The unexplained female predominance of systemic lupus erythematosus: clues from genetic and cytokine studies

A Comprehensive Systematic Review of Natural Biomedicines for Immune-Mediated and Inflammatory Dermatologic Diseases

BACKGROUND

Natural biomedicines (NBMs) are frequently used to manage immune-mediated and inflammatory dermatologic diseases (IMIDDs). This systematic review evaluates the efficacy, safety, and clinical relevance of NBMs in IMIDDs, providing an evidence-based analysis to guide dermatologic practice.

METHODS

Following PRISMA guidelines, a systematic search was conducted in PubMed, Embase, Medline, and Google Scholar for randomized controlled trials (RCTs) investigating NBMs in IMIDDs from 1990 to 2023. Studies were included if they met predefined eligibility criteria: RCT design, relevant IMIDD condition, NBM intervention, and quantitative outcome measures. Risk of bias was assessed using the Jadad scale. Results were synthesized qualitatively due to heterogeneity in study designs and outcome measures.

RESULTS

Of 1364 records screened, 95 RCTs were included, encompassing 5265 participants across 23 countries. Indigo naturalis, fish oil (⍵-3), and aloe vera demonstrated the most consistent efficacy in managing psoriasis, systemic lupus erythematosus (SLE), atopic dermatitis (AD), and lichen planus (LP). Indigo naturalis significantly improved erythema, scaling, and PASI scores in psoriasis patients. Fish oil showed benefits in SLE disease activity indices and AD severity, while aloe vera demonstrated improvements in SCORAD and LP severity criteria. Most NBMs exhibited favorable safety profiles, although adverse event reporting was inconsistent.

DISCUSSION

While these findings highlight the potential of NBMs in dermatologic care, methodological limitations, including small sample sizes, heterogeneity in study designs, and lack of direct comparisons to conventional therapies, limit definitive conclusions. Additionally, not all natural agents can be easily searched and captured in systematic reviews, which may have restricted the scope of included NBMs. Future research should emphasize high-quality RCTs, standardized outcome measures, and comparative studies against conventional treatments.

TRIAL REGISTRATION

The review protocol is registered with Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/UH9XJ ).

Real-World Prevalence, Incidence and Management of Systemic Lupus Erythematosus in Germany: A Retrospective Claims Data Analysis

INTRODUCTION

This study evaluated the prevalence and incidence of systemic lupus erythematosus (SLE) in Germany and explored real-world data on sequence of therapy (SOT; sequence of drugs as prescribed in clinical practice).

METHODS

This retrospective, observational, longitudinal cohort study using German claims data from the WIG2 GmbH Scientific Institute for Health Economics and Health System Research database (January 2011-December 2019), extrapolated to the statutory health insurance (SHI)-insured population, evaluated prevalence and incidence in an epidemiological analysis group and SLE treatment patterns in an incident cohort (subgroup ≥ 18 years of age with incident disease and ≥ 24-month follow-up post index date). Analyses were descriptive.

RESULTS

Based on the epidemiological analysis (N = 3017), annual SLE prevalence per 100,000 gradually increased from 40.47 in 2012 to 59.87 in 2019 in the SHI population. In contrast, annual SLE incidence was relatively stable, ranging from 8.83 in 2012 to 8.86 in 2019. In the incident cohort (n = 941), based on SOT analysis (n = 681), treatment gaps of > 60 days were common: 67.1%, 51.2% and 54.9% in SOT1, SOT2 and SOT3, respectively. Corticosteroids were the most frequent monotherapy in SOT1 (31.0% vs 0% in SOT2/SOT3); 30.0-70.0% of patients received a corticosteroid combination therapy across SOTs. Over 50% of patients in each SOT received an antimalarial therapy (combination or monotherapies). The use of biologic disease-modifying drugs was low, ranging from 0.4% in SOT1 to 9.7% in SOT3.

CONCLUSIONS

Our data demonstrate an increased prevalence of SLE with stable incidence in Germany, suggesting improved survival of affected patients. Nevertheless, suboptimal treatment patterns, including limited use of biologics, reflect a high unmet need for optimised and personalised therapies in patients with SLE.

Tubo-Ovarian Mass Leading to Necrotizing Fasciitis in a Patient With Systemic Lupus Erythematosus: A Case Report

Acute abdominal pain is a common clinical problem in emergency and non-emergency cases. Acute abdomen in systemic lupus erythematosus (SLE) is a challenging diagnostic and therapeutic problem that carries high mortality and morbidity rates. The present study reports a case of a 45-year-old female, a known case of SLE, hypothyroidism, and seizure disorder. The patient presented with chief complaints of pain in the left iliac and lumbar region with a history of amenorrhea for three to four months. Based on the clinical findings, laboratory investigations, and diagnostic assessment involving ultrasonography (USG), the diagnosis of acute abdomen along with tubo-ovarian mass with dermoid cyst and SLE with lupus nephritis and seizure disorder was confirmed. The patient was operated with total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy with loop colostomy. The patient was placed in the surgical intensive care unit for observation; however, sepsis developed, and the trauma from the exploratory laparotomy led to septic shock, followed by hypotension and ultimately cardiac arrest. Hence, the cause of death was attributed to sepsis with shock and multiple organ dysfunction syndromes. In conclusion, acute abdomen in SLE suggests that systemic measurement and early laparotomy may improve the prognosis; however, due to chronic inflammatory status and immune-compromised state, the cases should be handled with utmost caution with a multidisciplinary approach due to the increase in the mortality rate.

