18: Systemic Lupus Erythematosus and Lupus‐Like Syndromes

CHAPTER 18
Systemic Lupus Erythematosus and Lupus‐Like Syndromes


Vijay Rao1,3, Rosalind Ramsey‐Goldman2 and Caroline Gordon1,3


1 University of Birmingham, Birmingham, UK


2 Solovy Arthritis Research Society Research; Northwestern University Feinberg School of Medicine, Chicago, USA


3 Department of Rheumatology; Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK


Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of unknown cause (Rahman and Isenberg, 2008), with a wide variety of manifestations that is usually characterized by remissions and relapses. SLE is part of a spectrum of autoimmune diseases that includes discoid lupus, drug‐induced lupus, neonatal lupus, Sjögren’s syndrome, antiphospholipid antibody syndrome, dermatomyositis/polymyositis and overlap syndromes. Antiphospholipid antibody may occur as a primary disorder or secondary to SLE or another autoimmune condition, such as autoimmune hypothyroidism or chronic active hepatitis. It is possible to achieve good disease control but life‐long follow‐up is needed to prevent and treat flares, to limit the complications due to damage and reduce the risk of premature death. Thus, it is important that the primary care physician, patient and hospital specialists are involved closely in the management of these diseases.


Causes


Systemic lupus erythematosus is a multifactorial disease due to a complex interplay of genetic and environmental factors that vary between individuals (Boxes 18.1 and 18.2). SLE is characterized by multiple immune abnormalities including dendritic, B‐ and T‐cell dysfunction, resulting in the development of autoantibodies and autoreactive T‐cells. Defective clearance of apoptotic cells and immune complexes contributes to pathogenesis, with the activation of complement playing a major role in tissue damage. There is increasing evidence that the cytokine interferon‐alpha (IFN‐alpha) plays a role in activating genes involved in the disease, and that interleukin (IL)‐6 and Il‐10 levels are increased in active disease. Antiphospholipid antibodies are a specific family of autoantibodies directed against anionic phospholipids located in cell membranes. The pathogenic mechanisms in antiphospholipid syndrome relate to the prothrombotic effects of these antibodies in vivo.



Neutrophil extracellular traps (NETs) are produced from low‐density granulocytes (LDG) and are networks of extracellular decondensed chromatin fibres containing histones and several cytoplasmic proteins. Material produced from NETs stimulates plasmacytoid dendritic cells to release IFN‐alpha, a critical cytokine in lupus pathogenesis. Some lupus patients lack the ability to efficiently degrade NETs. Lupus neutrophils are predisposed toward NETosis, with both IFN‐alpha and autoantibodies serving as potential triggers. Elevated serum levels of matrix metalloproteinase‐9 (MMP‐9) are externalized from LDG‐NETs and lead to endothelial dysfunction and atherosclerosis in SLE through activation of MMP‐2 (Knight and Kaplan, 2012).


Epidemiology


There are significant disparities in the incidence and prevalence rates of SLE disease worldwide (Pons‐Estel et al., 2010; Somers et al., 2014). This variability may be due to true population differences or to dissimilar methods of case ascertainment. Nevertheless, the consistent trend reflects that the burden of disease is highest in women and higher among non‐white ethnic groups (Table 18.1).


Table 18.1 Prevalence and incidence of systemic lupus erythematosus worldwide


















































































Country Prevalence (per 100 000) Incidence (per 100 000)
United Kingdom
(Nottingham, Birmingham)

• Adults 20.6–28.7 4.48–4.94
• Women 37.6–53.1 7.46–8.31
• White/Caucasians 20.2–36.3 2.5–3.4
• Black/Afro‐Caribbeans 197.2–206.0 11.9–31.9
• Asians 64.0–96.5 4.1–15.2
Iceland 35.9 3.3
Spain 34.1 2.2
Sweden 38.9 4.8
USA
• Adults 70.1–74.1 5–6.2
• Women 124.2–131.5 8.4–10.4
• White/Caucasians 46.6–50.9 3.2–4.4
• Black/African‐Americans 102.0–109.8 6.9–9.0
• Puerto Rican (New York only) 18.0 2.3
Canada 20.6–42.3 0.9–7.4
Australia (Aborigines) 11.0 13.4–89.3
Japan 3.7–19.3 0.9–2.9
Martinique 64.2 4.7

