Factors predictive of serious infections over time in systemic lupus erythematosus patients: data from a multi-ethnic, multi-national, Latin American lupus cohort

Aim

The aim of this study was to identify factors predictive of serious infections over time in patients with systemic lupus erythematosus (SLE).

Methods

A multi-ethnic, multi-national Latin American SLE cohort was studied. Serious infection was defined as one that required hospitalization, occurred during a hospitalization or led to death. Potential predictors included were sociodemographic factors, clinical manifestations (per organ involved, lymphopenia and leukopenia, independently) and previous infections at baseline. Disease activity (SLEDAI), damage (SLICC/ACR Damage Index), non-serious infections, glucocorticoids, antimalarials (users and non-users), and immunosuppressive drugs use; the last six variables were examined as time-dependent covariates. Cox regression models were used to evaluate the predictors of serious infections using a backward elimination procedure. Univariable and multivariable analyses were performed.

Results

Of the 1243 patients included, 1116 (89.8%) were female. The median (interquartile range) age at diagnosis and follow-up time were 27 (20–37) years and 47.8 (17.9–68.6) months, respectively. The incidence rate of serious infections was 3.8 cases per 100 person-years. Antimalarial use (hazard ratio: 0.69; 95% confidence interval (CI): 0.48–0.99; p = 0.0440) was protective, while doses of prednisone >15 and ≤60 mg/day (hazard ratio: 4.18; 95 %CI: 1.69–10.31; p = 0.0019) and >60 mg/day (hazard ratio: 4.71; 95% CI: 1.35–16.49; p = 0.0153), use of methylprednisolone pulses (hazard ratio: 1.53; 95% CI: 1.10–2.13; p = 0.0124), increase in disease activity (hazard ratio: 1.03; 95% CI: 1.01–1.04; p = 0.0016) and damage accrual (hazard ratio: 1.22; 95% CI: 1.11–1.34; p < 0.0001) were predictive factors of serious infections.

Conclusions

Over time, prednisone doses higher than 15 mg/day, use of methylprednisolone pulses, increase in disease activity and damage accrual were predictive of infections, whereas antimalarial use was protective against them in SLE patients.

Predictive factors of flares in systemic lupus erythematosus patients: data from a multiethnic Latin American cohort

Purpose The purpose of this paper is to determine the factors predictive of flares in systemic lupus erythematosus (SLE) patients. Methods A case-control study nested within the Grupo Latino Americano De Estudio de Lupus (GLADEL) cohort was conducted. Flare was defined as an increase ≥4 points in the SLEDAI. Cases were defined as patients with at least one flare. Controls were selected by matching cases by length of follow-up. Demographic and clinical manifestations were systematically recorded by a common protocol. Glucocorticoid use was recorded as average daily dose of prednisone and antimalarial use as percentage of time on antimalarial and categorized as never (0%), rarely (>0-25%), occasionally (>25%-50%), commonly (˃50%-75%) and frequently (˃75%). Immunosuppressive drugs were recorded as used or not used. The association between demographic, clinical manifestations, therapy and flares was examined using univariable and multivariable conditional logistic regression models. Results A total of 465 cases and controls were included. Mean age at diagnosis among cases and controls was 27.5 vs 29.9 years, p = 0.003; gender and ethnic distributions were comparable among both groups and so was the baseline SLEDAI. Independent factors protective of flares identified by multivariable analysis were older age at diagnosis (OR = 0.929 per every five years, 95% CI 0.869-0.975; p = 0.004) and antimalarial use (frequently vs never, OR = 0.722, 95% CI 0.522-0.998; p = 0.049) whereas azathioprine use (OR = 1.820, 95% CI 1.309-2.531; p < 0.001) and SLEDAI post-baseline were predictive of them (OR = 1.034, 95% CI 1.005-1.064; p = 0.022). Conclusions In this large, longitudinal Latin American cohort, older age at diagnosis and more frequent antimalarial use were protective whereas azathioprine use and higher disease activity were predictive of flares.

Early discoid lupus erythematosus protects against renal disease in patients with systemic lupus erythematosus: longitudinal data from a large Latin American cohort

Objectives

The objective of this study was to examine whether early discoid lupus erythematosus (DLE) would be a protective factor for further lupus nephritis in patients with systemic lupus erythematosus (SLE).

Methods

We studied SLE patients from GLADEL, an inception longitudinal cohort from nine Latin American countries. The main predictor was DLE onset, which was defined as physician-documented DLE at SLE diagnosis. The outcome was time from the diagnosis of SLE to new lupus nephritis. Univariate and multivariate survival analyses were conducted to examine the association of DLE onset with time to lupus nephritis.

Results

Among 845 GLADEL patients, 204 (24.1%) developed lupus nephritis after SLE diagnosis. Of them, 10 (4.9%) had DLE onset, compared to 83 (12.9%) in the group of 641 patients that remained free of lupus nephritis (hazard ratio 0.39; P = 0.0033). The cumulative proportion of lupus nephritis at 1 and 5 years since SLE diagnosis was 6% and 14%, respectively, in the DLE onset group, compared to 14% and 29% in those without DLE ( P = 0.0023). DLE onset was independently associated with a lower risk of lupus nephritis, after controlling for sociodemographic factors and disease severity at diagnosis (hazard ratio 0.38; 95% confidence interval 0.20–0.71).

Conclusions

Our data indicate that DLE onset reduces the risk of further lupus nephritis in patients with SLE, independently of other factors such as age, ethnicity, disease activity, and organ damage. These findings have relevant prognosis implications for SLE patients and their clinicians. Further studies are warranted to unravel the biological and environmental pathways associated with the protective role of DLE against renal disease in patients with SLE.