Disease diagnostics using machine learning of B cell and T cell receptor sequences

Clinical diagnosis typically incorporates physical examination, patient history, various laboratory tests, and imaging studies but makes limited use of the human immune system's own record of antigen exposures encoded by receptors on B cells and T cells. We analyzed immune receptor datasets from 593 individuals to develop MAchine Learning for Immunological Diagnosis, an interpretive framework to screen for multiple illnesses simultaneously or precisely test for one condition. This approach detects specific infections, autoimmune disorders, vaccine responses, and disease severity differences. Human-interpretable features of the model recapitulate known immune responses to severe acute respiratory syndrome coronavirus 2, influenza, and human immunodeficiency virus, highlight antigen-specific receptors, and reveal distinct characteristics of systemic lupus erythematosus and type-1 diabetes autoreactivity. This analysis framework has broad potential for scientific and clinical interpretation of immune responses.

Impact of systemic lupus erythematosus on the reproductive health of women before and after disease onset: an observational study

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that can significantly affect reproductive health. This study aims to assess reproductive health metrics among SLE patients in Indian settings to compare fertility rates and the impact of the disease on pregnancy with data from the general population. The independent, prospective, multicenter, observational study collected data from SLE patients at seven centres in India through a database created by the Indian Rheumatology Association. Data were gathered using structured proformas validated by experts. The final analysis included women aged > 15 years (total cohort), after excluding male subjects and those with inadequate data. Participants were categorized into married and unmarried cohorts, and various reproductive health metrics were analyzed pre- and post-disease. The total cohort included 631 subjects with an average age at recruitment of 36.46 ± 12.31 years, and mean age at menarche of 13.74 ± 1.44 years. The total cohort had an average of 1.8 pregnancies per woman, with an abortion rate of 0.35. The married cohort showed a pregnancy wastage ratio of 201.43. The cumulative fertility rate noted for the married cohort was 1.40, while for the total cohort was 1.04. Significant differences in pregnancy outcomes were observed before and after the onset of SLE, with pregnancies declining from 703 to 136 (P < 0.0001). A significant increase in pregnancy complications, including pregnancy-induced hypertension, small for gestational age, and pre-eclampsia, was noted before and after disease onset (P < 0.0001). Central nervous system and skin involvement also became more prevalent post-disease (P = 0.046 and P = 0.040, respectively). The study highlights the significant impact of SLE on pregnancy, both before and after disease onset, noting reduced pregnancies and live births, along with increased rates of pregnancy loss, stillbirths, and abortions. Complications such as hypertension and pre-eclampsia were more common after disease onset. These findings emphasize the need for targeted healthcare strategies and collaborative efforts to improve reproductive outcomes in patients with SLE.

Monoclonal antibodies for the management of cutaneous lupus erythematosus: an update on the current treatment landscape

Cutaneous lupus erythematosus (CLE) is a complex autoimmune disease often characterized by a multitude of skin findings. CLE is generally classified into three main categories: acute CLE, subacute CLE and chronic CLE. The current therapeutic guidelines for CLE include counselling patients on general measures and medication regimens. Treatment options include optimized photoprotection, avoidance of environmental triggers, corticosteroids, topical and systemic immunomodulators, and antimalarials. To date, no biologic medications (i.e. monoclonal antibodies, mAbs) are approved for CLE. The first mAb for the treatment of both systemic lupus erythematosus (SLE) and active lupus nephritis was belimumab, and was approved for these diseases in 2011 and 2020, respectively. Belimumab is a specific inhibitor of B-lymphocyte stimulator. Anifrolumab, a type I interferon receptor antagonist, was approved in 2021 for SLE. Other mAbs with different targets, including a novel biologic that inhibits blood dendritic cell antigen 2, are currently under investigation for CLE. This review will describe the general treatment landscape for CLE. Selected studies related to these various mAbs will be discussed, as well as their safety profiles and efficacies demonstrated in clinical trials. Biologic medications can potentially augment the number of treatment options for patients living with CLE.

An essential role for TASL in mouse autoimmune pathogenesis and Toll-like receptor signaling

TASL is an immune adaptor that binds to the solute carrier SLC15A4 and facilitates activation of the transcription factor IRF5 during Toll-like receptor (TLR) signaling. Similar to IRF5 and SLC15A4, single nucleotide polymorphisms (SNPs) within TASL have been implicated in increased susceptibility to systemic lupus erythematosus (SLE) in patients. However, the biological function of TASL in vivo and how SLE-associated SNPs increase disease risk is unknown. Here we report that mice deficient in Tasl lack responses to TLR7/9 stimulation and are protected from autoimmune symptoms induced by Aldara or pristane. Loss of Tasl reduces IRF5 phosphorylation and cytokine production in multiple immune cell types but has no effect on other aspects of TLR signaling. Conversely, an SLE-associated TASL risk variant increases TASL protein expression via codon usage, resulting in augmented cytokine production in human cells. Altogether, our study validates the essential function of TASL in TLR signaling and autoimmune pathogenesis.

Identification of RNA uridylation subtypes, and the prognostic and therapeutic value of RNA uridylation in systemic lupus erythematosus

The uridylation of 3'-RNA-a major process in epitranscriptomics- is catalyzed by terminal uridylyl transferases (TUTases), which are involved in multiple diseases and the immune response. Nonetheless, the role of TUTases in systemic lupus erythematosus (SLE) remains unknown. Here we identified increased level of MTPAP and ZCCHC6 and decreased level of PAPD5 and ZCCHC11 in SLE patients from Gene Expression Omnibus (GEO) GSE50772, GSE65391, and GSE121239. The random forest model was applied to screen 4 TUTase candidates (MTPAP, ZCCHC6, PAPD5, and ZCCHC11) to predict the susceptibility of SLE. A nomogram was constructed based on the 4 selected TUTase regulators. Decision curve analysis indicated that patients could benefit from the nomogram. Moreover, based on the 4 differentially expressed genes, individuals with SLE were divided into three patterns (Cluster A-C) using the consensus clustering method. Cluster B was enriched in adaptive immune cells, with the lowest TCE signature expression, manifesting a higher Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) than that in Cluster A and C. whereas, Cluster C was enriched in innate immune cells, with the highest T-cell exhaustion (TCE) signature expression, manifesting lower SLEDAI than that in Cluster B. Clinically, lupus nephritis (LN) patients manifested increased expression of MTPAP and ZCCHC6 and decreased expression of PAPD5 and ZCCHC11 in PBMCs using Quantitative Polymerase Chain Reaction (q-PCR). Immunohistochemistry (IHC) illustrated higher level of ZCCHC6 in the kidneys of LN patients than that in NC. In summary, TUTases could predict the occurrence of SLE and stratify patients based on their immune characteristics, eventually predicting the disease activity and guiding immune therapy.

