary NPSLE, 23 non-NPSLE) and 31 healthy controls underwent conventional MRI (cMRI) and DSC-MRI. Attribution of NPSLE to lupus or not was based on multidisciplinary assessment including cMRI results and response to treatment. Cerebral blood volume and flow were estimated in 18 normal-appearing white and deep grey matter areas.ResultsThe most common manifestations were mood disorder, cognitive disorder and headache. Patients with primary NPSLE had lower cerebral blood flow and volume in several normal-appearing white matter areas compared with controls (P<0.0001) and lower cerebral blood flow in the semioval centre bilaterally, compared with non-NPSLE and patients with secondary NPSLE (P<0.001). A cut-off for cerebral blood flow of 0.77 in the left semioval centre discriminated primary NPSLE from non-NPSLE/secondary NPSLE with 80% sensitivity and 67%–69% specificity. Blood flow values in the left semioval centre showed substantially higher sensitivity than cMRI (81% vs 19%–24%) for diagnosing primary NPSLE with the combination of the two modalities yielding 94%–100% specificity in discriminating primary from secondary NPSLE.ConclusionPrimary NPSLE is characterised by significant hypoperfusion in cerebral white matter that appears normal on cMRI. The combination of DSC-MRI-measured blood flow in the brain semioval centre with conventional MRI may improve NPSLE diagnosis.
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Zhang N, Cao J, Zhao M, Sun L. The introspection on the diagnosis and treatment process of a case of Guillain-Barré syndrome (GBS) attributed to systemic lupus erythematosus (SLE): A case report. Medicine (Baltimore) 2017; 96:e9037. [PMID: 29245299 PMCID: PMC5728914 DOI: 10.1097/md.0000000000009037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an autoimmune inflammatory connective tissue disorder. It may cause neurologic damage which is mainly characterized by central and mental system, while peripheral sexual damage is relatively rare in which Guillain-Barré Syndrome (GBS) as the first performance is more rare . GBS is an autoimmune peripheral neuropathy usually triggered by an antecedent bacterial or viral infection, with SLE being a rare cause. PATIENT CONCERNS A 65-year-old male presented to the hospital with progressive numbness and adynamia in extremities. His vital signs were stable. 5 days later, his condition aggravated and mechanical ventilation was necessitated owing to severe dyspnea. DIAGNOSES Based on the clinical symptoms and results of the lumbar puncture and electromyography, he was first diagnosed as GBS, however, after treatment his condition was deteriorate and the blood test showed abnormal immune indices, then renal biopsy was performed, which confirmed the diagnosis of peripheral nervous system in patients with systemic lupus erythematosus (PNS-SLE). INTERVENTIONS Firstly he was treated with intravenous immunoglobulin (IVIG) for 5 days. After his condition deterioration, he was conducted endotracheal intubation and, finally, a tracheostomy was performed. Later on he was treated with steroid therapy for several weeks. OUTCOMES The patient showed remarkable recovery and was able to walk on his own by the time of discharge. LESSONS PNS-SLE can, by itself, be one of the main causes of morbidity and mortality. Electromyography and renal biopsy should be considered when relevant. Peripheral neuropathy in SLE should be given greater recognition, and rarer forms of presentation should be taken seriously in the differential diagnosis when the clinical picture is atypical. Glucocorticoids may play an important role in the treatment of PNS-SLE.
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Affiliation(s)
- Nan Zhang
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
- Department of Neurology, Yidu Central Hospital, Weifang, Shandong, China
| | - Jie Cao
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
| | - Meng Zhao
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
| | - Li Sun
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, Jilin
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van der Meulen PM, Barendregt AM, Cuadrado E, Magro-Checa C, Steup-Beekman GM, Schonenberg-Meinema D, Van den Berg JM, Li QZ, Baars PA, Wouters D, Voskuyl AE, Ten Berge IRJM, Huizinga TWJ, Kuijpers TW. Protein array autoantibody profiles to determine diagnostic markers for neuropsychiatric systemic lupus erythematosus. Rheumatology (Oxford) 2017; 56:1407-1416. [PMID: 28460084 DOI: 10.1093/rheumatology/kex073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Indexed: 12/11/2022] Open
Abstract
Objective The aim was to investigate the association between autoantibodies (autoAbs) and neuropsychiatric (NP) involvement in patients with SLE and to evaluate whether any autoAb or a combination of these autoAbs could indicate the underlying pathogenic process. Methods Using a multiplexed protein array for 94 antigens, we compared the serum autoAb profiles of 69 NPSLE patients, 203 SLE patients without NP involvement (non-NPSLE) and 51 healthy controls. Furthermore, we compared the profiles of NPSLE patients with clinical inflammatory (n = 38) and ischaemic (n = 31) NP involvement. Results In total, 75 IgG and 47 IgM autoAbs were associated with SLE patients in comparison with healthy controls. Comparing NPSLE with non-NPSLE and healthy control sera, 9 IgG (amyloid, cardiolipin, glycoprotein 2, glycoprotein 210, heparin, heparan sulphate, histone H2A, prothrombin protein and vimentin) and 12 IgM (amyloid, cardiolipin, centromere protein A, collagen II, histones H2A and H2B, heparan sulphate, heparin, mitochondrial 2, nuclear Mi-2, nucleoporin 62 and vimentin) autoAbs were present at significantly different levels in NPSLE. The combination of IgG autoAbs against heparan sulphate, histone H2B and vimentin could differentiate NPSLE from non-NPSLE (area under the curve 0.845, 99.97% CI: 0.756, 0.933; P < 0.0001). Compared with non-NPSLE, four IgG and seven IgM autoAbs were significantly associated with inflammatory NPSLE. In ischaemic NPSLE, three IgG and three IgM autoAbs were significantly different from non-NPSLE patients. Conclusion In our cohort, the presence of high levels of anti-heparan sulphate and anti-histone H2B combined with low levels of anti-vimentin IgG autoAbs is highly suggestive of NPSLE. These results need to be validated in external cohorts.