Impact of hypertension and hyperhomocysteinemia on arterial thrombosis in primary antiphospholipid syndrome

The aim of this study was to evaluate traditional risk factors for coronary artery disease (CAD), homocysteine, anti-oxidized low-density lipoprotein (anti-oxLDL), anti-lipoprotein lipase (anti-LPL) and endothelin-1 (ET-1) in patients with primary anti-phospholipid syndrome (APS), furthermore verify possible association among these variables and arterial thrombosis. Thirty-eight women with primary APS and 30 age-and-sex-matched controls were evaluated. Patients presented higher-LDL and triglycerides levels and lower-HDL levels than controls. Anti-LPL antibodies were not detected in both groups. The mean number of risk factors was higher in patients than in controls ( P = 0.030). Anti-oxLDL antibodies, homocysteine and ET-1 mean levels were similar between groups, but abnormal homocysteine levels were found only among primary APS patients ( P = 0.031). Hypertension and the presence of at least one risk factor for CAD were more prevalent in patients with arterial involvement than those without. Homocysteine levels and mean number of risk factors for CAD were significantly higher in patients with arterial thrombosis than controls. In a multivariate analysis hypertension was the only independently associated with arterial thrombosis (OR 14.8, 95% CI = 2.1—100.0, P = 0.006). This study showed that in primary APS patients other risk factors besides anti-phospholipid antibodies contribute for the occurrence of arterial events and the most important factor was hypertension. Lupus (2007) 16, 782—787.

Long-term persistence of anti-β2 glycoprotein I in treated leprosy patients

β2 glycoprotein I (β2GPI) is a phospholipid binding protein that plays an important role in endothelial stability, blood coagulation, clearance of apoptotic debris and other physiologic processes. Anti-β2GPI antibodies occur in normal individuals and transiently during the course of infections, but are also associated with thrombotic events in autoimmune disease: the antiphospholipid syndrome (APS). A total of 31 out of 37 treated leprosy patients previously found to present high titers of IgM anti-β2GPI and/or anticardiolipin antibodies (aCL) remained positive for IgM antiphospholipid antibodies (aPL), and exhibited high titers of anti-β2GPI. The 37 patients were part of the 77 aPL-positive patients from a previous study that evaluated 158 leprosy patients. The median time elapsed between the first and second sample was 66 months. None of the 37 patients had any thrombotic event and 24 had a reactional state and were still requiring the use of prednisone, thalidomide or both. None of them fulfilled World Health Organization criteria for leprosy recurrence.

The effect of acute physical exercise on cytokine levels in patients with systemic lupus erythematosus

Background

Acute exercise increases IL-6, IL-10 and TNF-α levels in healthy subjects. There is no study evaluating the effect of exercise on cytokines level in systemic lupus erythematosus (SLE) patients.

Objective

Our aim was to assess IL-10, IL-6 and TNF-α levels at baseline and after acute physical exercise in patients with SLE.

Methods

In total, 27 female SLE patients and 30 healthy controls were evaluated. Serum levels of IL-10, IL-6 and TNF-α at baseline and soon after the ergospirometric test were measured by ELISA test. Student's t-tests and Mann–Whitney test were used for intra- and inter-group comparisons; p values <0.05 were considered significant.

Results

Patients with SLE presented worse ergospirometric parameters compared with controls: VO2max (25.78 ± 5.51 vs. 32.74 ± 5.85 ml/kg/min, p < 0.001); maximum heart rate (174.18 ± 12.36 vs. 185.15 ± 2.07 bpm, p = 0.001); maximum ventilation (65.51 ± 15.68 vs. 80.48 ± 18.98 l/min, p = 0.001) and maximum speed (7.70 ± 1.24 vs. 9.40 ± 1.22 km/h, p < 0.001). At baseline, SLE patients presented higher levels of IL-6 (2.38 ± 1.70 vs. 1.71 ± 0.29 pg/ml, p = 0.035) and IL-10 (1.09 ± 1.55 vs. 0.30 ± 0.11 pg/ml, p = 0.037) than controls. Acute exercise in controls increased IL-6 level (1.71 ± 0.29 vs. 2.01 ± 0.27 pg/ml, p = 0.003) without change in IL-10 and TNF-α levels. However, no significant change in cytokine levels was observed in SLE patients after acute exercise.

Conclusion

This is the first study evaluating the effect of acute exercise on cytokine levels in patients with SLE. In contrast to healthy controls, acute physical exercise did not increase the levels of IL-6 in patients with SLE, and seems to be safe in those patients with inactive or mild active disease.

Oral microbial colonization in patients with systemic lupus erythematous: correlation with treatment and disease activity

Treating patients with systemic lupus erythematosus (SLE) with steroids and immunosuppressive drugs may interfere in the presence of potentially opportunistic microorganisms in the oral cavity. The aim of this study was to evaluate the presence of Candida spp., Staphylococcus spp., Enterobacteria and Pseudomonas spp. in the oral cavity of SLE patients, compared with healthy controls. A group of 40 patients who had received therapy for at least 60 days was selected (19-53 years). For the control group, 40 healthy individuals matched for age, gender and use of partial prosthesis were selected. Oral rinse samples were collected and plated on specific culture media. After incubation, the number of colony forming units (CFU) was obtained and the isolates were identified at species level. Microbial counts were compared between SLE and control by analysis of variance (ANOVA) and Mann-Whitney (p < 0.05 significant). Microorganism counts in patients with and without immunosuppressive drugs, as well with active and inactive disease (according to SLEDAI score) were also compared. No significant differences in CFU/mL between SLE and control patients were observed (yeasts, p = 0.55; Staphylococci, p = 0.24; Enterobacteria/Pseudomonas spp., p = 0.26). No differences in microbial counts were observed regarding clinical parameters tested. The most frequent species isolated in the SLE group were Candida albicans, Staphylococcus epidermidis and Klebsiella oxytoca. In conclusion, no differences in frequency and microorganism levels were found between SLE patients and healthy individuals.

Short-term effect of leflunomide in patients with Takayasu arteritis: an observational study

OBJECTIVES

To evaluate the efficacy of leflunomide in controlling disease activity in patients with Takayasu arteritis (TA) refractory or intolerant to conventional treatment.

METHODS

We conducted a prospective open-label study of 15 TA patients (mean age 36.2 years) with active disease based on clinical assessment, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and magnetic resonance angiography (MRA). Patients received leflunomide 20 mg/day for at least 6 months and were followed up for a mean of 9.1 months. Adverse events attributable to leflunomide were recorded.