Adenohypophysis-Inducible Sex Hormones Correlate with Interleukin-6, -8, and Tumor Necrosis Factor-α in Patients with Systemic Lupus Erythematosus

Adenohypophysis-inducible sex hormones include prolactin (PRL), follicle-stimulating hormone (FSH), and luteinizing hormone (LH). These hormones influence the occurrence of lupus erythematosus by affecting the endocrine and immune systems. The present study analyzed the relationship between serum sex hormones and several cytokines in patients with systemic lupus erythematosus (SLE). Compared with the healthy controls, early-onset SLE female patients with menopause had higher PRL levels than the healthy controls and cutaneous lupus erythematosus (CLE) group. FSH levels were higher in male patients with SLE than in the healthy controls or CLE group. In SLE patients, the estradiol levels correlated negatively with interleukin (IL)-8. The levels of FSH versus IL-8, PRL versus IL-6, PRL versus tumor necrosis factor (TNF)-α, and LH versus IL-8 levels were moderately positively correlated. In conclusion, PRL, FSH, and LH are positively associated with IL-6, IL-8, and TNF-α in the sera from SLE patients, which indicates that sex hormone levels can serve as an indicator of disease activity during SLE diagnosis.

Systemic lupus erythematosus: An imitator for inflammatory bowel disease

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that may involve any organ in the body. Inflammation of the bowel wall as a presenting symptom of SLE is uncommon and can lead to delays in diagnosis and treatment. Here, we discuss the case of an adolescent male who presented with weight loss, intermittent fevers, abdominal pain, vomiting, and diarrhea. Initially, inflammatory bowel disease (IBD) was suspected, but endoscopic evaluation did not support this diagnosis. A computed tomography scan of the abdomen revealed signs of serositis, concerning for an inflammatory process and the patient was referred to Rheumatology for further evaluation. Autoimmune serologies were obtained and combined with clinical findings confirmed a diagnosis of SLE. This case advances our understanding of SLE as a multisystemic disease and highlights an unusual presentation involving the gastrointestinal tract, which can mimic IBD and potentially delay the diagnosis and treatment process.

Mechanisms Underlying Gender Influence on the Clinical Course and Immunopathogenesis of Systemic Lupus Erythematosus: An Explorative Review

Systemic lupus erythematosus (SLE) is an autoimmune disorder with a complex clinical course and diverse presentations. The immunopathogenesis of SLE has long intrigued physicians and researchers. Despite its extensive global prevalence, there is no specific treatment to prevent and treat SLE, and in the majority of SLE patients, the management involves controlling disease remissions and symptom reactivations or flares. SLE patients suffer from damage to different organs of the body, complicating disease management. They are predisposed to infectious diseases that could contribute to enhanced disease progression. Devising effective management strategies requires a comprehensive understanding of the effects of the disease and its influence on the immune system. SLE affects females more frequently than men. However, male SLE patients often suffer from more severe disease than females. Gender variations have also been noted in clinical manifestations in patients with SLE. In light of this, additional research is needed to understand these variations and promote the progress of gender-specific patient management and treatment strategies. This review aimed to compare the influence of gender on the clinical consequences, immunopathogenesis, and associated consequences between male and female SLE patients. An extensive literature search was conducted to collect relevant data. PubMed, MEDLINE, Embase, and Google Scholar were searched from inception to the present for articles that compared clinical outcomes and associated disorders in terms of gender among SLE patients. We also explored the immunopathogenesis, mechanisms underlying gender-based clinical effects of SLE, and infectious disease-related consequences. Additionally, we provide key updates regarding the treatment and management of SLE.

Regional variations in serum IL-35 levels and association with systemic lupus erythematosus: a systematic review and meta-analysis

Interleukin (IL)-35 is an anti-inflammatory cytokine that regulates autoimmune diseases, including systemic lupus erythematosus (SLE). However, the association between the cytokine and disease may vary by geographical region. This study performed a meta-analysis to quantitatively assess the correlation between the serum IL-35 levels in SLE patients and sub-group analyses were conducted. Four main electronic databases-Scopus, Embase, Science Direct, PubMed-were searched for relevant studies. After a database search, Endnote software was used to find and remove duplicate studies. Random-effects models were used to estimate standard mean differences in serum/plasma IL-35 levels by Hedges' g with 95% confidence intervals (CIs). Publication bias was assessed with funnel plots, and risk of bias was assessed according to the Newcastle-Ottawa Scale (NOS). Sixteen studies met the eligibility criteria and were included in a qualitative review; data from 15 studies were included in the meta-analysis. Total IL-35 levels (pg/mL) did not differ among patients with active SLE and healthy controls (Hedges's g: 0.22, 95% CI - 0.51, 0.95, p = 0.55). Sub-group analysis revealed that IL-35 levels in patients with active SLE were lower than in healthy controls in Chinese studies (Hedges's g: - 3.11, 95% CI - 5.72, - 0.51), but not in non-Chinese studies (Hedges's g: 1.63, 95% CI - 0.31, 3.57). This regional difference was statistically significant (p < 0.01). The analysis comparing patients with inactive SLE and healthy controls showed a similar trend. This study suggests that serum IL-35 levels are lower in patients with SLE in studies from China, but not other regions. However, standardized protocols with large sample sizes are needed to confirm these findings.