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Affiliation(s)
- Pomme M van der Meulen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Center
| | - Anouk M Barendregt
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Center
| | - Eloy Cuadrado
- Astrocyte Biology and Neurodegeneration Group, Netherlands Institute for Neuroscience, Amsterdam
| | - César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Center
| | - J Merlijn Van den Berg
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Center
| | - Quan-Zhen Li
- Department of Immunology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul A Baars
- Department of Experimental Immunology, Academic Medical Center, Amsterdam
| | | | | | - Ineke R J M Ten Berge
- Department of Internal Medicine, Clinical Immunology & Nephrology, Academic Medical Center, Amsterdam, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Center
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Magro-Checa C, Beaart-van de Voorde LJJ, Middelkoop HAM, Dane ML, van der Wee NJ, van Buchem MA, Huizinga TWJ, Steup-Beekman GM. Outcomes of neuropsychiatric events in systemic lupus erythematosus based on clinical phenotypes; prospective data from the Leiden NP SLE cohort. Lupus 2017; 26:543-551. [DOI: 10.1177/0961203316689145] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The objective of this study was to assess whether clinical and patient’s reported outcomes are associated with a different pathophysiological origin of neuropsychiatric events presenting in systemic lupus erythematosus. Methods A total of 232 neuropsychiatric events presenting in 131 systemic lupus erythematosus patients were included. Neuropsychiatric systemic lupus erythematosus diagnosis was established per event by multidisciplinary evaluation. All neuropsychiatric events were divided according to a suspected underlying pathophysiological process into one of the following: non-neuropsychiatric systemic lupus erythematosus related, inflammatory and ischaemic neuropsychiatric systemic lupus erythematosus. The clinical outcome of all neuropsychiatric events was determined by a physician-completed four-point Likert scale. Health-related quality of life was measured with the subscales of the patient-generated Short Form 36 (SF-36) health survey questionnaire. The change between scores at paired visits of all domain scores, mental component summary (SF-36 MCS) and physical component summary (SF-36 PCS) scores were retrospectively calculated and used as patient-reported outcome. The association among these outcomes and the different origin of neuropsychiatric events was obtained using multiple logistic regression analysis. Results The clinical status of 26.8% non-neuropsychiatric systemic lupus erythematosus events, 15.8% ischaemic neuropsychiatric systemic lupus erythematosus and 51.6% inflammatory neuropsychiatric systemic lupus erythematosus improved after re-assessment. Almost all SF-36 domains had a positive change at re-assessment in all groups independently of the origin of neuropsychiatric events. Neuropsychiatric systemic lupus erythematosus ( B = 0.502; p < 0.001) and especially inflammatory neuropsychiatric systemic lupus erythematosus ( B = 0.827; p < 0.001) had better clinical outcome, with change in disease activity being the only important predictor. The change in SF-36 MCS was also independently associated with neuropsychiatric systemic lupus erythematosus ( B = 5.783; p < 0.05) and inflammatory neuropsychiatric systemic lupus erythematosus ( B = 11.133; p < 0.001). Disease duration and change in disease activity were the only predictors in both cases. The change in SF-36 PCS was only negatively associated with age. Conclusion Inflammatory neuropsychiatric systemic lupus erythematosus events have better clinical outcome and meaningful improvement in SF-36 MCS than ischaemic neuropsychiatric systemic lupus erythematosus or non-neuropsychiatric systemic lupus erythematosus.