Clinical presentations


Systemic lupus erythematosus


The American Rheumatology Association’s 1982 classification criteria for systemic lupus erythematosus were revised in 1997 (Box 18.3). These criteria were designed not for diagnosis but for classifying patients into studies and clinical trials. The diagnosis of SLE should be considered if a patient has characteristic features of lupus, even if they do not fulfil four of the 11 criteria. For example, a 25‐year‐old woman with malar rash, positive antinuclear antibody and histologically proven glomerulonephritis obviously has systemic lupus erythematosus, despite fulfilling only three criteria (Table 18.2).


Table 18.2 Cumulative percentage incidence of clinical features of systemic lupus erythematosus








































Feature (%)
Arthritis 72–94
Alopecia 52–80
Skin rash 74–90
Photosensitivity 10–62
Malar rash 37–90
Oral ulcers 30–61
Fever 74–91
Neuropsychiatric 19–63
Renal 35–73
Cardiac 10–29
Pleuropulmonary 9–54

The Systemic Lupus Collaborating Clinics (SLICC) revised and validated the American College of Rheumatology (ACR) SLE classification criteria (Table 18.3). The SLICC criteria for SLE classification require: (1) fulfilment of at least four criteria, with at least one clinical criterion AND one immunological criterion OR (2) lupus nephritis as the sole clinical criterion in the presence of ANA or anti‐dsDNA antibodies (Petri et al., 2012). These criteria are meant to be clinically more relevant, allowing the inclusion of more patients with clinically defined lupus in studies and clinical trials than when using the current ACR criteria.


Table 18.3 Clinical and immunological criteria used in the SLICC classification criteria.


Source: Petri et al. (2012), reproduced with permission of John Wiley & Sons








































Clinical criteria Immunological criteria
Acute cutaneous lupus: malar rash, maculopapular rash, photosensitive rash and non‐indurated psoriasiform rash ANA
Chronic cutaneous lupus: discoid lupus, lupus panniculitis, mucosal lupus and chilblain lupus Anti‐dsDNA antibodies
Oral ulcers Anti‐Sm antibodies
Non‐scarring alopecia Antiphospholipid antibody
Synovitis: swelling or effusion OR tenderness in 2 or more joints and 30 minutes or more of morning stiffness Low complement
Serositis: pleurisy for more than 1 day (symptoms/pleural effusions/rub)
Pericardial pain for more than 1 day/pericardial effusion/rub/ECG evidence)
Direct Coombs test (in absence of haemolytic anemia)
Renal: urine protein/creatinine (or 24 h urine protein) representing 500 mg of protein/24 h
Or red blood cell casts
Neurological: seizures, psychosis, myelitis, mononeuritis multiplex, peripheral or cranial neuropathy, acute confusional state
Haemolytic anaemia
Leukopenia (<4000/mm3 at least once)
Or lymphopenia (<1000/mm3 at least once)
Thrombocytopenia (<100 000/mm3 at least once)

General features


Fatigue is common, troublesome and difficult to evaluate. It may be associated with depression or fibromyalgia secondary to SLE, hypothyroidism (often autoimmune in nature), anaemia, pulmonary or cardiovascular problems. Other constitutional symptoms of active disease include fever, malaise, anorexia, lymphadenopathy and weight loss.


The most common form of anaemia is a normochromic normocytic anaemia of chronic disease. Some patients develop an antibody‐mediated haemolytic anaemia and others an iron deficiency anaemia secondary to peptic ulceration or gastritis (usually due to non‐steroidal anti‐inflammatory drugs.


