Ocular involvement in systemic lupus erythematosus patients: a paradigm shift based on the experience of a tertiary referral center

Objective

To evaluate ocular involvement in a cohort of systemic lupus erythematosus (SLE) patients of a tertiary referral center and to compare the results with the existing literature.

Methods

Patients underwent a complete ophthalmological evaluation, including visual acuity, slit-lamp examination, fluorescein staining, Schirmer-I test, Goldmann applanation tonometry, fundoscopy, 10-2 automated threshold visual fields, fundus autofluorescence and spectral-domain optical coherence tomography to screen for hydroxychloroquine (HCQ) macular toxicity.

Results

A total of 161 patients (16 men and 145 women) were enrolled in this study. The mean age was 47.6 years and the mean disease duration was 11.5 years. Fifty patients (31.1%) had at least one ocular manifestation of SLE. The most frequent manifestation was dry eye syndrome (12.4%), immediately followed by cataracts (11.2%) and HCQ macular toxicity (11.2%). Among patients with HCQ maculopathy, two presented with an atypical spectral-domain optical coherence tomography pattern. Five patients (3.1%) presented with glaucoma, two patients (1.2%) presented with SLE retinopathy while only one presented with lupus choroidopathy (0.6%).

Conclusions

Compared with previous studies, we conclude there has been a significant reduction in disease-related ocular complications, particularly those associated with poor systemic disease control. On the other hand, drug and age-related complications are assuming a prominent role in the ophthalmic care of these patients.

[Spontaneous regression of symptomatic lumbar disc herniation]

Lumbar disc herniation is very common, sometimes leading to disability of the patient, and in a significant number of cases can only be solved with surgery. This paper reports a case with a large symptomatic disc herniation, which suffered spontaneous regression, and no surgery was necessary. The case is documented on serial MRI, consistent with the clinical improvement of the patient.

Bacillary angiomatosis by Bartonella quintana in an HIV-infected patient

Bacillary angiomatosis and bacillary peliosis are opportunistic infections caused by Bartonella henselae and Bartonella quintana, which occur in patients with late-stage infection. We report a case of bacillary angiomatosis in an HIV-infected patient with skin, bone, and probably liver involvement, The identification of the agent (B quintana ) was done by polymerase chain reaction in the skin specimen. The patient had complete regression of all lesions after a 6-month regimen of oral erythromycin.

[Infective endocarditis]

Two different series of patients with Infectious Endocarditis (IE), hospitalized in the same ward of Curry Cabral Hospital in Lisbon, are presented and compared. The two series were separated by a ten-year period--the first included patients observed from 1970 to 1976 and the second from 1988 to 1998. In the first series (20 patients), IE occurred mainly in patients with previous cardiac valvular lesion, the course was subacute and Streptococcus viridans was the predominant agent. In the last series (65 patients), most of the patients were young and had no previous valvular lesions. Right side endocarditis predominated and the course was acute. Most of patients were drug addicts and had HIV infection. Staphylococcus aureus was the predominant agent. The ages of the two series were significantly different (p < 0.005). The diagnostic value of transthoracic and transesophageal echocardiography is stressed. The details of the evolution of patients with HIV infection are presented according to the values of CD4+ lymphocyte counts. The relatively good prognosis of IE in drug addicts with antibiotic treatment, even with HIV infection, is emphasized.

[The hemolytic-uremic syndrome]

The microangiopathic thrombotic syndromes--thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS)--are characterized by microangiopathic hemolytic anemia, thrombocytopenia, renal dysfunction, fever and central nervous system abnormalities. Today they are considered as two extremes of a continuous spectrum named TTP--HUS. The syndrome is an uncommon disease with a high mortality rate, despite treatment. The authors describe a case of hemolytic uremic syndrome in a young adult patient. Initially the clinical course and the first biopsy suggested a favourable prognosis, but the early recurrence with severe hypertension was followed by a fatal outcome 6 months later. Concerning this clinical case, the authors present a review of the most recent aspects of the pathogenesis and treatment of this syndrome.

Breakdown of the inner and outer blood retinal barrier in streptozotocin-induced diabetes

Using vitreous fluorophotometry and quantitative fluorescence microscopy the authors studied the permeability of the blood-retinal barrier (BRB) to fluorescein in control and in 8 days streptozotocin-induced diabetic rats. Vitreous fluorophotometry showed that fluorescein permeates BRB in control and in diabetic rats. However, in diabetic rats the permeability to fluorescein was significantly increased as compared to control rats. The vitreous penetration ratio (VPR) values for total and free fluorescein at 60 min, were higher for diabetic rats (231.2+/-12.9 min-1 for total fluorescein and 1299.24+/-58.0 min-1 for free fluorescein) than for control rats (95.5+/-3.5 min-1 for total fluorescein and 646.6+/-55. 0 min-1 for free fluorescein) (P<0.05). Quantitative confocal fluorescence microscopy confirmed these findings and identified the site of leakage across the BRB by comparing the relative importance of the fluorescein leakage across the outer and inner BRB. In control rats the fluorescence levels remained relatively low in the photoreceptor layer, next to the outer BRB but in the inner nuclear layer, next to the inner BRB reached values that were almost ten times higher. These results suggest that in retinas of control rats fluorescein penetrates predominantly through the inner BRB. In diabetic rats the fluorescence levels in the photoreceptor and in the inner nuclear layer were significantly increased as compared to the fluorescence levels in controls rats. Nevertheless, in the inner nuclear layer the fluorescence levels were also generally higher than the fluorescence levels at the photoreceptor layer. The rates of fluorescence levels between the inner nuclear layer and the photoreceptor layer were apparently 3:1, 60 min after the single intravenous injection of fluorescein. Also, the fluorescein penetration in the inner nuclear layer of the diabetic rats is higher than that observed in the inner nuclear layer of the control rats (P<0.001). These findings suggest that the permeability to fluorescein of both components of the BRB is increased 8 days after the induction of diabetes by streptozotocin and that the permeability of the retinal vasculature is preferentially affected.