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Affiliation(s)
- C Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - H A M Middelkoop
- Department of Neurology and Clinical Neuropsychology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Psychology, Section Health, Medical and Neuropsychology, Leiden University, Leiden, The Netherlands
| | - M L Dane
- Department of Neurology and Clinical Neuropsychology, Leiden University Medical Center, Leiden, The Netherlands
| | - N J van der Wee
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | - M A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - T W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - G M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Magro-Checa C, Zirkzee EJ, Beaart-van de Voorde LJ, Middelkoop HA, van der Wee NJ, Huisman MV, Eikenboom J, Kruyt ND, van Buchem MA, Huizinga TW, Steup-Beekman GM. Value of multidisciplinary reassessment in attribution of neuropsychiatric events to systemic lupus erythematosus: prospective data from the Leiden NPSLE cohort. Rheumatology (Oxford) 2017; 56:1676-1683. [DOI: 10.1093/rheumatology/kex019] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 11/14/2022] Open
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34
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Monahan RC, Beaart-van de Voorde LJJ, Steup-Beekman GM, Magro-Checa C, Huizinga TWJ, Hoekman J, Kaptein AA. Neuropsychiatric symptoms in systemic lupus erythematosus: impact on quality of life. Lupus 2017; 26:1252-1259. [PMID: 28420059 PMCID: PMC5593126 DOI: 10.1177/0961203317694262] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Assess quality of life in patients with systemic lupus erythematosus (SLE) presenting with neuropsychiatric symptoms (neuropsychiatric SLE, NPSLE). Methods Quality of life was assessed using the Short-Form 36 item Health Survey (SF-36) in patients visiting the Leiden NPSLE clinic at baseline and at follow-up. SF-36 subscales and summary scores were calculated and compared with quality of life of the general Dutch population and patients with other chronic diseases. Results At baseline, quality of life was assessed in 248 SLE patients, of whom 98 had NPSLE (39.7%). Follow-up data were available for 104 patients (42%), of whom 64 had NPSLE (61.5%). SLE patients presenting neuropsychiatric symptoms showed a significantly reduced quality of life in all subscales of the SF-36. Quality of life at follow-up showed a significant improvement in physical functioning role (p = 0.001), social functioning (p = 0.007), vitality (p = 0.023), mental health (p = 0.014) and mental component score (p = 0.042) in patients with neuropsychiatric symptoms not attributed to SLE, but no significant improvement was seen in patients with NPSLE. Conclusion Quality of life is significantly reduced in patients with SLE presenting neuropsychiatric symptoms compared with the general population and patients with other chronic diseases. Quality of life remains considerably impaired at follow-up. Our results illustrate the need for biopsychosocial care in patients with SLE and neuropsychiatric symptoms.
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Affiliation(s)
- R C Monahan
- 1 Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - G M Steup-Beekman
- 1 Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C Magro-Checa
- 1 Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T W J Huizinga
- 1 Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J Hoekman
- 2 Faculty of Health Care, University of Applied Sciences, Leiden, The Netherlands
| | - A A Kaptein
- 3 Section Medical Psychology, Leiden University Medical Centre, Leiden, The Netherlands
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Magro-Checa C, Zirkzee EJ, Huizinga TW, Steup-Beekman GM. Management of Neuropsychiatric Systemic Lupus Erythematosus: Current Approaches and Future Perspectives. Drugs 2016; 76:459-83. [PMID: 26809245 PMCID: PMC4791452 DOI: 10.1007/s40265-015-0534-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is a generic definition referring to a series of neurological and psychiatric symptoms directly related to systemic lupus erythematosus (SLE). NPSLE includes heterogeneous and rare neuropsychiatric (NP) manifestations involving both the central and peripheral nervous system. Due to the lack of a gold standard, the attribution of NP symptoms to SLE represents a clinical challenge that obligates the strict exclusion of any other potential cause. In the acute setting, management of these patients does not differ from other non-SLE subjects presenting with the same NP manifestation. Afterwards, an individualized therapeutic strategy, depending on the presenting manifestation and severity of symptoms, must be started. Clinical trials in NPSLE are scarce and most of the data are extracted from case series and case reports. High-dose glucocorticoids and intravenous cyclophosphamide remain the cornerstone for patients with severe symptoms that are thought to reflect inflammation or an underlying autoimmune process. Rituximab, intravenous immunoglobulins, or plasmapheresis may be used if response is not achieved. When patients present with mild to moderate NP manifestations, or when maintenance therapy is warranted, azathioprine and mycophenolate may be considered. When symptoms are thought to reflect a thrombotic underlying process, anticoagulation and antiplatelet agents are the mainstay of therapy, especially if antiphospholipid antibodies or antiphospholipid syndrome are present. Recent trials on SLE using new biologicals, based on newly understood SLE mechanisms, have shown promising results. Based on what we currently know about its pathogenesis, it is tempting to speculate how these new therapies may affect the management of NPSLE patients. This article provides a comprehensive and critical review of the literature on the epidemiology, pathophysiology, diagnosis, and management of NPSLE. We describe the most common pharmacological treatments used in NPSLE, based on both a literature search and our expert opinion. The extent to which new drugs in the advanced development of SLE, or the blockade of new targets, may impact future treatment of NPSLE will also be discussed.