RESULTS

At baseline, 14 TA patients had active disease despite therapy with corticosteroids and immunosuppressive agents, while one patient had intolerance to current treatment. In the follow-up visit, we found a significant decrease in the frequency of patients with active TA (93% vs. 20%, p = 0.002), in the mean daily dose of prednisone (34.2 vs. 13.9 mg, p < 0.001) and in the median values of ESR (29.0 vs. 27.0 mm/h, p = 0.012) and CRP (10.3 vs. 5.3 mg/L, p = 0.012). Two patients (13.3%) developed new angiographic lesions in the follow-up MRA. Three patients (20%) experienced mild adverse events during the study and none discontinued therapy.

CONCLUSIONS

This is the first open-label study to demonstrate improvement in disease activity and acute phase reactants with 20 mg/day of leflunomide in TA patients who were refractory or intolerant to conventional therapy with corticosteroids and immunosuppressive agents. Leflunomide was safe and a steroid-sparing effect was observed. A double-blind controlled study is desirable to confirm this finding.

Anti-β2-glycoprotein I antibodies are highly prevalent in a large number of Brazilian leprosy patients

OBJECTIVES

To determine the prevalence of anticardiolipin (aCL) and anti-β2-glycoprotein I (anti-β2GPI) antibodies in leprosy patients, during and after specific multidrug therapy (MDT), and to evaluate a possible association between these antibodies and some clinical characteristics of leprosy, including clinical forms, reactional episodes and treatment.

METHODS

The study included 158 leprosy patients, 129 gender-and-age matched healthy individuals, and 38 women with primary antiphospholipid syndrome (APS). Clinical and demographic characteristic of leprosy patients were collected, and serum samples, obtained from all participants, were kept frozen at - 20°C. Antibodies were measured either by an in house-developed ELISA (aCL) or by a commercial ELISA (anti-β2GPI).

RESULTS AND CONCLUSIONS

Increased levels of aCL and anti-β2GPI antibodies were found in leprosy patients and in the APS group, however, in contrast to APS, the predominant isotype in leprosy was IgM. The frequency of aCL and anti-β2GPI antibodies was significantly higher in leprosy patients than in healthy individuals (15.8% vs. 3.1%; p>0.01; 46.2% vs. 9.4%, p>0.01), respectively. The lepromatous form predominated among aCL positive leprosy patients (p>0.01). There was no difference in aCL and anti-β2GPI positivity between leprosy patients taking MDT and those completed MDT as cured. Furthermore the duration of discharged period (period between discharge from MDT and the realization of the study) had no effect on anti-β2GPI positivity, and a slight increase in aCL positivity was observed in patients with longer follow up periods (p=0.04), suggesting that the presence of antiphospholipid antibodies (aPL) was not a transient phenomenon. Although aPL in leprosy were frequent and β2GPI-dependent as those found in APS, IgM was the predominant isotype, and there was no association with thrombosis or other APS manifestations.

Trends in systemic lupus erythematosus mortality rates in the state of Sao Paulo, Brazil from 1985 to 2004

OBJECTIVES

To estimate mortality rates and mortality trends from SLE in the state of São Paulo, Brazil.

MATERIAL AND METHODS

The official data bank was used to study all deaths occurred from 1985 to 2004 in which SLE was mentioned as the underlying cause of death. Besides the overall mortality rate, the annual gender- and age-specific mortality rates were estimated for each calendar year by age bracket (0-19 years, 20-39 years, 40-59 years and over 60 years) and for the sub-periods 1985-1995 (first) and 1996-2004 (second), by decades. Chi-square test was used to compare the mortality rates between the two periods, as well the mortality rates according to educational level considering years of study. Pearson correlation coefficient test was used to analyse mortality trends. The crude rates were adjusted for age by the direct method, using the standard Brazilian population in 2000.

RESULTS

A total of 2,601 deaths (90% female) attributed to SLE were analysed. The mean age at death was significantly higher in the second than in the first sub-period (36.6+/-15.6 years vs. 33.9+/-14.0 years; p<0.001). The overall adjusted mortality rate was 3.8 deaths/million habitants/year for the entire period and 3.4 deaths/million inhabitants/year for the first and 4.0 deaths/million inhabitants/year for the second sub-period (p<0.001). In each calendar year, the mortality rate was significantly lower for the better educated group. Throughout the period, there was a significant increase in mortality rates only among women over 40.

CONCLUSIONS

SLE patients living in the state of São Paulo still die at younger ages than those living in developed countries. Our data do not support the theory that there was an improvement in the SLE mortality rate in the last 20 years in the state of Sao Paulo. Socio-economic factors, such as the difficulty to get medical care and adequate treatment, may be the main factors to explain the worst prognosis for our patients.

Atorvastatin therapy reduces interferon-regulated chemokine CXCL9 plasma levels in patients with systemic lupus erythematosus

A recent study showed transcriptional levels of interferon-inducible chemokines in peripheral blood cells were associated with disease activity and organ damage in systemic lupus erythematosus, and may be useful in monitoring disease activity and prognosis. Our objective was to evaluate the capacity of atorvastatin to reduce plasma levels of interferon-regulated chemokines (CCL2, CCL3 and CXCL9) and to study the correlation between these chemokines and disease activity in patients with systemic lupus erythematosus. Eighty-eight female patients with systemic lupus erythematosus were divided into two groups: 64 receiving 20 mg/day of atorvastatin (intervention group) and 24 without atorvastatin (control group). All patients were followed for 8 weeks. At baseline and after 8 weeks laboratory tests were performed for all patients. Plasma levels of chemokines were measured by ELISA using commercial kits (DuoSet, R&D Systems, Minneapolis, USA). In a univariate analysis we found correlation between CCL2, CCL3 and CXCL9 plasma levels and SLEDAI score. In the intervention group we observed a significant decrease in CXCL9 plasma levels comparing baseline and levels at the end of the study (p = 0.04); however, no differences were observed regarding CCL2 or CCL3 plasma levels in this study. No significant difference was observed in the plasma levels of these chemokines in the control group. We conclude that treatment with atorvastatin was associated with a significant decrease in the plasma levels of CXCL9 in patients with systemic lupus erythematosus. As the plasma levels of CXCL9 correlated with the SLEDAI score, we ask whether reducing levels of this chemokine could help to control systemic lupus erythematosus activity.