Androgens contribute to sex bias of autoimmunity in mice by T cell-intrinsic regulation of Ptpn22 phosphatase expression

Autoimmune diseases such as systemic lupus erythematosus (SLE) display a strong female bias. Although sex hormones have been associated with protecting males from autoimmunity, the molecular mechanisms are incompletely understood. Here we report that androgen receptor (AR) expressed in T cells regulates genes involved in T cell activation directly, or indirectly via controlling other transcription factors. T cell-specific deletion of AR in mice leads to T cell activation and enhanced autoimmunity in male mice. Mechanistically, Ptpn22, a phosphatase and negative regulator of T cell receptor signaling, is downregulated in AR-deficient T cells. Moreover, a conserved androgen-response element is found in the regulatory region of Ptpn22 gene, and the mutation of this transcription element in non-obese diabetic mice increases the incidence of spontaneous and inducible diabetes in male mice. Lastly, Ptpn22 deficiency increases the disease severity of male mice in a mouse model of SLE. Our results thus implicate AR-regulated genes such as PTPN22 as potential therapeutic targets for autoimmune diseases.

Addressing the research gap: access to care hinders genetic discovery in systemic lupus erythematosus patients throughout the African diaspora

Systemic lupus erythematosus (SLE) is a complex autoimmune condition that disproportionately impacts non-White ethnic and racial groups, particularly individuals in the African diaspora who experience heightened incidence, prevalence, and adverse outcomes. Genetic and epigenetic factors play significant roles in SLE risk, however these factors neither explain the whole of SLE risk nor the stark racial disparities we observe. Moreover, our understanding of genetic risk factors within African ancestry populations is limited due to social and environmental influences on research participation, disease presentation, and healthcare access. Globally, the African diaspora faces barriers in accessing essential SLE diagnostic tools, therapeutics, healthcare practitioners, and high-quality clinical and translational research studies. Here, we provide insights into the current state of genetic studies within African ancestry populations and highlight the unique challenges encountered in SLE care and research across countries of varying income levels. We also identify opportunities to address these disparities and promote scientific equity for individuals affected by SLE within the global African diaspora.

Antiphospholipid Syndrome and Catastrophic Antiphospholipid Syndrome: A Comprehensive Review of Pathogenesis, Clinical Features, and Management Strategies

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPLs) that predispose individuals to thrombotic events and pregnancy-related complications. APS can occur as a primary condition or in association with other autoimmune diseases, most commonly systemic lupus erythematosus (SLE). Catastrophic APS (CAPS) is a rare, severe variant of APS, marked by rapid-onset, widespread thrombosis leading to multi-organ failure, often triggered by infections, surgical procedures, or cessation of anticoagulation therapy. Both APS and CAPS present significant clinical challenges due to their potential for severe morbidity and mortality. This comprehensive review aims to provide a detailed overview of the pathogenesis, clinical features, diagnostic criteria, and management strategies for APS and CAPS. The review highlights the immunological mechanisms underlying APS, including the role of aPLs, complement system activation, and endothelial cell dysfunction in developing thrombosis. It also outlines the clinical manifestations of APS, such as venous and arterial thrombosis, pregnancy morbidity, and neurological symptoms, along with the diagnostic criteria based on clinical and laboratory findings. The review delves into its pathogenesis, clinical presentation, and diagnostic challenges in the context of CAPS, emphasizing the need for immediate and intensive therapy to manage this life-threatening condition. Current management strategies for APS, including anticoagulant therapy, immunomodulatory treatments, and specific interventions for pregnancy-related complications, are discussed. The review highlights the importance of a multidisciplinary approach for CAPS, combining anticoagulation, high-dose corticosteroids, plasma exchange, and intravenous immunoglobulin. The review also addresses the prognosis and long-term outcomes for patients with APS and CAPS, underlining the necessity for ongoing monitoring and follow-up to prevent recurrent thrombotic events and manage chronic complications. Finally, future directions in research are explored, focusing on emerging therapies, biomarkers for early diagnosis, and the need for clinical trials to advance the understanding and treatment of these complex syndromes. By enhancing the understanding of APS and CAPS, this review aims to improve diagnosis, treatment, and patient care, ultimately leading to better health outcomes for those affected by these conditions.

Microbial influences on severity and sex bias of systemic autoimmunity

Commensal microbes have the capacity to affect development and severity of autoimmune diseases. Germ-free (GF) animals have proven to be a fine tool to obtain definitive answers to the queries about the microbial role in these diseases. Moreover, GF and gnotobiotic animals can be used to dissect the complex symptoms and determine which are regulated (enhanced or attenuated) by microbes. These include disease manifestations that are sex biased. Here, we review comparative analyses conducted between GF and Specific-Pathogen Free (SPF) mouse models of autoimmunity. We present data from the B6;NZM-Sle1NZM2410/AegSle2NZM2410/AegSle3NZM2410/Aeg-/LmoJ (B6.NZM) mouse model of systemic lupus erythematosus (SLE) characterized by multiple measurable features. We compared the severity and sex bias of SPF, GF, and ex-GF mice and found variability in the severity and sex bias of some manifestations. Colonization of GF mice with the microbiotas taken from B6.NZM mice housed in two independent institutions variably affected severity and sexual dimorphism of different parameters. Thus, microbes regulate both the severity and sexual dimorphism of select SLE traits. The sensitivity of particular trait to microbial influence can be used to further dissect the mechanisms driving the disease. Our results demonstrate the complexity of the problem and open avenues for further investigations.