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Affiliation(s)
- César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Elisabeth J Zirkzee
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Tom W Huizinga
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Ziegelasch M, van Delft MAM, Wallin P, Skogh T, Magro-Checa C, Steup-Beekman GM, Trouw LA, Kastbom A, Sjöwall C. Antibodies against carbamylated proteins and cyclic citrullinated peptides in systemic lupus erythematosus: results from two well-defined European cohorts. Arthritis Res Ther 2016; 18:289. [PMID: 27912793 PMCID: PMC5135817 DOI: 10.1186/s13075-016-1192-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 11/22/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Articular manifestations are common in systemic lupus erythematosus (SLE) whereas erosive disease is not. Antibodies to cyclic citrullinated peptide (anti-CCP) are citrulline-dependent in rheumatoid arthritis (RA), whereas the opposite is suggested in SLE, as reactivity with cyclic arginine peptide (CAP) is typically present. Antibodies targeting carbamylated proteins (anti-CarP) may occur in anti-CCP/rheumatoid factor (RF)-negative cases long before clinical onset of RA. We analysed these antibody specificities in sera from European patients with SLE in relation to phenotypes, smoking habits and imaging data. METHODS Cases of SLE (n = 441) from Linköping, Sweden, and Leiden, the Netherlands, were classified according to American College of Rheumatology (ACR) and/or Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria. IgG anti-CCP, anti-CAP and anti-CarP were analysed by immunoassays. Radiographic data from 102 Swedish patients were available. RESULTS There were 16 Linköping (6.8%) and 11 Leiden patients (5.4%) who were anti-CCP-positive, of whom approximately one third were citrulline-dependent: 40/441 (9.1%) were anti-CarP-positive, and 33% of the anti-CarP-positive patients were identified as anti-CCP-positive. No associations were found comparing anti-CCP or anti-CarP with ACR-defined phenotypes, immunologic abnormalities or smoking habits. Radiographically confirmed erosions were found in 10 patients, and were significantly associated with anti-CCP, anti-CarP and RF. Musculoskeletal ultrasonography scores were higher in anti-CCP-positive compared to anti-CCP-negative patients. CONCLUSIONS In the hitherto largest anti-CarP study in SLE, we demonstrate that anti-CarP is more prevalent than anti-CCP and that the overlap is limited. We obtained some evidence that both autoantibodies seem to be associated with erosivity. Similar pathogenetic mechanisms to those seen in RA may be relevant in a subgroup of SLE cases with a phenotype dominated by arthritis.
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Affiliation(s)
- Michael Ziegelasch
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Myrthe A. M. van Delft
- Department of Rheumatology, Leiden University Medical Center, C1-R, LUMC, PO Box 9600, Leiden, 2300 RC The Netherlands
| | - Philip Wallin
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Thomas Skogh
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, C1-R, LUMC, PO Box 9600, Leiden, 2300 RC The Netherlands
| | - Gerda M. Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, C1-R, LUMC, PO Box 9600, Leiden, 2300 RC The Netherlands
| | - Leendert A. Trouw
- Department of Rheumatology, Leiden University Medical Center, C1-R, LUMC, PO Box 9600, Leiden, 2300 RC The Netherlands
| | - Alf Kastbom
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Rheumatology Unit, University Hospital, Linköping, SE-581 85 Sweden
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Alessi H, Dutra LA, Braga Neto P, Pedroso JL, Toso FF, Kayser C, Barsottini OGP. Neuropsychiatric Lupus in clinical practice. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:1021-1030. [DOI: 10.1590/0004-282x20160150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/11/2016] [Indexed: 12/20/2022]
Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple organs, characterized by the production of autoantibodies and the development of tissue injury. The etiology of SLE is partially known, involving multiple genetic and environmental factors. As many as 50% of patients with SLE have neurological involvement during the course of their disease. Neurological manifestations are associated with impaired quality of life, and high morbidity and mortality rates. Nineteen neuropsychiatric syndromes have been identified associated with SLE, and can be divided into central and peripheral manifestations. This article reviews major neuropsychiatric manifestations in patients with SLE and discusses their clinical features, radiological findings and treatment options.
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Affiliation(s)
| | | | - Pedro Braga Neto
- Universidade Estadual do Ceará, Brasil; Universidade Federal do Ceará, Brasil
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Magro-Checa C, Ercan E, Wolterbeek R, Emmer B, van der Wee NJ, Middelkoop HA, Kruyt ND, Ronen I, van Buchem MA, Huizinga TW, Steup-Beekman GM. Changes in White Matter Microstructure Suggest an Inflammatory Origin of Neuropsychiatric Systemic Lupus Erythematosus. Arthritis Rheumatol 2016; 68:1945-54. [DOI: 10.1002/art.39653] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 02/16/2016] [Indexed: 11/12/2022]
Affiliation(s)
| | - Ece Ercan
- C. J. Gorter Center for High Field MRI, Leiden University Medical Center; Leiden The Netherlands
| | - Ron Wolterbeek