Vitamin D deficiency in patients with active systemic lupus erythematosus

We investigated the effects of disease activity on bone metabolism in 36 patients with systemic lupus erythematosus (SLE). Changes in bone remodeling were not explained by corticosteroid use. A high prevalence of 25OHD deficiency in SLE patients indicates the need for vitamin D replacement, mainly during high disease activity periods.

INTRODUCTION

We investigated the effects of SLE disease activity on bone metabolism, their relation to inflammatory cytokines and vitamin D levels.

METHODS

We performed a cross-sectional analysis of 36 SLE patients classified according to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) in high activity (group I: 12 patients, mean age 29.6 years) or in minimal activity (group II: 24 patients, mean age 30.0 years), and compared them to normal controls (group III: 26 women, 32.8 years). Serum calcium, phosphorus, parathyroid and sex hormones, bone remodeling markers, interleukin (IL)-6, soluble IL-6 receptor (sIL-6R), IL-1, tumor necrosis factor-alpha (TNF), 25-hydroxivitamin D (25OHD), and 1,25-dihydroxyvitamin D3 were measured, plus bone mineral density.

RESULTS

All cytokines were significantly higher in SLE groups; IL-6 could differentiate SLE patients from controls. In group I, 25OHD levels were lower (P < 0.05), which was related to the SLEDAI (R = -0.65, P < 0.001). In multiple regression analysis, the 25OHD level was associated with SLEDAI, osteocalcin and bone-specific alkaline phosphatase. The SLEDAI score was positively correlated with all measured cytokines and especially TNF (R = 0.75, P < 0.001).

CONCLUSIONS

SLE patients demonstrated changes in bone remodeling strongly related to disease activity. A high prevalence of 25OHD deficiency was observed in SLE patients, indicating the need for vitamin D replacement.

Atorvastatin therapy improves endothelial-dependent vasodilation in patients with systemic lupus erythematosus: an 8 weeks controlled trial

INTRODUCTION

Patients with systemic lupus erythematosus (SLE) have recognized reduction in endothelium-dependent vasodilation. Evidence demonstrates that statins are able to improve endothelial function independently on their hypolipemic action.

OBJECTIVES

To evaluate the efficacy of atorvastatin in improving vasodilation in SLE patients with and without conventional risk factors for coronary heart disease (CHD).

PATIENTS AND METHODS

Sixty-four SLE women, mean age 31 +/- 8 yrs, received atorvastatin 20 mg/day during 8 weeks. Thirty-one patients in this intervention group did not have conventional risk factors for CHD, while 33 others had hypertension, dyslipidaemia and/or obesity. Twenty-four SLE control patients, mean age 34 +/- 7.5 yrs, not receiving atorvastatin were followed during the same time period. High-resolution ultrasound was used to measure brachial artery diameter in resting conditions, during reactive hyperaemia and after sub-lingual glyceryl trinitrate (GTN). Measurements were performed at baseline and at the end of the study (8 weeks).

RESULTS

Atorvastatin was associated with a significant increase in flow-mediated dilation (FMD) [3.8 (2.8-7.9%) vs 6.9 (4.2-10.7%), P < 0.001] while GTN-mediated dilation (GTND) was unaffected [20.9 (16.6-26.1%) vs 20.1(16.6-25.4%), P = 0.514]. FMD increase was observed in patients with conventional risk factors [4.1 (3.1-8.7%) vs 6.5 (4-10%), P = 0.046] and also for those without conventional risk factors for CHD [3.6 (2.6-7.3%) vs 7.1 (4.5-10.9%), P = 0.001]. Resting brachial artery diameter also increased significantly in patients receiving atorvastatin (2.79 +/- 0.30 mm vs 2.92 +/- 0.40 mm, P < 0.001). No significant difference in artery diameter and FMD was seen in control patients at the end of the study. When compared to the control patients, atorvastatin treatment was associated with significant increase in resting diameter (+0.13 +/- 0.1 mm vs -0.02 +/- 0.07 mm, P < 0.001) and FMD (+1.9 +/- 3.9% vs -0.3 +/- 1.8%, P = 0.009).

CONCLUSION

Our results demonstrate that an 8-week 20 mg/day atorvastatin series improved endothelium-dependent vasodilation in SLE patients independently on the presence of conventional risk factors for atherosclerotic disease.

High prevalence of vertebral deformity in premenopausal systemic lupus erythematosus patients

In this paper we searched for vertebral deformities in a group of 70 premenopausal systemic lupus erythematosus (SLE) patients (31.8 +/- 8.1 years old) and compared them to a matched control group of 22 healthy women (32.0 +/- 8.9 years old). Patients and controls performed spine X-ray (XR) morphometry and lumbar spine and femoral neck bone mineral density (BMD). Clinical data was obtained by a questionnaire and charts review. Thoracic or lumbar spine fracture was observed in 15 (21.4%) SLE patients, while no deformities were found in the control group (P = 0.018). BMD was not different amongst SLE patients and controls and between SLE patients with or without deformities. Although BMD could not predict what patient have deformity, seven patients (46.6%) with deformity had a lumbar spine or femoral neck Z-score less than - 1 SD [median = -0.59 (-3.72 to +0.88) and -0.20 (-4.05 to + 1.87)] respectively. In addition, we found a negative correlation between number of fracture per patient and lumbar spine and femoral neck BMD (R = 0.58, P = 0.04 and R = 0.84, P = <0.0001 respectively). No significant correlation was found between number of deformities and clinical data. This is the first study to search for vertebral deformities in SLE patients and to demonstrate a high prevalence of deformities in a relative young SLE population. These findings bring up the necessity to look for spine deformities in this group of women regardless the BMD.

Myocardial perfusion scintigraphy and coronary disease risk factors in systemic lupus erythematosus

OBJECTIVE

To evaluate the prevalence of myocardial perfusion abnormalities and the possible association between myocardial perfusion defects and traditional coronary artery disease (CAD) risk factors as well as systemic lupus erythematosus (SLE) related risk factors.