Engineering antigen-presenting cells for immunotherapy of autoimmunity

Autoimmune diseases are burdensome conditions that affect a significant fraction of the global population. The hallmark of autoimmune disease is a host's immune system being licensed to attack its tissues based on specific antigens. There are no cures for autoimmune diseases. The current clinical standard for treating autoimmune diseases is the administration of immunosuppressants, which weaken the immune system and reduce auto-inflammatory responses. However, people living with autoimmune diseases are subject to toxicity, fail to mount a sufficient immune response to protect against pathogens, and are more likely to develop infections. Therefore, there is a concerted effort to develop more effective means of targeting immunomodulatory therapies to antigen-presenting cells, which are involved in modulating the immune responses to specific antigens. In this review, we highlight approaches that are currently in development to target antigen-presenting cells and improve therapeutic outcomes in autoimmune diseases.

KLF2 enhancer variant rs4808485 increases lupus risk by modulating inflammasome machinery and cellular homoeostasis

OBJECTIVE

A recent genome-wide association study linked KLF2 as a novel Asian-specific locus for systemic lupus erythematosus (SLE) susceptibility. However, the underlying causal functional variant(s), cognate target gene(s) and genetic mechanisms associated with SLE risk are unknown.

METHODS

We used bioinformatics to prioritise likely functional variants and validated the best candidate with diverse experimental techniques, including genome editing. Gene expression was compared between healthy controls (HCs) and patients with SLE with or without lupus nephritis (LN+, LN-).

RESULTS

Through bioinformatics and expression quantitative trait locus analyses, we prioritised rs4808485 in active chromatin, predicted to modulate KLF2 expression. Luciferase reporter assays and chromatin immunoprecipitation-qPCR demonstrated differential allele-specific enhancer activity and binding of active histone marks (H3K27ac, H3K4me3 and H3K4me1), Pol II, CTCF, P300 and the transcription factor PARP1. Chromosome conformation capture-qPCR revealed long-range chromatin interactions between rs4808485 and the KLF2 promoter. These were directly validated by CRISPR-based genetic and epigenetic editing in Jurkat and lymphoblastoid cells. Deleting the rs4808485 enhancer in Jurkat (KO) cells disrupted NLRP3 inflammasome machinery by reducing KLF2 and increasing CASPASE1, IL-1β and GSDMD levels. Knockout cells also exhibited higher proliferation and cell-cycle progression than wild type. RNA-seq validated interplay between KLF2 and inflammasome machinery in HC, LN+ and LN-.

CONCLUSIONS

We demonstrate how rs4808485 modulates the inflammasome and cellular homoeostasis through regulating KLF2 expression. This establishes mechanistic connections between rs4808485 and SLE susceptibility.

Chronic Dermatographic Urticaria Secondary to Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) poses significant challenges in diagnosis and management due to its diverse clinical manifestations, including various skin abnormalities. Chronic dermatographic urticaria, although less recognized, has been suggested to have an association with SLE; however, evidence supporting this connection remains limited. We present a case of chronic dermatographic urticaria secondary to SLE in a 26-year-old female. Despite ineffective conventional treatments, the initiation of hydroxyzine resulted in notable symptom improvement without adverse effects. This case underlines the importance of recognizing and addressing less common dermatological manifestations in SLE, emphasizing the need for a comprehensive approach to optimize patient outcomes. It highlights the potential utility of hydroxyzine in managing the refractory symptoms of chronic dermatographic urticaria in SLE patients. This report contributes to the expanding evidence regarding the complex interplay between SLE and dermatographic urticaria, necessitating further research to understand underlying mechanisms and establish optimal treatment strategies. Enhanced awareness and understanding of such associations are crucial for facilitating early diagnosis and tailored management approaches in patients with SLE, ultimately improving their quality of life and clinical outcomes.

Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease characterised by the presence of autoantibodies towards nuclear antigens, immune complex deposition, and chronic inflammation at classic target organs such as skin, joints, and kidneys. Despite substantial advances in the diagnosis and management of SLE, the burden of disease remains high. It is important to appreciate the typical presentations and the diagnostic process to facilitate early referral and diagnosis for patients. In most patients, constitutional, mucocutaneous, and musculoskeletal symptoms represent the earliest complaints; these symptoms can include fatigue, lupus-specific rash, mouth ulcers, alopecia, joint pain, and myalgia. In this Seminar we will discuss a diagnostic approach to symptoms in light of the latest classification criteria, which include a systematic evaluation of clinical manifestations (weighted within each domain) and autoantibody profiles (such as anti-double-stranded DNA, anti-Sm, hypocomplementaemia, or antiphospholipid antibodies). Non-pharmacotherapy management is tailored to the individual, with specific lifestyle interventions and patient education to improve quality of life and medication (such as hydroxychloroquine or immunosuppressant) adherence. In the last decade, there have been a few major breakthroughs in approved treatments for SLE and lupus nephritis, such as belimumab, anifrolumab, and voclosporin. However the disease course remains variable and mortality unacceptably high. Access to these expensive medications has also been restricted across different regions of the world. Nonetheless, understanding of treatment goals and strategies has improved. We recognise that the main goal of treatment is the achievement of remission or low disease activity. Comorbidities due to both disease activity and treatment adverse effects, especially infections, osteoporosis, and cardiovascular disease, necessitate vigilant prevention and management strategies. Tailoring treatment options to achieve remission, while balancing treatment-related comorbidities, are priority areas of SLE management.