Nitric oxide synthase activity and L-arginine metabolism in the retinas from streptozotocin-induced diabetic rats

1. Nitric oxide synthase (NOS) activity was studied in the retinas from normal rats and in the retinas from two groups of streptozotocin-induced (8 days and 4 months) diabetic rats. In each animal group, the NOS activity was correlated to the concentration of amino acids related to L-arginine metabolism and to L-arginine uptake. 2. Retinas from both groups of streptozotocin-induced diabetes (8 days and 4 months) showed an increased NOS activity compared with the NOS activity in retinas from normal rats. In retinas lysate from normal rats, the NOS activity was most potently inhibited by NO-Arg (1 mM), whereas, in both groups of streptozotocin-induced diabetes, the NOS activity was most potently inhibited by the NOS inhibitor aminoguanidine (0.5 mM). 3. The basal levels of the amino acids related to L-arginine metabolism-namely, L-arginine, L-citrulline, L-ornithine and L-glutamine-in retinas from both groups of rats with streptozotocin-induced diabetes were decreased compared with the amino acid levels in retinas from normal rats. 4. The uptake of L-[3H]arginine in retinas from both groups of rats with streptozotocin-induced diabetes was increased compared with the uptake of of L-[3H]arginine in retinas from normal rats.

[Palpebral metastasis revealing a gastric adenocarcinoma]

The authors present a case of a gastric adenocarcinoma in which the major manifestation was cutaneous metastases of the eyelids--in a review of the literature, no reports were found. Based upon this unusual case and in light of present knowledge, we decided to revise the concept of cutaneous metastases secondary to internal neoplasia, in particular, these with a gastric localization.

[Will acanthosis nigricans be a new cutaneous manifestation of human immunodeficiency virus infection?]

The authors describe a clinical case of AIDS presented by three opportunistic infections (esophageal candidiasis, tuberculosis and atypical mycobacteriosis) and a dermatological manifestation--acanthosis nigricans--not described in medical literature as accompanying those entities. The exclusion of most common etiologies of acanthosis nigricans and its regression following treatment for those infections suggests that with AIDS it behaves like a paraneoplastic syndrome. Screening for HIV antibodies should be the rule whenever this dermatological manifestation is present.

[Gastroduodenal, ileocolic and perianal Crohn's disease]

The authors present a case of Crohn's disease that initially showed common localisations, and later a rare gastro-duodenal involvement. When the definitive diagnosis of the latter was reached there were already signs of obstruction at the exit of the stomach. Treatment with Prednisolone I.M. and Omeprazole was not successful, and surgery was necessary as a last recourse to resolve the obstruction. A theoretic revision of the main clinical, diagnostic, and therapeutic aspects of this rare from of involvement of Crohn's disease is also presented.

[Myxoma of the left atrium presenting as repeated cerebrovascular disorders]

Infarction of the central nervous system secondary to embolism from a left atrial myxoma is a recognized phenomenon. However, a myxoma as the source of an embolus may be overlooked, if, during the evaluation of a patient with a stroke of unknown etiology, an index of suspicion is not present. We report a case of a 57-year old woman presenting three episodes of cerebral infarction always in the same brain territory, suggesting a carotid pathology. The physical examination of the patient only showed a loud S1 with no other sounds and neurologic alterations, namely, right hemiparesia and aphasia. Diagnosis was made by two-dimensional echocardiography and better delineation was obtained by magnetic resonance imaging (MRI). The patient subsequently received a successful ressection of the myxoma. Eighteen months later the patient was well.

[Mucocutaneous pathology in HIV infection]

Several infectious, neoplastic or inflammatory skin diseases, may be early manifestations of HIV infection. We reviewed the clinical data of 226 HIV seropositive male patients with cutaneous disease, from a total of 337 inpatients at the Infectious Diseases Unit--Department of Medicine 1--Curry Cabral Hospital, from 1985 to 1991. Some considerations are made about the most common dermatological disorders: oral candidiasis, seborrheic dermatitis, Kaposi's sarcoma, herpes simplex infection, drug-related skin disorders, herpes zoster and dermatophytosis. The high prevalence of cutaneous manifestations in HIV infection, the uncommon clinical findings and their occasional therapeutic problems, makes an early diagnosis essential.

