Hematological Manifestations of SLE at Initial Presentation: Is It Underestimated?

Platelet ındices as potential biomarkers of perinatal outcomes in women with SLE during pregnancy

AIM

This study aimed to assess the platelet parameters and their prognostic value for perinatal outcomes in pregnant women with systemic lupus erythematosus (SLE).

METHODS

This retrospective study involved 180 participants, 90 pregnant women with SLE and 90 healthy pregnant women. Clinical and demographic variables including routine first-trimester neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and platelet parameters such as platelet distribution width (PDW), mean platelet volume (MPV), plateletcrit (PCT) were compared between the groups. The perinatal outcomes of the whole study group were also compared.

RESULTS

SLE patients had lower leukocyte (p = 0.001), lymphocyte (p = 0.001) and platelet counts (p = 0.018), higher PDW (p = 0.002), MPV (p = 0.001), NLR (p = 0.008) and PLR (p = 0.015) and lower PCT (p = 0.015) than the control group. The groups had no significant difference in hemoglobin levels (p = 0.936). SLE patients had higher rates of cesarean section (p = 0.002), small for gestational age (SGA) (p = 0.019) and stillbirth (p = 0.017) and lower birth weight (p = 0.001) than the control group. PCT was a significant predictor of stillbirth with a cut-off value of 0.21, sensitivity of 64.3% and specificity of 83.3% (AUC: 0.843, p < 0.001).

CONCLUSION

Pregnant women with SLE have altered platelet parameters and increased inflammatory markers compared to healthy pregnant women. PCT is a simple and useful marker for predicting stillbirth risk in SLE pregnancies.

Association of signal transducer and activator of transcription 4 gene (restriction site7582694) single nucleotide polymorphism with systemic lupus erythematosus

Background — Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease characterized by production of autoantibodies and deposition within various organs. The incidence of SLE averages 5 cases per 100,000 population. Various genome wide studies have shown association of STAT4 (signal transducer and activator of transcription 4) gene with SLE and lupus nephritis (LN). Therefore, this study was designed to determine single nucleotide polymorphism (SNP) in STAT4 (rs7582694) in local SLE, LN patients and healthy controls. Objective — To determine the frequency of STAT4 (rs7582694) gene polymorphism in systemic lupus erythematosus, lupus nephritis patients and healthy controls. Methods — It was a case-control study. Eighty samples were recruited for each of two study groups. Deoxyribonucleic acid (DNA) extraction was carried out using standard phenol chloroform method. Further, samples were processed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) conventional technique and genotypes were determined. Polymorphism analysis and allele frequencies were compared between groups using the chi-square test. Project was approved by the Ethical Review Board at the University of Health Sciences, Lahore, Pakistan. Results — Females were more inclined towards developing SLE. The study unveiled that SNP in STAT 4 gene (rs7582694) was associated with SLE patients in Pakistani population which indicates that this may play a role in susceptibility to SLE. Moreover, we infer that genetic variations within STAT4 (rs7582694) predispose patients to lupus nephritis. It was also evident that GG and GC genotypes were more susceptible of further transforming into SLE and LN. Conclusion: The findings of this study may contribute to a better understanding of underlying etiological and prognostic factors regarding SLE and LN.

A case of patient with renal lupus with an initial presentation of hemolytic uremic syndrome triggered by streptococcal infection

Systemic lupus erythematosus (SLE) is a systemic disease that is presented in a myriad of ways. Renal involvement is common in SLE and usually presents clinically as glomerulonephritis. We describe patients with SLE presented initially with hemolytic uremic syndrome which is a distinctive initial presentation.

Anaemia in Systemic Lupus Erythematosus Based on Iron Studies and Soluble Transferrin Receptor Levels

INTRODUCTION

Haematological alterations such as anaemia, neutropenia and thrombocytopenia are frequent in Systemic Lupus Erythematosus (SLE). Ferritin being an acute phase reactant can be falsely elevated in lupus cases.

AIM

To evaluate the haematological alterations and to re-categorise the types of anemia by soluble transferrin receptor levels in diagnosed cases of SLE.

MATERIALS AND METHODS

A sample of 30 newly diagnosed ANA positive SLE patients was taken. Complete blood counts, ESR, reticulocyte count, coagulation studies, diluted Russel Viper Venom Test (dRVVT), mixing studies, serological tests, high sensitivity CRP along with iron profile, transferrin saturation, soluble transferrin receptor (sol TFR) levels, anti-beta2 glycoprotein1, direct and indirect Coomb's test were estimated in cases diagnosed as SLE. Clinical symptoms were co-related with and Systemic Lupus Erythaematosus Disease Activity Index (SLEDAI) was estimated.

RESULTS

Anaemia was the most prevalent haematological alteration followed by thrombocytopenia. Further sub typing of anaemia was done by serum ferritin levels and using sol TFR assays. Ferritin is an acute phase reactant; it underestimated iron deficiency in patients of SLE. When sol TFR was used; patients with pure Anaemia of Chronic Disease (ACD) reduced from 68% to 26%, those with pure IDA reduced from 32% to 16% and a group with co-existing IDA & ACD (58%) was defined {Agreement=53%, p=0.09} by sol TFR which co-related with clinical response to Iron therapy in these patients. CRP was significantly raised in association with disease activity. Fever (p<0.0001), arthritis (p<0.03) were significantly related and CRP was elevated (p<0.04) in cases with high SLEDAI (severe flare).

CONCLUSION

Thus, in SLE, anaemia is the most frequent hematological alteration; iron deficiencies supercede in contrast to ACD and further autoimmune haemolytic anaemia. Sol TFR emerged as a better parameter to detect iron deficiency in patients of non- haemolytic anaemia in contrast to iron profile and ferritin levels.

Kozhikode criteria for diagnosing systemic lupus erythematosus as a hematological disorder

Systemic lupus erythematosus (SLE) is an autoimmune disease in which cells and tissues undergo damage mediated by tissue-binding autoantibodies. At its onset, it may involve one organ alone or more than one organ simultaneously; over a time, additional manifestations due to the involvement of other organs may occur. Our observations have confirmed that hematological manifestations are the commonest initial presentation in SLE. The criteria used till 2012 was the American College of Rheumatology (ACR) criteria, which is only a classification criterion and not really for diagnosis; if we rely on ACR criteria, the diagnosis is often delayed. Time required for satisfying all four of the eleven criteria is variable and prolonged. Moreover, hematological manifestations are underrepresented in the ACR criteria. Based on the clinical observations made on patients evaluated in a tertiary center in North Kerala, an alternate diagnostic criterion named the Kozhikode criteria was proposed, especially for the diagnosis of SLE when it presents with hematological manifestations alone. The present study was an attempt to validate the same and to look for any association of diet and lifestyle with the disease.