Disease diagnostics using machine learning of immune receptors

Clinical diagnosis typically incorporates physical examination, patient history, and various laboratory tests and imaging studies, but makes limited use of the human system's own record of antigen exposures encoded by receptors on B cells and T cells. We analyzed immune receptor datasets from 593 individuals to develop MAchine Learning for Immunological Diagnosis (Mal-ID) , an interpretive framework to screen for multiple illnesses simultaneously or precisely test for one condition. This approach detects specific infections, autoimmune disorders, vaccine responses, and disease severity differences. Human-interpretable features of the model recapitulate known immune responses to SARS-CoV-2, Influenza, and HIV, highlight antigen-specific receptors, and reveal distinct characteristics of Systemic Lupus Erythematosus and Type-1 Diabetes autoreactivity. This analysis framework has broad potential for scientific and clinical interpretation of human immune responses.

Systemic lupus erythematosus and Atopic dermatitis: A two sample Mendelian randomization study

BACKGROUND

Systemic lupus erythematosus (SLE) and atopic dermatitis (AD) are common diseases in human populations. Previous studies have suggested a potential association between SLE and AD. However, the causal relationship and direction between the two conditions remain unclear.

OBJECTIVE

The aim of this study is to evaluate the causal relationship between SLE and AD.

METHODS

In this study, we employed Mendelian randomization (MR) analysis to investigate the causal relationship between SLE and AD. MR analysis has the advantage of reducing confounding factors, determining the direction of causality, and providing quantitative effect estimates. We obtained summary data from genome-wide association studies (GWAS) on SLE and AD from publicly available databases. Five MR methods, namely MR Egger, weighted median, inverse variance weighted, simple mode, and weighted mode, were used to assess the causal relationship between SLE and AD. Several techniques, including MR-Egger intercept, MR-PRESSO, and Cochran's Q test, were utilized to evaluate heterogeneity and pleiotropy.

RESULTS

Our study demonstrated a causal relationship between the prevalence of SLE and an increased risk of AD (MR Egger OR: 1.567, 95% CI: [1.041, 1.285], P = 0.009; IVW OR: 1.085, 95% CI: [1.005, 1.143], P = 0.035). Furthermore, sensitivity analyses did not detect heterogeneity or pleiotropy.

CONCLUSION

Our research finds that SLE is a contributing factor to the development of AD, providing valuable insights into the pathogenesis and prevention of both diseases. Key Points • Currently, there is no research that clearly indicates a causal relationship between SLE and AD. This study, for the first time, identified a positive causal relationship between SLE and AD. • The results of this study contribute to our understanding of the pathogenesis and treatment strategies for SLE and AD, providing some guidance for future clinical practice.

Cardiovascular Imaging in Women

Multimodality cardiovascular imaging is a cornerstone diagnostic tool in the diagnosis, risk stratification, and management of cardiovascular diseases, whether those involving the coronary tree, myocardial, or pericardial diseases in general and particularly in women. This manuscript aims to shed some light and summarize the very features of cardiovascular disease in women, explore their unique characteristics and discuss the role of cardiovascular imaging in ischemic heart disease and cardiomyopathies. The role of four imaging modalities will be discussed including nuclear medicine, echocardiography, noninvasive coronary angiography, and cardiac magnetic resonance.

Epstein-Barr virus reactivation and disease flare of systemic lupus erythematosus

SLE affects females rather than males with a ratio of about 9:1. Owing to the high morbidity with multiple organ involvement, SLE flare-up remains a challenge for women's health. In an accumulation of the past 70 years of studies globally, EBV has been found to be strongly associated with SLE. In the past two decades, EBV reactivation has been proven as prevalent in SLE patients as well as being strongly associated with higher SLE activity and higher prevalence of SLE flare. Hence, strategies to control EBV reactivation in SLE including pharmacological (such as Tenofovir prodrugs TDF and TAF) and non-pharmacological approaches are being developed. The heterogeneity of SLE constitutes clinical challenges, suggesting a stratification of SLE into subgroups based on EBV reactivation or non-reactivation is reasonable. Future-wise, adding anti-EBV reactivation medication to current immunosuppressants for the subgroup of SLE patients with EBV reactivation could be beneficial to achieve long-term remission of SLE.

Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety

Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.

Paranasal sinus occupancy assessed from magnetic resonance images-associations with clinical indicators in patients with systemic lupus erythematosus

OBJECTIVES

Nasal, paranasal sinus and mucosal disorders are common symptoms in autoimmune rheumatic diseases. Soft tissue changes and fluid accumulation in the osteomeatal complexes and paranasal sinuses manifest as opaqueness on radiological images which can be assessed using visual scoring and computational methods on CT scans, but their results do not always correlate. Using MRI, we investigate the applicability of different image analysis methods in SLE.

METHODS

We assessed paranasal sinus opaqueness on MRI from 51 SLE patients, using three visual scoring systems and expert-delineated computational volumes, and examined their association with markers of disease activity, inflammation, endothelial dysfunction and common small vessel disease (SVD) indicators, adjusting for age and sex-at-birth.

RESULTS

The average paranasal sinus volume occupation was 4.55 (6.47%) [median (interquartile range) = 0.67 (0.25-2.65) ml], mainly in the maxillary and ethmoid sinuses. It was highly correlated with Lund-Mackay (LM) scores modified at 50% opaqueness cut-off (Spearman's ρ: 0.71 maxillary and 0.618 ethmoids, P < 0.001 in all), and with more granular variations of the LM system. The modified LM scores were associated with SVD scores (0: B = 5.078, s.e. = 1.69, P = 0.0026; 2: B = -0.066, s.e. = 0.023, P = 0.0045) and disease activity (anti-dsDNA: B = 4.59, s.e. = 2.22, P = 0.045; SLEDAI 3-7: 2.86 < B < 4.30; 1.38 < s.e. < 1.63; 0.0083 ≤ P ≤ 0.0375). Computationally derived percent opaqueness yielded similar results.