Mucocutaneous manifestations


The most common mucocutaneous features are painful or painless mouth ulcers, diffuse alopecia (Figure 18.1), butterfly or malar rash (Figure 18.2) and photosensitivity. Nasal or vaginal ulcers may also occur. Mucocutaneous features are more prominent in Asians and whites. Subacute cutaneous lupus erythematosus is a non‐scarring rash found in areas of the body exposed to the sun. Discoid lesions are chronic scarring lesions that heal with hypo‐ or hyperpigmentation. Non‐scarring alopecia may be patchy or diffuse. Rapid, spontaneous hair loss indicates active disease. Raynaud’s phenomenon is usually milder than in scleroderma.

Back view of a head with patchy alopecia.

Figure 18.1 Patient with patchy alopecia

Front view of a woman with malar rash in systemic lupus erythematosus.

Figure 18.2 Malar rash in systemic lupus erythematosus


Musculoskeletal manifestations


Generalized arthralgia with early morning stiffness and no swelling is very common. A non‐erosive arthritis with joint tenderness and swelling may develop. Deformities are unusual but may occur due to ligamentous laxity (Jacoud’s arthropathy) (Figure 18.3) compared with rheumatoid arthritis where the deformities are due to joint erosions. Myalgia is common but inflammatory myositis occurs in only 5% of patients. Indeed, secondary causes of myopathy are more common and can be caused by corticosteroids, antimalarials and lipid‐lowering agents. Avascular necrosis and infection should be suspected if the patient complains of sudden‐onset, severe pain in only one joint. In addition, the risk of osteoporosis and subsequent fracture due to minimal or no trauma can be increased in patients with SLE.

Hand with Jacoud’s arthropathy.

Figure 18.3 Jacoud’s arthropathy


Haematological manifestations


Leucopenia may be an early clue to the diagnosis of SLE. Lymphopenia is the most common manifestation of SLE other than positive antinuclear antibodies and, in untreated patients, is caused by lymphocytotoxic antibodies. Mild neutropenia is relatively common in black people even without SLE, but values <1.5 × 109/L are usually related to disease or drugs. Thrombocytopenia may occur as an immune‐mediated condition associated with a risk of bleeding, as in idiopathic thrombocytopenic purpura, or as a milder abnormality with platelet counts >70 × 109/L associated with a risk of thrombosis in the antiphospholipid syndrome (see below).


Renal manifestations


Renal disease is an important determinant of the outcome of SLE. It can occur in up to 50% of white patients and 75% of black patients. Studies have shown that renal disease is also more severe in non‐white patients. Early nephritis is often asymptomatic, so regular urinalysis for protein, blood and casts is essential. Some patients present with nephrotic syndrome and a few with devastating accelerated hypertension and renal shutdown. Renal biopsy is helpful for assessing the severity, nature, extent and reversibility of the involvement and is an important guide to treatment and prognosis. For example, those with mesangial nephritis (class I) rarely progress to renal failure. In contrast, those with diffuse proliferative glomerulonephritis (class IV) are at risk for end‐stage renal disease.


Nervous system manifestations


Systemic lupus erythematosus may affect the central and peripheral nervous systems. Definitions for these manifestations have been proposed by a consensus group (Boxes 18.4 and 18.5). The most common manifestations are headache, seizures, aseptic meningitis and cerebrovascular accidents. Antiphospholipid antibodies (including anticardiolipin antibodies) have been implicated in cerebrovascular accidents and chorea. It is often hard to determine whether the depression and headaches are due to lupus itself; in many cases, they are related to psychosocial issues. Other possible causes such as sepsis, drugs, uraemia, severe hypertension and other metabolic causes must be sought and treated. Steroids are often blamed for inducing psychosis but if any doubt exists, patients should be given more, not less, steroid while under medical supervision, particularly if active lupus is evident in other systems.

Nov 5, 2018 | Posted by in RHEUMATOLOGY | Comments Off on 18: Systemic Lupus Erythematosus and Lupus‐Like Syndromes

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