PATIENTS AND METHODS

Female patients with SLE, disease duration >5 years, age 18-55 years, who had used steroids for at least one year were enrolled. Traditional CAD risk factors evaluated were arterial hypertension, diabetes mellitus, dyslipidaemia, postmenopausal status, smoking, obesity, and premature family CAD profile. Myocardial perfusion scintigraphy was evaluated by single photon emission computed tomography with technetium 99m-sestamibi at rest and after dipyridamole induced stress.

RESULTS

Eight two female patients with SLE without angina pectoris with mean (SD) age 37 (10) years, disease duration 127 (57) months, SLE Disease Activity Index (SLEDAI) score 6 (5), and SLICC/ACR-DI score 2 (2) were evaluated. Myocardial perfusion abnormalities were found in 23 patients (28%). The mean (SD) number of CAD risk factors was 2.2 (1.6). There was a significant positive correlation between age and number of CAD risk factors. Lower high density lipoprotein (HDL) cholesterol level showed a significant association with abnormal scintigraphy. Logistic regression analysis showed that lower HDL cholesterol level and diabetes mellitus were associated with myocardial perfusion abnormalities. Current vasculitis was also associated with abnormal scintigraphy.

CONCLUSIONS

Lower HDL cholesterol level and diabetes mellitus have a significant influence on abnormal myocardial perfusion results found in asymptomatic patients with SLE. Current vasculitis was associated with abnormal myocardial scintigraphy. These data suggest that abnormal myocardial scintigraphy may be related to subclinical atherosclerosis.

Coronary artery angiography in systemic lupus erythematosus patients with abnormal myocardial perfusion scintigraphy

OBJECTIVE

According to published studies, 16-82% of systemic lupus erythematosus (SLE) patients have abnormal findings on myocardial perfusion tests, but it has not been established whether these patients also have abnormal findings on coronary angiography. The aim of this study was to evaluate the frequency of abnormal findings on coronary angiography in SLE patients in whom myocardial perfusion scintigraphy revealed abnormalities.

METHODS

Ninety female SLE patients (ages 20-55 years, disease duration >5 years, and current or previous steroid treatment for >/=1 year) underwent myocardial perfusion scintigraphy with single-photon-emission computed tomography using (99m)Tc-sestamibi. Images were taken while the patient was at rest and after dipyridamole-induced stress. Myocardial perfusion defects were identified in 30 patients (33%). Twenty-one of these patients (mean +/- SD age 42 +/- 9; mean +/- SD disease duration 132 +/- 66 months) agreed to undergo coronary angiography.

RESULTS

Atherosclerotic plaques were identified by angiography in 8 of the 21 patients (38%). The majority of coronary abnormalities were localized in the anterior descending artery. The mean +/- SD number of risk factors for coronary artery disease (CAD) was significantly higher in the subgroup with (4.5 +/- 0.8) compared with the subgroup without (2.5 +/- 1.9) abnormal angiographic findings (P = 0.006). Arterial hypertension and postmenopause status were significantly associated with abnormal angiographic findings. Of the patients with at least 4 risk factors for CAD, coronary stenosis was present in 67% (P = 0.005). The number of American College of Rheumatology (ACR) criteria for SLE and scores on the SLE Disease Activity Index and the Systemic Lupus International Collaborating Clinics/ACR damage index were also higher in the subgroup with coronary stenosis (P < 0.05).

CONCLUSION

This is the first study to examine coronary angiography results in SLE patients with abnormal findings on myocardial scintigraphy. Our data suggest that myocardial scintigraphy can be used to screen SLE patients and that all patients with abnormal findings plus at least 4 risk factors for CAD should undergo coronary angiography.

Estimating the incidence of systemic lupus erythematosus in a tropical region (Natal, Brazil)

The objective of the study was to evaluate the incidence of Systemic Lupus Erythematosus (SLE) in a tropical urban community (Natal city, Brazil). Only patients living in Natal, a city in the northeastern area of Brazil, older than 15 years, and who fulfilled at least four of the American College of Rheumatology criteria between 1 January 2000 and 31 December 2000, were included. Four sources were used to identify new cases of SLE: (1) the University Hospital; (2) 'health units' and hospitals of the public health network; (3) specialists at private hospitals and outpatient clinics; and (4) three laboratories performing antinuclear antibody (ANA) determination. Census data from 2000 for Brazilian population was used to calculate incidence rate. The standardized mortality ratio (SMR) method and 95% confidence intervals (95% CI) were calculated. Forty-three patients were diagnosed as new SLE cases in 2000. The calculated incidence was 8.7/100,000/year (95% CI 6.3-11.7). Thirty-eight patients were female 14.1/100,000/year (95% CI 10.0-19.3) and five were male 2.2/100,000/year (95% CI 0.7-5.2). The mean age of new SLE cases was 31.8 years old. (95% CI 27.8-35.8). The mean age for females was 31.4 and for males was 35.0 years old. The median of disease duration (time between onset of the first ACR criterion for SLE and diagnosis) was 10 months (1-72 months). This study demonstrated a high incidence of SLE in Natal, apparently higher than reported in other places. The mean age at diagnosis seems lower than referred by other studies. The observed differences may be due to ethnic and/or environmental factors.

Scleroderma-like nailfold capillaroscopic abnormalities are associated with anti-U1-RNP antibodies and Raynaud's phenomenon in SLE patients

This study aimed to evaluate the association between nailfold capillary abnormalities and the presence of Raynaud's phenomenon (RP), anti-U1-RNP, and anti-cardiolipin (aCL) antibodies in SLE patients. One-hundred SLE patients were studied. Widefield nailfold capillaroscopy was considered abnormal according to five criteria. Intercapillary distance, capillary width and capillary length were registered by videomorphometry in two fingers in 100 patients and in four fingers in 40 of these patients. Both the presence of alterated capillaroscopy and the presence of scleroderma-pattern (SD-pattern), characterized by the presence of avascular areas and enlarged or giant loops, were associated with the isolated presence of RP (P < 0.001) or anti-U1-RNP antibodies (P < 0.01), as well as with the simultaneous presence of RP and anti-U1RNP antibodies (P < 0.001). There was a negative association between the presence of aCL antibodies and SD-pattern (P < 0.05). Higher figures for the videomorphometric parameters capillary width, intercapillary distance and capillary length (measured on four fingers) were observed in patients with RP. Patients presenting both RP and anti-U1-RNP antibodies showed higher figures for intercapillary distance and capillary width. This study demonstrated significant association between nailfold capillaroscopic abnormalities and either RP or anti-U1-RNP antibodies in SLE patients. The association of RP, anti-U1-RNP antibodies, and 'scleroderma-like' findings on nailfold capillaroscopy (SD-pattern) in patients with SLE may suggest a new SLE subset with subclinical features of systemic sclerosis.