- Leiden University Medical Center, Leiden, The Netherlands
| | - Bart Emmer
- Erasmus Medical Center; Rotterdam The Netherlands
| | - Nic J. van der Wee
- Leiden University Medical Center, and Leiden Institute for Brain and Cognition, Leiden University; Leiden The Netherlands
| | - Huub A. Middelkoop
- Leiden University Medical Center, and Leiden University; Leiden The Netherlands
| | - Nyika D. Kruyt
- Leiden University Medical Center, Leiden, The Netherlands
| | - Itamar Ronen
- C. J. Gorter Center for High Field MRI, Leiden University Medical Center; Leiden The Netherlands
| | - Mark A. van Buchem
- C. J. Gorter Center for High Field MRI, Leiden University Medical Center; Leiden The Netherlands
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39
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The diagnosis and clinical management of the neuropsychiatric manifestations of lupus. J Autoimmun 2016; 74:41-72. [PMID: 27427403 DOI: 10.1016/j.jaut.2016.06.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 06/21/2016] [Indexed: 01/03/2023]
Abstract
Neuropsychiatric (NP) involvement in Systemic Lupus Erythematosus (SLE), can be a severe and troubling manifestation of the disease that heavily impacts patient's health, quality of life and disease outcome. It is one of the most complex expressions of SLE which can affect central, peripheral and autonomous nervous system. Complex interrelated pathogenetic mechanisms, including genetic factors, vasculopathy, vascular occlusion, neuroendocrine-immune imbalance, tissue and neuronal damage mediated by autoantibodies, inflammatory mediators, blood brain barrier dysfunction and direct neuronal cell death can be all involved. About NPSLE a number of issues are still matter of debate: from classification and burden of NPSLE to attribution and diagnosis. The role of neuroimaging and new methods of investigation still remain pivotal and rapidly evolving as well as is the increasing knowledge in the pathogenesis. Overall, two main pathogenetic pathways have been recognized yielding different clinical phenotypes: a predominant ischemic-vascular one involving large and small blood vessels, mediated by aPL, immune complexes and leuko-agglutination which it is manifested with more frequent focal NP clinical pictures and a predominantly inflammatory-neurotoxic one mediated by complement activation, increased permeability of the BBB, intrathecal migration of autoantibodies, local production of immune complexes and pro-inflammatory cytokines and other inflammatory mediators usually appearing as diffuse NP manifestations. In the attempt to depict a journey throughout NPSLE from diagnosis to a reasoned therapeutic approach, classification, epidemiology, attribution, risk factors, diagnostic challenges, neuroimaging techniques and pathogenesis will be considered in this narrative review based on the most relevant and recent published data.
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40
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Magro-Checa C, Schaarenburg RA, Beaart HJL, Huizinga TWJ, Steup-Beekman GM, Trouw LA. Complement levels and anti-C1q autoantibodies in patients with neuropsychiatric systemic lupus erythematosus. Lupus 2016; 25:878-88. [DOI: 10.1177/0961203316643170] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective The objective of this paper is to analyse serum levels of anti-C1q, C1q circulating immune complexes (CIC), complement activation and complement components in systemic lupus erythematosus (SLE) patients during the first central nervous system neuropsychiatric (NP) event and to define the possible association between these results and clinical and laboratory characteristics. Methods A total of 280 patients suspected of having NP involvement due to SLE were recruited in the Leiden NPSLE-clinic. All SLE patients were classified according to the ACR 1982 revised criteria for the classification of SLE. The clinical disease activity was measured by the SLE Disease Activity Index 2000 (SLEDAI-2K) and NP diagnoses were classified according to the 1999 ACR case definitions for NPSLE. We measured in serum of all patients anti-C1q and C1q CIC levels, the activation capacity of complement (CH50 and AP50) and different complement components (C1q, C3, C4). Results In 92 patients the symptoms were attributed to SLE. NPSLE patients consisted of 63 patients with focal NPSLE and 34 patients with diffuse NPSLE. Anti-C1q antibodies were significantly higher and CH50, AP50 and C3 were significantly lower in NPSLE patients compared with SLE patients without NPSLE. This association was specially marked for diffuse NPSLE while no differences were found for focal NPSLE. After using potential predictors, decreased C4 remained significantly associated with focal NPSLE, but only when antiphospholipid antibodies (aPL) were included in the model. C3 and AP50 were independently associated with diffuse NPSLE. When SLEDAI-2K was included in the model these two associations were lost. When individual NPSLE syndromes were analysed, psychosis and cognitive dysfunction showed significantly lower values of complement activation capacity and all complement components. No significant associations were seen for other individual NPSLE syndromes. Conclusion The associations between diffuse NPSLE and anti-C1q, C3/AP50 and focal NPSLE and C4 may be explained by disease activity and the presence of aPL, respectively. The role of complement activation and complement components in lupus psychosis and cognitive dysfunction merits further research.