HLA antigens and lymphocytes in proliferative vitreoretinopathy

An immunohistopathological study was performed on 33 epiretinal membrane specimens obtained during vitreoretinal surgery from patients with rhegmatogenous retinal detachment complicated with proliferative vitreoretinopathy (PVR). Immunofluorescence and immunoperoxidase methods were used to detect major histocompatibility complex or HLA antigens and immunocompetent cells, and to identify the cellular and the extracellular component of the proliferative tissue. The following antigens were detected in epiretinal membranes: cytokeratin in 18 (of 18 cases studied for this antigen), glial fibrillary acidic protein in 20 (of 20), vimentin in 20 (of 20), actin in 16 (of 18), fibronectin in 20 (of 20), macrophage CD68 in 16 (of 18), leukocyte common antigen in 12 (of 18), T-cell CD45R in 13 (of 22), HLA-ABC in 27 (of 33), HLA-DR in all the 33 membranes and HLA-DR alpha chain in 32 of 33 membranes. We observed the presence of macrophages and of an activated T-cell population in PVR membranes. HLA-DR antigen expression was found on pigmented and nonpigmented epithelial cells and on mononuclear cells in all epiretinal membranes. The HLA-DR expression on retinal pigmented epithelial cells could play a role in triggering a local immune response in PVR. These findings suggest the involvement of immunological phenomena and probable interactions between the immune system and peptide growth factors.

[Yersinia enterocolitica. A seroprevalence study and report of 3 clinical cases]

Yersinia enterocolitica is a gram negative bacillus that emerged in the past two decades as an important enteric pathogen associated with a wide spectrum of clinical manifestations. The authors present a seroepidemiological survey, in 200 hospitalized patients, and describe three curious case reports of this infection, including a serious case of endocarditis.

[Human fascioliasis. Tomodensitometric aspects. Apropos of 2 cases]

The authors report two cases of hepatic fascioliasis in which the CT scans of the liver revealed multiple hepatic low density lesions, better seen after intravenous bolus injection of contrast material. This CT signs may help in the diagnosis, follow up and to access the efficacy of hepatobiliary fascioliasis treatment.

Primary neuroendocrine carcinoma of the eyelid, immunohistochemical and ultrastructural study

Primary neuroendocrine carcinomas of the skin were recognized as distinctive neoplasms and clinicopathologic information on their location on the eyelids have been reported. The authors present one case of primary neuroendocrine carcinoma occurring on the right lower lid in a 73-year-old woman. The clinical history, light and electron microscopic findings as well the results of an immunohistochemical study are described. The ultrastructural study demonstrated the characteristic membrane-bound dense-core neurosecretory granules. Immunoreactivity for neuron-specific enolase, keratin filaments, epithelial membrane antigen and calcitonin were observed and are strongly suggestive of a neuroendocrine differentiation in a neoplasm of epithelial origin. Various hypothesis concerning the origin of this tumor are discussed on the basis of the immunohistochemical findings. The authors also provide a brief review of the literature.

[Significance of the captopril test in the diagnosis of primary hyperaldosteronism --apropos of 4 clinical cases]

We describe four cases of primary hyperaldosteronism whose initial presentation was a moderate to severe hypertension. In three patients an adrenal adenoma was found; in another patient was due to unilateral adrenal hyperplasia. A good therapeutic response was achieved in all cases by unilateral adrenalectomy. The captopril test (Lyons version) proved useful to exclude essential hypertension and, may be, in distinguishing the new sub-types of primary hyperaldosteronism recently described. Indeed, only in the case of unilateral adrenal hyperplasia a fall in plasma aldosterone levels was observed. However, we feel that further investigation is needed to clarify this point.

[Three years of AIDS. Experience of the Curry Cabral Hospital with HIV infections (1985-1988)]

The AA. present a retrospective study on their experience with HIV positive patients, followed on the Infectious Diseases Department of the Hospital Curry Cabral, in Lisbon. This study was done in 90 patients seen since 1985 till March 1988. From the 90 patients, 81 were HIV--1 positive, 6 HIV--2 and 3 HIV1 + HIV2 positives. It is presented their distribution by sex (Male = 97.8%), age (mean--36.5 years), risk groups (homosexuals--64.4%, heterosexuals--21.1%, IVDA--7.7%, blood-related--5.6%), and their Walter Reed and CDC classifications. It is emphasised the increasing incidence of infected people along the years and an unexpected high rate of heterosexual males infected. It is also pointed the incidence of Kaposi (22%), Pneumocystis carinii pneumonia (55.6%), and Criptococosis (13.9%) in the WR6 group. The mortality rate was 31.3% for WR5 and 63.9% for WR6. We calculate some Relative Risks for clinical situations matched with risk groups and immunological status (meaning the T Helper lymphocitic count), and measured their statistical significance with the chi-square test. Besides the immunodeficiency, it was mentioned the associated lymphadenopathy and dermatological lesions, the HIV encephalopathy and the constitutional symptoms of the wasting syndrome.