CONCLUSION

In patients with SLE, MRI computational assessment of sinuses opaqueness and LM scores modified at a 50% cut-off may be useful tools in understanding the relationships among paranasal sinus occupancy, disease activity and SVD markers.

Lupus Nephritis Disguised: The Diagnostic Challenge of Eosinophilic Enteritis - A Case Report

Systemic lupus erythematosus (SLE) is a multi-systemic disorder affecting almost all systems of the body. Involvement of the kidney in this condition is known as lupus nephritis (LN). LN is one of the important disease manifestations of SLE with considerable influence on patient outcomes in terms of morbidity and mortality. A 33-year-old female came to the OPD with complaints of abdominal pain, infrequent loose stools since 4 months. The patient also had joint pain, predominantly small joints, since 2 months. Patient was admitted and all routine investigations were done. Patient underwent an oesophagogastroduodenoscopy (OGD) and colonoscopy for her abdominal pain and loose stools which did not respond to routine medication. Grossly there was edema present in the oesophagus and colon which on microscopy showed eosinophilic infiltration. Urine routine of the patient showed protein 1+and 24-hour urine protein quantification of 1427 mg/24 h. On further evaluation patient was found to have a positive ANA blot (dsDNA, AMAM2, Ro52 and Sm). The patient was planned for a renal biopsy in view of the proteinuria and positive ANA blot. The patient underwent a renal biopsy under USG guidance and was found to have Lupus nephritis Class 3 (ISN RPS staging). SLE is a multi-organ involving disease which if not diagnosed at the earliest can have serious complications and lead to end stage organ failure and even death. Atypical presentations often pose a diagnostic dilemma and may delay diagnosis and treatment. Early diagnosis and treatment can give patients of SLE a long and normal life. Diagnostic guidelines have helped in the diagnosis of such atypical presentations.

The functional TNFAIP3 rs2230926T/G (Phe127Cys) variant confers risk to systemic lupus erythematosus in a Latin American population

TNFAIP3 is a classical systemic lupus erythematosus (SLE)-associated risk locus identified by genome-wide association studies (GWASs) and replicated by candidate gene association studies primarily in Caucasians and Asians. However, in Latin American populations, its role on SLE susceptibility is not known. We conducted a case-control study to evaluate whether the TNFAIP3 rs2230926T/G (Phe127Cys) variant is associated with risk of developing SLE in a cohort of Mexican patients. The TNFAIP3 rs2230926T/G variant was analyzed in 561 patients with SLE and 499 control subjects, using TaqMan probes. We found that the G allele was associated with susceptibility to SLE under the allelic (OR 2.09, p = 0.005) and genotypic (OR 2.14, p = 0.004) models. In conclusion, our results show that TNFAIP3 rs2230926T/G is a risk factor for the development of SLE in the Mexican population.

Autoimmune Responses and Therapeutic Interventions for Systemic Lupus Erythematosus: A Comprehensive Review

Systemic Lupus Erythematosus (SLE) or Lupus is a multifactorial autoimmune disease of multiorgan malfunctioning of extremely heterogeneous and unclear etiology that affects multiple organs and physiological systems. Some racial groups and women of childbearing age are more susceptible to SLE pathogenesis. Impressive progress has been made towards a better understanding of different immune components contributing to SLE pathogenesis. Recent investigations have uncovered the detailed mechanisms of inflammatory responses and organ damage. Various environmental factors, pathogens, and toxicants, including ultraviolet light, drugs, viral pathogens, gut microbiome metabolites, and sex hormones trigger the onset of SLE pathogenesis in genetically susceptible individuals and result in the disruption of immune homeostasis of cytokines, macrophages, T cells, and B cells. Diagnosis and clinical investigations of SLE remain challenging due to its clinical heterogeneity and hitherto only a few approved antimalarials, glucocorticoids, immunosuppressants, and some nonsteroidal anti-inflammatory drugs (NSAIDs) are available for treatment. However, the adverse effects of renal and neuropsychiatric lupus and late diagnosis make therapy challenging. Additionally, SLE is also linked to an increased risk of cardiovascular diseases due to inflammatory responses and the risk of infection from immunosuppressive treatment. Due to the diversity of symptoms and treatment-resistant diseases, SLE management remains a challenging issue. Nevertheless, the use of next-generation therapeutics with stem cell and gene therapy may bring better outcomes to SLE treatment in the future. This review highlights the autoimmune responses as well as potential therapeutic interventions for SLE particularly focusing on the recent therapeutic advancements and challenges.

Treatment with a tissue-selective oestrogen complex does not affect disease pathology but reduces pre-BI cells in lupus-prone mice

OBJECTIVE

Systemic lupus erythematosus (SLE or lupus) is an autoimmune disease characterized by B-cell dysfunction, production of autoantibodies, and immune complex formation. Lupus is overrepresented in females, indicating that sex hormones play a role in the pathophysiology. Treatment with a tissue-selective oestrogen complex (TSEC) containing conjugated oestrogens and the selective oestrogen receptor modulator bazedoxifene (BZA) protects against postmenopausal vasomotor symptoms and osteoporosis, but its impact on organ damage in lupus is not fully understood.

METHOD

We used ovariectomized MRL/lpr mice, treated with two different physiological doses of 17β-oestradiol-3-benzoate (E2), BZA, or TSEC (E2 plus BZA), to assess early and late B-cell development and to determine histological disease manifestations in the kidneys and salivary glands.

