Cerebral atrophy related to corticotherapy in systemic lupus erythematosus (SLE)

The aim of this study was to evaluate the frequency and intensity of cerebral atrophy using CT scanning and the possible relation to corticosteroid therapy or disease in systemic lupus erythematosus (SLE) and to analyse the relationships between cerebral atrophy and activity disease and neuropsychiatric manifestations in lupus patients. We studied 107 consecutive SLE patients (American Rheumatology Association 1982 criteria) who were taking steroid drugs at the time and not selected for any particular manifestation (group 1). A complete clinical, neurological and laboratory evaluation was performed. The American College of Rheumatology's classification for neuropsychiatric manifestations and SLE disease activity index for activity were employed. Group 2 comprised 39 non-SLE patients with oral chronic steroid use (1 mg/k/day for more than 3 consecutive months); 50 normal individuals were the controls (group 3). There were no demographic differences between the groups. Brain CT was performed in all individuals and the frequency and the intensity (minimal, moderate and severe) of atrophy analysed, through well-defined measures and indices, by two neuroradiologists. Cerebral atrophy was significantly more frequent in groups 1 and 2 than in group 3, but with no significant difference between groups 1 and 2. The severity of cerebral atrophy was significantly higher in SLE patients (p<0.05), independent of steroid dose or duration of disease. In both groups no patient presented severe atrophy. Lupus patients with and without cerebral atrophy presented neuropsychiatric manifestations and activity disease in a similar proportion. The more frequent neuropsychiatric manifestation in lupus patients with cerebral atrophy was seizures (p<0.05). Chronic glucocorticoid therapy was responsible for cerebral atrophy, with a comparable incidence in both lupus and non-lupus patients compared to age and gender-matched normal subjects untreated with glucocorticoids. The disease activity was not related to cerebral atrophy in group 1 and seizures were the neurologic manifestation related to cerebral atrophy. The severity of the cerebral atrophy was independent of steroid dose, or duration of treatment. Moreover, the disease itself contributes to the severity of this process, but not to the development of cerebral atrophy.

Methotrexate in the treatment of ankylosing spondylitis

The authors carried out an open prospective study analyzing methotrexate (MTX) efficacy and toxicity in 34 patients with ankylosing spondylitis (AS) for a period of one year. All the patients presented with active axial disease, characterized by inflammatory spinal pain, prolonged morning stiffness, erythrocyte sedimentation rate (ESR) > or = 25 mm, and failure on treatment with non-steroidal anti-inflammatory drugs for a period of more than two years. MTX was taken at a single weekly intramuscular dose of 12.5 mg. Thirty-one patients (91%) concluded treatment. Eighteen patients (53%) were considered responders to MTX; most of them presented peripheral arthritis. Despite clinical improvement, axial measures were unaltered at the end of the study. The mean value of ESR decreased significantly at the end of the treatment (p=0.0001), predominantly in the responders group. Side effects were observed in 23 patients (68%) and included dyspeptic syndrome, transient elevation of liver enzymes, and dizziness. The results of this one year open study suggest that MTX can be an efficient drug in the treatment of AS.

Magnetic resonance imaging in the evaluation of patients with aseptic meningoencephalitis and connective tissue disorders

OBJECTIVE

To describe the role of magnetic resonance imaging (MRI) in the evaluation of patients with chronic and recurrent aseptic meningitis.

METHOD

A retrospective study of five patients with aseptic meningoencefalitis diagnosed by clinical and CSF findings. CT scans showed without no relevant findings.

RESULTS

MRI showed small multifocal lesions hyperintense on T2 weighted images and FLAIR, with mild or no gadolinium enhancement, mainly in periventricular and subcortical regions. Meningoencephalitis preceded the diagnosis of the underlying disease in four patients (Behçet's disease or systemic lupus erythematosus). After the introduction of adequate treatment for the rheumatic disease, they did not present further symptoms of aseptic meningoencephalitis.

CONCLUSION

Aseptic meningoencephalitis can be an early presentation of an autoimmune disease. It is important to emphasize the role of MRI in the diagnosis and follow-up of these patients.

Young age at onset, renal involvement, and arterial hypertension are of adverse prognostic significance in juvenile systemic lupus erythematosus

OBJECTIVE

To look for associations between mortality, clinical or laboratory data, and age at disease onset in systemic lupus erythematosus patients aged 16 years or younger at disease onset.

PATIENTS AND METHODS

The medical records of patients seen at the Clinics Hospital, State University of Campinas, São Paulo, Brazil, between 1979 and 1995 were reviewed retrospectively. All 59 included patients (48F/11M) fulfilled four or more American College of Rheumatology criteria for systemic lupus erythematosus. Patients with discold, drug-induced or neonatal lupus, or other systemic connective tissue diseases were excluded. Patients were studied individually then classified in three groups based on age at disease onset, as follows: Group I, < or = 9 years of age; Group II, 10-14 years of age; and Group III, 15-16 years of age. Clinical and laboratory abnormalities and mortality were compared in the three groups.