Methotrexate therapy in systemic lupus erythematosus

There are 12 non-controlled and only two controlled studies using methotrexate (MTX) in a total of 207 SLE patients in the literature. The majority of these studies evaluated mainly cutaneous and/or articular involvement and attained good results. Two studies evaluated a small number of patients with lupus nephritis, achieving discordant results. Two other studies in pediatric onset systemic lupus erythematosus (SLE) also presented conflicting results, it being relevant that the one with poor response had the majority of patients with nephritis. One of the controlled trials was retrospective and concluded that MTX was effective in the treatment of antimalarial-resistant lupus arthritis and that toxicity leading to discontinuation of MTX was infrequent. The other controlled study was a double-blind, randomized, placebo-controlled clinical trial that evaluated SLE patients with mild activity. The authors concluded that MTX was effective in controlling cutaneous and articular activity and permitted prednisone dose reduction. The side effects were frequent but only 10% of patients needed to discontinue the medication. The accumulative evidence suggests that MTX in a low weekly dose may be effective in SLE patients with articular and/or cutaneous involvement with no response to antimalarials and low-dose prednisone and in patients in whom we can not reduce prednisone dose due to articular or cutaneous activity. Caution is required concerning the side effects.

Vena cava thrombosis associated with nephrotic syndrome in the puerperal gestational cycle

CONTEXT

The puerperal gestational cycle is accompanied by a state of physiological hypercoagulability. Thromboembolic phenomena may occur at this time.

OBJECTIVE

To report on a clinic case involving a patient that presented a family history of thromboembolism and developed deep vein thrombosis in a lower limb and vena cava thrombosis during the puerperal gestational cycle, displaying nephrotic syndrome as the main complication.

DESIGN

Case report.

Takayasu arteritis. Treatment and prognosis in a university center in Brazil

The aim of this study was to evaluate the treatment and evolution of TA patients in a University Center in Brazil. This is a retrospective and descriptive study, that included all patients with TAs who attended the out-patient clinic at the Universidade Federal de Sao Palo, between 1993 and 1998. Twenty-four patients were women and 22 where white. The median age at the time of diagnosis was 27 yo. Full arteriography was performed in 28 patients and carotid duplex ultrasound plus computed tomography of aorta was done in two patients. Type I was found in 4, type II-a and type II in one case each, the type IV in 4 cases and the type V in 20 patients. Regarding the treatment only three patients with quiescent disease did not receive any medications. Twenty-seven patients (90%) received prednisone and only ten of these patients achieved disease control. Forth-eight percent of patients who received prednisone showed some side effects. Twelve patients received methotrexate associated to prednisone and 58% of them had a good response. Two patients who did not control disease activity with prednisone plus methotrexate received cyclophosphamide without good results. Some surgical procedure was performed in ten TA patients. Three patients died during the follow-up. This study showed that the majority of TA patients attended at a University Center needed association of prednisone and methotrexate to control disease activity, 30% needed some surgical procedures and that may be a cause of death in a young patient.

Double blind, randomized, placebo controlled clinical trial of methotrexate in systemic lupus erythematosus

OBJECTIVE

To evaluate the capacity of methotrexate (MTX) to control mild activity of systemic lupus erythematosus (SLE), and to evaluate the capacity of MTX to reduce steroid requirement, as well as to evaluate the side effects of MTX in patients with SLE.

METHODS

A prospective, randomized, controlled, double blind trial. Forty-one patients with SLE began and 37 completed the 6 months of study. The mean disease duration was 82.5 months. Twenty patients received MTX 15-20 mg/week (MTX group) and 21 received placebo (PL group). The dose of prednisone was maintained, increased, or reduced after the first month, according to monthly clinical and laboratory evaluation. Dose of prednisone, SLE Disease Activity Index (SLEDAI) scores, the score by visual analog scale (VAS) for articular pain, and laboratory results were recorded monthly. Both groups were homogeneous and comparable for clinical manifestations and laboratory results.

RESULTS

Two placebo patients dropped out due to severe flare of disease requiring hospitalization, and 2 patients taking MTX dropped out due to side effects (one with pulmonary tuberculosis, one with urticaria and severe dyspepsia). Thirty-seven patients (18 MTX and 19 PL) completed the study. At the end of the study 16 PL patients and one MTX patient presented articular complaints (p < 0.001). VAS scores for pain were significantly higher in the PL group than in the MTX group after the first month of study. Sixteen PL patients and 3 MTX patients presented cutaneous lesions after 6 months of treatment (p < 0.001). At the end of the study 4 MTX patients and 11 PL patients presented hypocomplementemia (p < 0.001). Mean SLEDAI scores in PL patients were significantly higher than in MTX patients at Months 3, 4, 5, and 6. It was possible to decrease the prednisone dose for 13 MTX patients during the study but for only one PL patient (p < 0.001). Fourteen MTX patients (70%) presented side effects, mainly dyspepsia and increase in hepatic enzyme serum levels, and 3 PL patients (14%) presented dyspepsia.

CONCLUSION

MTX 15 to 20 mg/week for 6 months was effective in controlling cutaneous and articular activity of SLE and permitted prednisone dose reduction. At these doses MTX presented frequent but mild side effects that did not result in drug discontinuation in the majority of patients.

Long-term thalidomide use in refractory cutaneous lesions of systemic lupus erythematosus

OBJECTIVE

To evaluate the efficacy of long-term thalidomide treatment in cutaneous lesions of systemic lupus erythematosus (SLE), not responsive to conventional therapy.