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Affiliation(s)
- C Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R A Schaarenburg
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - H J L Beaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - T W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - G M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - L A Trouw
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Ercan E, Magro-Checa C, Valabregue R, Branzoli F, Wood ET, Steup-Beekman GM, Webb AG, Huizinga TWJ, van Buchem MA, Ronen I. Glial and axonal changes in systemic lupus erythematosus measured with diffusion of intracellular metabolites. Brain 2016; 139:1447-57. [PMID: 26969685 DOI: 10.1093/brain/aww031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/20/2016] [Indexed: 12/21/2022] Open
Abstract
Systemic lupus erythematosus is an inflammatory autoimmune disease with multi-organ involvement. Central nervous system involvement in systemic lupus erythematosus is common and results in several neurological and psychiatric symptoms that are poorly linked to standard magnetic resonance imaging outcome. Magnetic resonance imaging methods sensitive to tissue microstructural changes, such as diffusion tensor imaging and magnetization transfer imaging, show some correlation with neuropsychiatric systemic lupus erythematosus (NPSLE) symptoms. Histological examination of NPSLE brains reveals presence of cerebral oedema, loss of neurons and myelinated axons, microglial proliferation and reactive astrocytosis, microinfacrts and diffuse ischaemic changes, all of which can affect both diffusion tensor imaging and magnetization transfer imaging in a non-specific manner. Here we investigated the underlying cell-type specific microstructural alterations in the brain of patients with systemic lupus erythematosus with and without a history of central nervous system involvement. We did so combining diffusion tensor imaging with diffusion-weighted magnetic resonance spectroscopy, a powerful tool capable of characterizing cell-specific cytomorphological changes based on diffusion of intracellular metabolites. We used a 7 T magnetic resonance imaging scanner to acquire T1-weighted images, diffusion tensor imaging datasets, and single volume diffusion-weighted magnetic resonance spectroscopy data from the anterior body of the corpus callosum of 13 patients with systemic lupus erythematosus with past NPSLE, 16 patients with systemic lupus erythematosus without past NPSLE, and 19 healthy control subjects. Group comparisons were made between patients with systemic lupus erythematosus with/without past NPSLE and healthy controls on diffusion tensor imaging metrics and on diffusion coefficients of three brain metabolites: the exclusively neuronal/axonal N-acetylaspartate, and the predominantly glial creatine + phosphocreatine and choline compounds. In patients with systemic lupus erythematosus with past NPSLE, significantly higher diffusion tensor imaging mean and radial diffusivities were accompanied by a significantly higher intracellular diffusion of total creatine (0.202 ± 0.032 μm(2)/ms, P = 0.018) and total choline (0.142 ± 0.031 μm(2)/ms, P = 0.044) compared to healthy controls (0.171 ± 0.024 μm(2)/ms, 0.124 ± 0.018 μm(2)/ms, respectively). Total N-acetylaspartate, total creatine and total choline diffusion values from all patients with systemic lupus erythematosus correlated positively with systemic lupus erythematosus disease activity index score (P = 0.033, P = 0.040, P = 0.008, respectively). Our results indicate that intracellular alterations, and in particular changes in glia, as evidenced by increase in the average diffusivities of total choline and total creatine, correlate with systemic lupus erythematosus activity. The higher diffusivity of total creatine and total choline in patients with NPSLE, as well as the positive correlation of these diffusivities with the systemic lupus erythematosus disease activity index are in line with cytomorphological changes in reactive glia, suggesting that the diffusivities of choline compounds and of total creatine are potentially unique markers for glial reactivity in response to inflammation.
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Affiliation(s)
- Ece Ercan
- C. J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cesar Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Romain Valabregue
- Institut du Cerveau et de la Moelle épinière - ICM, Centre for NeuroImaging Research - CENIR, Paris, France Sorbonne Universités, UPMC Paris 06, Inserm UMR S 1127, CNRS UMR 7225, F-75013, Paris, France
| | - Francesca Branzoli
- Institut du Cerveau et de la Moelle épinière - ICM, Centre for NeuroImaging Research - CENIR, Paris, France Sorbonne Universités, UPMC Paris 06, Inserm UMR S 1127, CNRS UMR 7225, F-75013, Paris, France
| | - Emily T Wood
- Department of Neuroscience, Johns Hopkins University, Baltimore, Maryland, USA Translational Neuroradiology Unit and 4 Neuroimmunology Clinic (NINDS), National Institutes of Health, Bethesda, Maryland, USA
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew G Webb
- C. J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Itamar Ronen
- C. J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Magro-Checa C, Zirkzee EJ, Huizinga TW, Steup-Beekman GM. Management of Neuropsychiatric Systemic Lupus Erythematosus: Current Approaches and Future Perspectives. Drugs 2016. [PMID: 26809245 DOI: 10.1007/s40265-015-0534-3"] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is a generic definition referring to a series of neurological and psychiatric symptoms directly related to systemic lupus erythematosus (SLE). NPSLE includes heterogeneous and rare neuropsychiatric (NP) manifestations involving both the central and peripheral nervous system. Due to the lack of a gold standard, the attribution of NP symptoms to SLE represents a clinical challenge that obligates the strict exclusion of any other potential cause. In the acute setting, management of these patients does not differ from other non-SLE subjects presenting with the same NP manifestation. Afterwards, an individualized therapeutic strategy, depending on the presenting manifestation and severity of symptoms, must be started. Clinical trials in NPSLE are scarce and most of the data are extracted from case series and case reports. High-dose glucocorticoids and intravenous cyclophosphamide remain the cornerstone for patients with severe symptoms that are thought to reflect inflammation or an underlying autoimmune process. Rituximab, intravenous immunoglobulins, or plasmapheresis may be used if response is not achieved. When patients present with mild to moderate NP manifestations, or when maintenance therapy is warranted, azathioprine and mycophenolate may be considered. When symptoms are thought to reflect a thrombotic underlying process, anticoagulation and antiplatelet agents are the mainstay of therapy, especially if antiphospholipid antibodies or antiphospholipid syndrome are present. Recent trials on SLE using new biologicals, based on newly understood SLE mechanisms, have shown promising results. Based on what we currently know about its pathogenesis, it is tempting to speculate how these new therapies may affect the management of NPSLE patients. This article provides a comprehensive and critical review of the literature on the epidemiology, pathophysiology, diagnosis, and management of NPSLE. We describe the most common pharmacological treatments used in NPSLE, based on both a literature search and our expert opinion. The extent to which new drugs in the advanced development of SLE, or the blockade of new targets, may impact future treatment of NPSLE will also be discussed.
