Paroxysmal nocturnal hemoglobinuria in systemic lupus erythematosus: a case report

Introduction

Paroxysmal nocturnal hemoglobinuria is an acquired disorder of hemopoiesis and is characterized by recurrent episodes of intravascular hemolysis due to an increased sensitivity to complement-mediated hemolysis. Systemic lupus erythematosus with paroxysmal nocturnal hemoglobinuria is very rare. We report a case of paroxysmal nocturnal hemoglobinuria that developed in a patient with systemic lupus erythematosus and lupus nephritis.

Case presentation

A 29-year-old Mongolian woman had systemic lupus erythematosus, which manifested only as skin lesions when she was 12 years old. She had leg edema and proteinuria when she was 23 years old, and a renal biopsy revealed lupus nephritis (World Health Organization type IV). She had been treated with steroids and immunosuppressant therapy. At 29, she had headaches, nausea, general fatigue, and severe pancytopenia and was admitted to our hospital. A laboratory evaluation showed hemolytic anemia. Further examination showed a neutrophil alkaline phosphatase score of 46 points, a CD55 value of 18%, and a CD59 value of 78.6%. The results of Ham test and sugar water tests were positive. The constellation of symptoms throughout the clinical course and the laboratory findings suggested paroxysmal nocturnal hemoglobinuria.

Conclusions

To the best of our knowledge, systemic lupus erythematosus with paroxysmal nocturnal hemoglobinuria is very rare. Clinicians should be aware of the association between autoimmune and hematological diseases.

Fatty acid composition of plasma and kidney in rats with anti-Thy1.1 nephritis

BACKGROUND

n-3 Polyunsaturated fatty acids (PUFA) are reported to ameliorate atherosclerotic and inflammatory diseases because they compete with arachidonic acid and reduce its inflammatory metabolites. In the present study, the fatty acid composition of plasma and kidney in rats with anti-Thy1.1 nephritis was investigated.

MATERIALS AND METHODS

A group of male Wister rats weighing about 200 g was injected with anti-Thy1.1 antibody (1.25 mL/kg) through their tail veins (nephritis group). Rats in the control group were injected with saline. Five days after the injection, urinary protein levels were determined. All rats were then sacrificed and fatty acid composition of plasma and kidney were analyzed.

RESULTS

Eicosapentaenoic acids (EPA) levels in the kidney phospholipid (PL) fraction in the nephritis group were significantly lower than those in the control group (0.67 +/- 0.06 mol% vs. 0.96 +/- 0.06 mol%, p < 0.05). EPA levels in the plasma PL fraction in the nephritis group were also significantly lower than those in the control group (0.38 +/- 0.05 mol% vs. 0.59 +/- 0.03 mol%, p < 0.05). Urinary protein levels 5 days after the injection were inversely correlated with EPA levels in the kidney PL fraction (r2 = 0.65, p = 0.01). These results suggested that decreased EPA levels in the kidney PL fraction might play an important role in anti-Thy1.1 nephritis.

Effects of eicosapentaenoic acids on oxidative stress and plasma fatty acid composition in patients with lupus nephritis

Eicosapentaenoic acid (EPA) is one of the major components of fish oil, which was reported to have antiatherogenic, anti-inflammatory and immune suppressive effects. In the present study, highly purified EPA was administered to patients with lupus nephritis and the effects of EPA on urinary 8-isoprostane, a reliable marker of oxidative stress, were investigated in these patients. Six outpatients (1 man and 5 women), with lupus nephritis diagnosed by renal biopsy, were entered in the study. We administered 1800 mg EPA ethyl-ester (purity > 95%) daily and examined the urinary 8-isoprostane levels and plasma fatty acid composition before and 3 months after EPA treatment. The urinary 8-isoprostane levels were significantly decreased after the treatment compared with those before the treatment (from 530 +/- 113 pg/mg x Cr to 235 +/- 49 pg/mg x Cr, p = 0.02). The EPA levels in the plasma phospholipid (PL) fraction were significantly increased after the treatment (from 3.30 +/- 0.64 mol% to 8.01 +/- 0.47 mol%, p < 0.001). Arachidonic acid (AA) levels in the plasma PL fraction were significantly decreased after the treatment (from 9.47 +/- 0.28 mol% to 7.33 +/- 0.43 mol%, p < 0.001). The ratios of EPA to AA were significantly increased after the treatment (from 0.35 +/- 0.07 to 1.14 +/- 0.16, p < 0.001). Thus, this preliminary study indicated that EPA might exert beneficial effects on lupus nephritis by decreasing the oxidative stress.

Effects of eparlestat on plasma levels of advanced glycation end products in patients with type 2 diabetes

Advanced glycation end products (AGE) are produced by a nonenzymatic reaction between glucose and proteins in the plasma of diabetic patients. Recently, AGE have been reported to promote and accelerate diabetic complications and atherosclerosis. The activity of aldose reductase (AR) is increased in diabetic patients. AGE are reported also to be produced by increased levels of fructose through increased activity of AR in diabetes. Consequently, we administered eparlestat, one of AR inhibitors, to diabetic patients and investigated the plasma carboxymethyl-lysine (CML) concentration, one of the AGE, before and after the administration of eparlestat. Though plasma CML concentration did not show any significant changes in all patients after the administration of eparlestat in the present study (from 2.7 +/- 0.3 mU/mL to 2.5 +/- 0.2 mU/mL; 3 months, 2.9 +/- 0.3 mU/mL; 6 months), plasma CML concentration were significantly decreased 3 months after the administration of eparlestat in the patients whose CML concentration before the treatment was higher than 3 mU/mL (from 3.4 +/- 0.2 mU/mL to 2.6 +/- 0.2 mU/mL; 3 months, p = 0.017). Serum thrombomodulin and HbA1c levels did not show any significant changes. These results suggest that the administration of eparlestat may be beneficial in preventing diabetic complications by decreasing plasma CML in diabetic patients.

Systemic lupus erythematosus associated with transverse myelitis and parkinsonian symptoms

A 31-year old woman developed transverse myelitis after 10 years remission since she was first diagnosed as systemic lupus erythematosus. Although pulse methyl prednisolone resolved her myelitis, Parkinson-like symptoms developed subsequently after reduction of steroid. Treatments including apheresis did not improve her Parkinson-like symptoms such as rigidity, akinesia, impairment of speech and mask-like facial expression. Levodopa was effective as a symptomatic therapy. Orally administered cyclophosphamide eventually led her to remission and withdrawal from levodopa. Her clinical course and the absence of other possible causes prompted us to conclude that Parkinsonian symptoms as well as transverse myelitis may have developed as manifestations of central nervous system lupus.