RESULTS

The most frequent clinical manifestations were joint symptoms (91.5%), renal involvement (71.1%), malar rash (61%), alopecia (61%), fever (59.3%) and photosensitivity (52.5%). Laboratory findings included antinuclear antibody in 94.9% of cases. LE cells in 71.1%, low serum complement in 65.3%, anti-DNA in 63.4%, hematuria in 62.7%, and proteinuria in 61%. The mortality rate was 23.7% (9F/5M) overall, 18.7% in females, and 45.4% in males (P = 0.07). The cause of death was infection in eight patients (57.1% of decedents), central nervous system disease in five (35.7%), and renal insufficiency in one (7.2%). Disease onset before 15 years of age (P = 0.026), renal involvement (P = 0.03), and arterial hypertension (P = 0.002) were predictive of mortality. Mortality was not influenced by gender or race.

Uncommon features of polyarteritis nodosa: psychosis and angio-oedema

Psychosis and swelling of the face and hands are rarely observed in adult polyarteritis nodosa (PAN). We describe a 21-year-old woman who presented with fever, livedo reticularis, tender subcutaneous nodules and arthritis. These manifestations did not respond to prednisone, but remitted when the drug was tapered. She had had psychosis since the age of 16 years. During the flares of the disease she presented with facial, periorbital and hand swelling. This finding is rarely observed in adult PAN. Arteriography showed multiple small aneurysms, of the mesenteric vessels consistent with a diagnosis of PAN. Our report discusses the diagnosis of PAN and emphasises the uncommon presentation of this case.

Antithrombin, protein S and protein C and antiphospholipid antibodies in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) have an increased risk of thrombosis, related to the lupus anticoagulant or anticardiolipin antibodies (ACL). Antithrombin (AT), protein C (PC) and protein S are natural anticoagulants with a very important role in the regulation of coagulation and fibrinolysis, and in the prevention of thrombosis. Total protein S (TPS), free protein S (FPS), AT and PC were measured in 53 unselected patients with SLE in order to verify their relation with previous history of thrombosis or the presence of anticardiolipin antibodies (ACL). The influence of prednisone use on the concentration of these natural anticoagulants was also analysed. The control group was formed by 20 blood donors. The PC concentration was increased in patients with ACL, when compared to controls (p < 0.01), or patients without ACL (p = 0.01). FPS levels were decreased in patients with SLE in relation to controls (p = 0.01), but not related to thrombosis or ACL. There was no difference in plasmatic concentration of AT and TPS, between patients and controls. PC, AT and TPS were increased in patients under prednisone use (p < 0.01). There was no association between concentration of natural anticoagulants and a history of thrombosis. Although decreased FPS was found, or results suggest that it seems not to be a risk factor for thrombosis in SLE. Since PC and AT were not decreased, they should not be involved with thromboembolic complications in these patients. The use of prednisone can influence concentration of natural anticoagulants in patients with SLE.

Evaluation of the hypothalamic-pituitary-gonadal axis in males with systemic lupus erythematosus

OBJECTIVE

To evaluate the hypothalamic-pituitary-gonadal axis in male patients with systemic lupus erythematosus (SLE).

METHODS

We studied 7 male patients with SLE and compared them with 10 age matched healthy controls. Clinical data, laboratory tests, drugs used, and disease activity for SLE (SLE Disease Activity Index) were determined. The basal serum levels of cortisol, total testosterone (T), free testosterone (FT), androstenedione, dehydroepiandrosterone sulfate (DHEAS), estradiol (E2), prolactin (PRL), luteinizing hormone (LH), and follicle stimulating hormone (FSH) were measured in all individuals. In addition, response of LH and FSH to stimulation with luteinizing hormone releasing hormone (LHRH, 100 microg, intravenously) and response of T and FT to stimulation with human chorionic gonadotropins (HCG, 1500 u intramuscular for 3 days) were examined.

RESULTS

Patients with SLE had lower basal levels of T and FT than controls but this difference was not significant. DHEAS and A levels were significantly lower in patients than in controls. The low response of FT after stimulation with HCG indicated diminished testis function (mainly Leidyg cells). In contrast to other studies, the E2 level was significantly lower in patients than in controls. The groups did not differ in LH levels at baseline or after stimulation with LHRH. However, basal levels of FSH were significantly higher in patients.

CONCLUSION

These results suggest that the hypothalamic-pituitary-axis function was normal in patients with SLE. The testis had diminished function, shown by reduced response of FT to stimulation with HCG, but possible inhibitory effects of glucocorticoid therapy must be considered.