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Affiliation(s)
- César Magro-Checa
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Elisabeth J Zirkzee
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Tom W Huizinga
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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A multimodal MRI approach to identify and characterize microstructural brain changes in neuropsychiatric systemic lupus erythematosus. NEUROIMAGE-CLINICAL 2015; 8:337-44. [PMID: 26106559 PMCID: PMC4474280 DOI: 10.1016/j.nicl.2015.05.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/08/2015] [Accepted: 05/13/2015] [Indexed: 01/09/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with multi-organ involvement and results in neurological and psychiatric (NP) symptoms in up to 40% of the patients. To date, the diagnosis of neuropsychiatric systemic lupus erythematosus (NPSLE) poses a challenge due to the lack of neuroradiological gold standards. In this study, we aimed to better localize and characterize normal appearing white matter (NAWM) changes in NPSLE by combining data from two quantitative MRI techniques, diffusion tensor imaging (DTI) and magnetization transfer imaging (MTI). 9 active NPSLE patients (37 ± 13 years, all females), 9 SLE patients without NP symptoms (44 ± 11 years, all females), and 14 healthy controls (HC) (40 ± 9 years, all females) were included in the study. MTI, DTI and fluid attenuated inversion recovery (FLAIR) images were collected from all subjects on a 3 T MRI scanner. Magnetization transfer ratio (MTR), mean diffusivity (MD), fractional anisotropy (FA), radial diffusivity (RD), axial diffusivity (AD) maps and white matter lesion maps based on the FLAIR images were created for each subject. MTR and DTI data were then co-analyzed using tract-based spatial statistics and a cumulative lesion map to exclude lesions. Significantly lower MTR and FA and significantly higher AD, RD and MD were found in NPSLE compared to HC in NAWM regions. The differences in DTI measures and in MTR, however, were only moderately co-localized. Additionally, significant differences in DTI measures, but not in MTR, were found between NPSLE and SLE patients, suggesting that the underlying microstructural changes detected by MD are linked to the onset of NPSLE. The co-analysis of the anatomical distribution of MTI and DTI measures can potentially improve the diagnosis of NPSLE and contribute to the understanding of the underlying microstructural damage. NAWM is investigated in NPSLE and SLE using MTI and DTI. Differences in DTI and MTR between NPSLE and HC are widespread but only moderately co-localized. Significant differences in MD between SLE and NPSLE suggest link to onset of NPSLE.
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Key Words
- ACR, American College of Rheumatology
- AD, axial diffusivity
- DTI, diffusion tensor imaging
- Diffusion tensor imaging
- FA, fractional anisotropy
- FLAIR, fluid attenuated inversion recovery
- HC, healthy controls
- MD, mean diffusivity
- MTI, magnetization transfer imaging
- MTR, magnetization transfer ratio
- Magnetic resonance imaging
- Magnetization transfer imaging
- NAWM, normal appearing white matter
- NP, neurological and psychiatric
- NPSLE, neuropsychiatric systemic lupus erythematosus
- Neuropsychiatric systemic lupus erythematosus
- Normal appearing white matter
- RD, radial diffusivity
- SLE, systemic lupus erythematosus
- Systemic lupus erythematosus
- TBSS, tract based spatial statistics
- WM, white matter
- WMH, white matter hyperintensities
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Zirkzee EJM, Magro Checa C, Sohrabian A, Steup-Beekman GM. Cluster analysis of an array of autoantibodies in neuropsychiatric systemic lupus erythematosus. J Rheumatol 2015; 41:1720-1. [PMID: 25086139 DOI: 10.3899/jrheum.140027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Elisabeth J M Zirkzee
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands;
| | - César Magro Checa
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Azita Sohrabian
- Department of Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Piga M, Peltz MT, Montaldo C, Perra D, Sanna G, Cauli A, Mathieu A. Twenty-year brain magnetic resonance imaging follow-up study in Systemic Lupus Erythematosus: Factors associated with accrual of damage and central nervous system involvement. Autoimmun Rev 2015; 14:510-6. [PMID: 25617815 DOI: 10.1016/j.autrev.2015.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
To evaluate the long-term progression of cerebral MRI abnormalities in patients with longstanding SLE, 30 patients (age 53.5 ± 11.3) underwent brain MRI at baseline (b-MRI) and after 19.4 ± 3.7 years of follow-up (fu-MRI). Two neuroradiologists visually analyzed the MRIs comparing: 1) white matter hyperintensities (WMHIs), 2) cerebral volume, and 3) parenchymal defects; these outcomes were also built in a modified MRI scoring system (mMSS) to estimate the cumulative parenchymal damage. The independent risk factors for accrual of MRI brain damage, as well as the association between MRI abnormalities and the development of new neuropsychiatric (NP) manifestations classified according to the 1999 ACR case definition were also analyzed. Twenty-three patients (76.7%) showed worsening of mMSS; 19 (63.3%) had increased number and volume of WMHIs, 8 (26.7%) had significant cerebral volume loss, and 6 (20%) showed new ischemic parenchymal lesions. Only 6 patients had normal MRI. Antimalarial agents (p=0.006; OR 0.08) were protective against worsening of WMHIs. High cumulative dose of corticosteroids (p=0.026; OR 8.8) and dyslipidemia (p=0.044; OR 10.1) were associated with increased mMSS and cerebral volume loss, respectively. Higher mMSS score at baseline was independently associated with worsening of WMHIs (p=0.001; OR 5.7) and development of new NP events (p=0.019; OR 2.0); higher load of deep WMHIs at b-MRI (p=0.018; OR 2.0) was independently associated with stroke risk. This study shows that MRI brain damage in SLE patients progresses independently from NP involvement as effect of potentially modifiable risk factors and it is associated with increased risk of new NP events.