PATIENTS AND METHODS

Were selected 18 SLE patients (ACR criteria) with active cutaneous lesions not responsive to chloroquine, photoprotectors and low doses prednisone and who presented good response to thalidomide but relapsed after withdrawal of the drug. All female patients had no risk of pregnancy. Thalidomide was reintroduced and maintained at low dose (25-100 mg/day) for a minimum of 6 months.

RESULTS

Eighteen patients (16 females) with mean age of 34.2 yo (16-57 y.o.) received thalidomide for 6-21 months (mean 8.5 m). The mean dose of prednisone at beginning of study was 38.3 mg/d and at the end was 9.7 mg/d (p < 0.05). Complete remission of cutaneous lesions was observed in thirteen patients (72%) and partial remission in five (28%). Side effects observed were: drowsiness in eight patients, intestinal constipation in 5, transient oliguria in 1, paresthesia of hand with normal electromyography in another one. All side effects disappeared with reduction of thalidomide dose and no patient needed to stop treatment owing to side effect.

CONCLUSION

Thalidomide is a good alternative therapy to SLE patients with refractory cutaneous lesions and without any risk of pregnancy.

Demographic, clinical, and angiographic data of patients with Takayasu arteritis in Brazil

We collected clinical, demographic, and angiographic data of Takayasu arteritis (TA) patients followed at Rheumatology Division of three Public University Centers (UNIFESP, USP, and UNICAMP) located in São Paulo State, Brazil. Clinical and demographic data were obtained from 73 patients (61 female; 50 white) The mean age at time of diagnosis was 27 y.o. and the mean follow-up time was 5 years. The following clinical features were observed along the evolution of these patients: absent or reduced pulses in upper limbs (85%), arterial bruit (64.5%), claudication of upper members (57%), headache (45%), hypertension (35.5%), dizziness (29%), cardiac bruit (29%), weight loss (27.5%), arthralgia or arthritis (26%), fever (24.5%) and claudication of lower limbs (20.5%). According to new angiographic classification of Takayasu arteritis performed in 28 patients followed at UNTFESP, with routine full aortography, 21% were classified as type I, 4% as type IIa, 4% as type III, 14% as type IV and 57% as type V. No patients had type IIb. Patients with Takayasu arteritis in São Paulo State Brazil showed female predominance and arterial involvement pattern similar to the one observed in Japan, with more than 20% classified as type I with exclusive involvement of the branches from the aortic arch.

Clinical implications of autoantibodies in HIV infection

OBJECTIVE

To study the frequency and specificity of autoantibodies in HIV-infected subjects and their association with rheumatic manifestations, immunodeficiency, and prognosis.

DESIGN

Prospective study of sequentially selected HIV-infected patients. Indirect immunofluorescence reading was performed by two independent observers blinded for the patient diagnosis. Enzyme-linked immunosorbent assay (ELISA) was performed using coded serum samples.

SETTING

The study was performed at the Infectious Disease and Rheumatology Divisions of a tertiary care university hospital.

PATIENTS

One hundred sequentially selected HIV-infected patients formed group A. Controls included 80 non-HIV-infected high-risk individuals (group B), 20 herpesvirus-infected patients (group C), and 30 healthy blood donors (group D).

MAIN OUTCOME MEASURES

Patients were followed for 2 years and evaluated for the presence of immunodeficiency, rheumatic manifestations, circulating autoantibodies and total CD4+ cell count. Indirect immunofluorescence was used to investigate antinuclear antibodies, antibodies to native DNA, smooth muscle, parietal cell, glomeruli, thyroid, and neutrophil cytoplasm. Agglutination was used to detect antibodies to erythrocytes and rheumatoid factor. ELISA was used to determine antibodies to cardiolipin and denatured DNA. CD4+ lymphocytes were counted by flow cytometry. Immunoglobulin (Ig) G, IgM and IgA serum levels were determined by radial immunodiffusion.

RESULTS

HIV-infected patients presented higher overall frequency of autoantibodies than the other groups. No difference was observed between immunodeficient and asymptomatic HIV-infected patients. The most frequent specificities were antibodies to cardiolipin and to denatured DNA. Ig serum levels did not correlate with the occurrence of autoantibodies. The presence of autoantibodies was associated with lower CD4+ cell counts and with higher mortality within 2 years. Rheumatic manifestations were observed in 35 HIV-infected patients and were not associated with the occurrence of autoantibodies or the presence of immunodeficiency.

CONCLUSIONS

HIV infection is associated with an increased incidence of autoantibodies. Although not related to the occurrence of rheumatic manifestations, the presence of autoantibodies was significantly associated with lower CD4+ lymphocyte counts and increased mortality, which implies prognostic significance to this phenomenon in the context of HIV infection.

C2 deficiency in blood donors and lupus patients: prevalence, clinical characteristics and HLA-associations in the Brazilian population

The objective of the present study was to investigate the prevalence, clinical characteristics, and HLA association of C2 deficiency in the Brazilian population. The frequency of C2 deficiency profile (C2Q degree profile) was 2.2% among 1503 blood donors and 6.6% among 166 patients with systemic lupus erythematosus (SLE). A higher incidence of clinical manifestations possibly related to immune complex disease was observed among blood donors with C2Q degree profile and their relatives with C2Q degree profile when compared to the normal C2 relatives. The comparison of clinical and laboratory features between SLE patients with C2Q degree profile and those with normal C2 revealed earlier disease onset, higher frequency of oral ulcerations and lower frequency of anti-native DNA antibodies in the first group. The HLA study conducted on 18 individuals with C2Q degree profile (11 blood donors and 7 SLE patients) confirmed the previously reported association with the antigens HLA-A25, B18 and DR2, supporting the concept that probably most C2 deficiency cases, throughout the world, are due to a single mutation in the C2 gene in linkage disequilibrium with the A25B18DR2 haplotype.

[Study of bone density in systemic scleroderma]

BACKGROUND

Osteopenia in systemic sclerosis (scleroderma) patients was reported in X-ray studies of hands and by proximal and distal forearm bone mass measurement. It has been suggested that bone loss in these patients might be due to chronic ischemia, immobilization and early menopause. Nevertheless, it is not established if these patients present generalized osteopenia. To shed light into this point we studied bone mineral density in the spine, proximal femur and total body in patients with systemic sclerosis.