Systemic lupus erythematosus: clinical and laboratory aspects related to age at disease onset

OBJECTIVE

To analyse the clinical and laboratory parameters in patients with SLE according to their age at disease onset a retrospective study was undertaken of 272 Brazilian patients fulfilling the 1982 ARA criteria for SLE who were referred to the University Hospital of Campinas between 1973-1992.

METHODS

The patients were divided into three groups according to their age at disease onset: Group A: under the age of 16 (39 patients); Group B age 17 to 49 (223 patients); Group C over the age of 50 (10 patients). Various clinical and laboratorial parameters were analysed and compared among these groups.

RESULTS

There were no significant differences in terms of race, time of disease onset or time of follow-up. Group A had more male patients than Groups B (p < 0.05) or C. Alopecia as an early manifestation, seizures and gastrointestinal involvement were more frequent in Group A (p < 0.05). Raynaud's phenomenon was lower in Group A than in Groups B and C (p < 0.05). Pericarditis was higher in Group C than in Groups A or B (p < 0.05). Nephrotic syndrome was lower in Group C than in Group A (p < 0.05). Positive LE cells were higher in Groups A and C than in Group B (p < 0.05). Anti-DNA antibodies were more prevalent in Group A than in B (p < 0.05). Anti-cardiolipin antibodies were more frequent in adult patients (p < 0.05) (Group B). The mortality rate was higher in Group A than in B or C (p < 0.05).

CONCLUSION

The clinical presentation and course of SLE may be influenced by the age at disease onset. Younger patients showed a poorer prognosis with more seizures, gastrointestinal involvement, nephrotic syndrome, and a higher rate of mortality than the other groups. Group A included more male patients and also exhibited more positive LE cells and anti-DNA antibodies. Raynaud's phenomenon was lower in these young patients. Elderly patients (C) presented more pericarditis and showed mild disease.

[Morphology of bone marrow in systemic lupus erythematosus]

Autoimmune-mediated cell destruction in peripheral blood has been considered the most frequent cause of cytopenias seen in systemic lupus erythematosus. On the other hand, several bone marrow abnormalities have been documented by case reports as well as retrospective studies. In the present prospective analysis we addressed the question of the frequency and features of bone marrow abnormalities in SLE patients presenting peripheral blood cytopenias. In 12 of the 21 patients examined, we found foci of an exudative necrotic reaction characterized by edema, necrotic cells (nucleophagocytosis) and an infiltrate by lymphocytes, plasma cells and macrophages. Reticulin fibers were increased in these foci in 8 cases. Surprisingly, hemopoiesis was hyperplastic in only 6 patients, but was grossly diminished in 12 cases. In 14 patients atypical elements of one or more cell lines could be observed. Most commonly (11 cases), an increase in megakaryocytes with atypical elements showing small pleomorphic nuclei could be seen, together with normal nuclei. Cell atypia in the erythroid line was found in 8 cases, and abnormal granulocytic precursors were seen in 3 cases. No ring sideroblasts could be observed in any case. All these features provide persuasive evidence that the bone marrow is a common target organ affected by autoaggression in SLE. Central and peripheral mechanisms acting to produce peripheral cytopenias must be assumed in most cases.

Systemic lupus erythematosus in 18 Brazilian males: clinical and laboratory analysis

The clinical and laboratory features of 18 males were compared with 254 female patients with systemic lupus erythematosus (SLE). At disease onset male patients were younger than female. Nephropathy, nephrotic syndrome and thrombocytopenia were significantly more frequent in male patients (p < 0.05). Pleuritis occurred as the initial symptom at a significantly higher frequency in males (p < 0.05). No significant immunological difference was found between two groups, except for anti-Sm antibodies which were more frequent in males than in females, but were measured in few patients. We concluded that male patients with SLE have a more severe disease, with higher morbidity, specially related to renal disease.

Neuropsychiatric manifestations of systemic lupus erythematosus: the value of anticardiolipin, antigangliosides and antigalactocerebrosides antibodies

In an attempt to find a serological marker for neuropsychiatric manifestations (NPM) of SLE, sera from 66 patients (classified in three groups, according to their NPM-defined, probable and without NPM) were analysed by ELISA for IgG and IgM anticardiolipin, antigangliosides and antigalactocerebrosides antibodies. A strong correlation was found between IgM antigangliosides and antigalactocerebrosides antibodies and NPM, but not with IgG class. IgM and IgG antibodies anticardiolipin were not correlated with NPM in this study. Both IgM antigangliosides and antigalactocerebrosides antibodies disappeared in seven patients with definite but clinically inactive NPM. The analysis of these autoantibodies showed an important role predictive for NPM in SLE; the negative test decreases the chance of the NPM.