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Affiliation(s)
- Matteo Piga
- Chair of Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Italy.
| | | | | | - Daniela Perra
- Chair of Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Italy.
| | - Giovanni Sanna
- Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, London, UK; Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK.
| | - Alberto Cauli
- Chair of Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Italy.
| | - Alessandro Mathieu
- Chair of Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Italy.
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Zardi EM, Taccone A, Marigliano B, Margiotta DP, Afeltra A. Neuropsychiatric systemic lupus erythematosus: Tools for the diagnosis. Autoimmun Rev 2014; 13:831-9. [DOI: 10.1016/j.autrev.2014.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/30/2014] [Indexed: 01/18/2023]
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47
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Sciascia S, Bertolaccini ML, Roccatello D, Khamashta MA, Sanna G. Autoantibodies involved in neuropsychiatric manifestations associated with systemic lupus erythematosus: a systematic review. J Neurol 2014; 261:1706-14. [DOI: 10.1007/s00415-014-7406-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 06/05/2014] [Accepted: 06/06/2014] [Indexed: 11/28/2022]
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48
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Zirkzee EJM, Huizinga TWJ, Bollen ELEM, Buchem MAV, Middelkoop HAM, Wee NJAVD, Cessie SL, Steup-Beekman GM. Mortality in neuropsychiatric systemic lupus erythematosus (NPSLE). Lupus 2013; 23:31-8. [DOI: 10.1177/0961203313512540] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The standardized mortality ratio (SMR) for systemic lupus erythematosus (SLE) is three; SMR increases to six in case of renal involvement. Up to now data on survival in case of neuropsychiatric involvement in SLE (NPSLE) have been scarce, therefore we calculated an SMR for NPSLE. Furthermore, we identified characteristics that influenced survival by Cox regression analyses. All patients suspected of NPSLE in our center since 1989 were evaluated and included in this study when a diagnosis of primary NPSLE could be established. Patient’s life/death status was tracked using the civic registries. Thirty-two (19%) of the 169 included NPSLE patients died within a median follow-up period of six years (range 0.5–24 years). This resulted in a significantly increased mortality rate compared to the general population: SMR 9.5 (95% CI 6.7–13.5). Hazard ratios (HRs) were highest in patients with acute confusional state (HR 3.4) and older age at diagnosis of NPSLE (HR 1.1). A decreased mortality risk was seen with the prescription of antiplatelet therapy (HR 0.22). The time period in which NPSLE was diagnosed did not significantly influence survival. Most frequent causes of death were infection and NPSLE itself.
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Affiliation(s)
- EJM Zirkzee
- Department of Rheumatology, Leiden University Medical Center, Netherlands
| | - TWJ Huizinga
- Department of Rheumatology, Leiden University Medical Center, Netherlands
| | - ELEM Bollen
- Department of Neurology, Leiden University Medical Center, Netherlands
| | - MA van Buchem
- Department of Radiology, Leiden University Medical Center, Netherlands
| | - HAM Middelkoop
- Department of Neurology and Clinical Neuropsychology, Leiden University Medical Center, Netherlands
- Institute of Psychology, Clinical Neuropsychology Unit, University of Leiden, Netherlands
| | - NJA van der Wee
- Department of Psychiatry, Leiden University Medical Center, Netherlands
- Leiden Institute for Brain and Cognition, University of Leiden, Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology and Medical Statistics, Leiden University Medical Center, Netherlands
| | - GM Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center, Netherlands
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Neuropsychiatric manifestations in systemic lupus erythematosus: physiopathogenic and therapeutic basis. ACTA ACUST UNITED AC 2013; 9:331-3. [PMID: 23746788 DOI: 10.1016/j.reuma.2013.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 02/11/2013] [Accepted: 02/19/2013] [Indexed: 01/17/2023]
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50
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Zirkzee E, Steup-beekman G, Huizinga T. Dr. Zirkzee, et al reply. J Rheumatol 2013; 40:204. [PMID: 23487860 DOI: 10.3899/jrheum.121345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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