PATIENTS AND METHOD

Twenty-five Caucasian women were evaluated. Mean age of patients was 48 +/- 12 years and mean time of disease was 7 +/- 7 years; 13 were postmenopausal (8 +/- 8 years). Bone mass was measured in the spine, proximal femur and total body by using a dual-photon absorptiometry with X rays source (Lunar-Model DPX).

RESULTS

Bone mass in different sites was not statistically different from the age-matched control healthy women. Mean bone mass of patients with limited form was not different from patients with diffuse form of systemic sclerosis. Patients with calcinosis had lower bone mass at proximal femur than those without this alteration.

CONCLUSIONS

Patients with systemic sclerosis do not present bone loss and this disease in not a risk factor for generalized osteoporosis.

Controlled trial with chloroquine diphosphate in systemic lupus erythematosus

INTRODUCTION

Antimalarials have been recognized as effective drugs for the treatment of articular and cutaneous manifestations of systemic lupus erythematosus (SLE), but its potential in the management of systemic features of the disease has not yet been thoroughly evaluated.

OBJECTIVES

This study intended to evaluate the efficacy of chloroquine diphosphate (CDP) in preventing flares and in reducing the maintenance corticosteroid dose in patients with SLE without life-threatening manifestations.

MATERIALS AND METHODS

Twenty-four SLE patients with no life-threatening manifestation were enrolled in a 12-month double blind placebo-controlled trial with CDP (250 mg/day). Patients were subjected each month to clinical examination by a rheumatologist and to SLE-relevant laboratory tests. At each visit, prednisone dose could be adjusted according to the clinical status. Ophthalmologic examination was performed every six months. Outcome measures included SLEDAI score and the required prednisone dose. SLE flare was defined as an increase in SLEDAI score of at least three points. Prednisone dose reduction was defined as a minimum 50% dose decrease with no concomitant disease flare.

RESULTS

Twenty-three patients completed the study. One patient in the placebo (PL) group dropped out due to severe dyspepsia. No major side-effect was observed in the remaining patients. PL and CDP groups showed no significant difference at the beginning of the study with regard to sex, age, ethnic classification, disease duration, SLEDAI and prednisone dose. Along the trial the prednisone dose became progressively lower in CDP group as compared to PL group and the difference reached statistical significance at 4, 6 and 12 months. SLEDAI score was higher in PL group in all evaluations, being the difference statistically significant at 4 months. Flare-up episodes were registered in two patients in CDP group and in ten patients in PL group. The estimated reactivation risk was 4.6 times greater in PL group as compared to CDP group.

CONCLUSIONS

CDP at a 250 mg/day dose was able to prevent disease exacerbation, reduce the required prednisone dose, and help inducing a better control of patients with non life-threatening SLE. These data suggest that antimalarials might have a broader indication in the treatment of SLE other than solely the management of skin and articular manifestations.

Fibromyalgia versus rheumatoid arthritis: a longitudinal comparison of the quality of life

OBJECTIVE

To evaluate and compare the quality of life of patients with fibromyalgia (FM) and rheumatoid arthritis (RA).

METHODS

Forty-four women with FM and 41 with RA were studied. There were 3 evaluations, with a 3-month interval. Besides special and general clinical examinations, the following tests were applied: pain numerical scale (PNS), Health Assessment Questionnaire (HAQ), Fibromyalgia Impact Questionnaire (FIQ), Arthritis Helplessness Index (AHI), Modified Post-Sleep Inventory (PSI), and questions about sleep disorders and socioeconomic impact.

RESULTS

Results include the following: tender points (TP): FM = 13.9, RA = 2.9; PNS: FM = 7.2, RA = 6.8; HAQ: FM = 0.90, RA = 1.22; FIQ: FM = 47.2, RA = 42.5; AHI: FM = 32.7, RA = 31.8; sleep quality--mean duration of daily sleep: FM = 6.7 h, RA = 6.1; PSI scores: FM = 64.6, RA = 57.2. On questioning regarding economic impact, there was a decrease in family income for 65% of patients with FM and 75.1% for those with RA. Fifty-five percent of patients with FM and 66.6% of those with RA received social security aid. At followup evaluation, there was a statistically significant improvement in the following items for the patients with FM: TP count, HAQ, and AHI. The patients with RA improved in number of TP and AHI.

CONCLUSION

FM has a negative impact on quality of life, similar to RA. Clinical, functional, and economic problems related to the disease were observed. The alteration observed remained relatively stable during the study period, except for physical disability.

Treatment of the cutaneous lesions of systemic lupus erythematosus with thalidomide

Twenty three patients with SLE and cutaneous lesions not responsive to chloroquine, photoprotectors and corticosteroid in doses < 0.5 mg/kg/day were treated with thalidomide 300 mg/day. Three patients presented side effects and had to discontinue treatment. Eighteen of the remaining 20 patients (90%) had complete remission of the cutaneous lesions and 2 had partial improvement. Another important parameter of improvement was a reduction in the average prednisone dose required from 40.5 mg/day to 17.4 mg/day. The most frequent side effects were drowsiness in 52% of cases and abdominal distention in 22%. These symptoms were reversed by dose reductions in all but one patient. Thalidomide was shown to be efficient in the treatment of cutaneous lesions unresponsive to more usual treatments.

Systemic lupus erythematosus: a family study of 25 probands

We studied 120 first-degree relatives (FDRs) of 25 systemic lupus erythematosus (SLE) probands and 59 non-genetically associated individuals who were in close contact with the SLE patients. A significantly greater frequency of antinuclear antibody (ANA) positivity was found among the FDRs than in the control group (p less than 0.01). No significant difference was found in ANA positive between the female and male FDRs. Articular complaints or Raynaud's phenomenon were observed in 15% of the FDRs and in only 2% of the controls (p less than 0.05). Female FDRs had a greater number of rheumatic complaints than male FDRs (p less than 0.05) and a significant association was found between rheumatic complaints and ANA positivity (p less than 0.001) among the total FDRs.