RESULTS

TSEC treatment reduced the frequency of the pre-BI population in bone marrow to levels equivalent to treatment with physiological doses of E2 alone but did not affect any of the other examined B-cell populations. Our earlier studies indicated that TSEC treatment did not aggravate disease development in ovariectomized MRL/lpr mice, while protecting against trabecular bone loss. Here, we follow up on our previous study and show that neither ovariectomy alone nor TSEC treatment of ovariectomized MRL/lpr mice influenced perivascular lymphocyte infiltration to the kidneys or salivary glands.

CONCLUSION

TSEC does not aggravate a mouse model of lupus, when given in doses that protect against postmenopausal lupus-associated bone loss. This indicates that further investigations into TSEC as a treatment for osteoporosis or vasomotor symptoms in postmenopausal women with SLE are warranted.

The risk of pediatric cardiovascular diseases in offspring born to mothers with systemic lupus erythematosus: a nationwide study

Background

Systemic lupus erythematosus (SLE), a common autoimmune disease predominantly affecting women, has been linked to various complications during pregnancy. The transfer of anti-Ro/SSA antibodies from SLE-affected mothers to their offspring can lead to neonatal lupus and cardiac issues. This study investigated the association between maternal SLE and the risk of pediatric cardiovascular disorders.

Methods

The study utilized South Korea's National Health Insurance Service (NHIS) database, covering 3,505,737 children born between 2007 and 2017 and tracked until 2020. Maternal SLE cases were identified using the World Health Organization's International Classification of Diseases Tenth revision (ICD-10) codes and linked with delivery records. Cardiologic disorders were categorized into congenital heart disease (CHD), arrhythmic disorders, and acquired heart disease. Propensity score matching with 1:4 ratios was applied to the set control group.

Results

Among 3,505,737 children, 0.7% (n = 23,330) were born to mothers with SLE. The incidence of preterm birth was significantly higher in the maternal SLE group (5.9% vs. 3.0%). Compared with the control group, children born to mothers with SLE exhibited a significantly elevated risk of overall CHDs (5.5%, adjusted odds ratio [aOR] 1.21; 95% confidence interval [CI] 1.14-1.29), including atrial septal defect (1.18; 1.09-1.28) and patent ductus arteriosus (1.15; 1.03-1.30). In addition, a notably higher risk was observed in arrhythmic disorders (complete atrioventricular block 7.20; 2.41-21.49) and acquired cardiac disorders, including cardiomyopathy (1.40; 1.17-1.68) and mucocutaneous lymph node syndrome (MCLS) (1.27; 1.15-1.43).

Conclusions

Maternal SLE is associated with congenital and acquired cardiac disorders in offspring, including structural, arrhythmic, and MCLS. This study highlights the need for continuous cardiovascular monitoring from the prenatal stage to preadolescence in these children due to multifactorial influences involving maternal autoantibodies, genetic predisposition, and environmental factors.

Increased development of T-bet+CD11c+ B cells predisposes to lupus in females: Analysis in BXD2 mouse and genetic crosses

Cardinal features of lupus include elevated B cell activation and autoantibody production with a female sex preponderance. We quantified interactions of sex and genetic variation on the development of autoimmune B-cell phenotypes and autoantibodies in the BXD2 murine model of lupus using a cohort of backcrossed progeny (BXD2 x C57BL/6J) x BXD2. Sex was the key factor leading to increased total IgG, IgG2b, and autoantibodies. The percentage of T-bet+CD11c+ IgD+ activated naive B cells (aNAV) was higher in females and was associated with increased T-bet+CD11c+ IgD- age-related B cells, Fas+GL7+ germinal center B cells, Cxcr5-Icos+ peripheral T-helper cells, and Cxcr5+Icos+ follicular T-helper cells. IFN-β was elevated in females. Variation in aNAV cells was mapped to Chr 7 in a locus that shows significant interactions between the female sex and heterozygous B/D variant. Our results suggest that activation of naive B cells forms the basis for the female-predominant development of autoantibodies in lupus-susceptible BXD2 mice.

Performance of a New Instrument for the Measurement of Systemic Lupus Erythematosus Disease Activity: The SLE-DAS

Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease that affects multiple organ systems and manifests in a relapsing-remitting pattern. Consequently, it is paramount for rheumatologists to assess disease activity, identify flare-ups, and establish treatment goals for patients with SLE. In 2019, the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) was introduced as a novel tool for measuring disease activity. This tool refines the parameters of the established SLE Disease Activity Index 2000 (SLEDAI-2K) to enhance the assessment process. This review aims to provide an introduction to the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) and summarizes research on its development, its comparison with existing disease activity measures, and its performance in clinical settings. Literature searches on PubMed using the keyword "SLE-DAS" were conducted, covering publications from March 2019 to September 2023. Studies that compared SLE-DAS with other SLE disease activity measurement tools were reviewed. Findings indicated that SLE-DAS consistently performs on par with, and sometimes better than, traditional measures in assessing clinically meaningful changes, patient improvement, disease activity, health-related quality of life, hospitalization rates, and disease flare-ups. The association between SLE-DAS and mortality rates among patients with SLE, however, remains to be further explored. Although SLE-DAS is a promising and potentially effective tool for measuring SLE disease activity, additional research is needed to confirm its effectiveness and broaden its clinical use.

Characterization of virus-mediated autoimmunity and the consequences for pathological process in patients with systemic lupus erythematosus

INTRODUCTION/OBJECTIVES

This study aimed to identify differentially expressed genes (DEGs) of systemic lupus erythematosus (SLE) using gene expression-based computational methodologies to analyze disease-immune interactions, which affect the development and progression of SLE.

METHOD

Twenty-six patients with SLE and 46 healthy controls were selected from the Gene Expression Omnibus (GEO) database. The significantly enriched immune and virus-related gene lists were computed and visualized by using the DEGs from the gene set enrichment analysis (GSEA). Quantification of 38 immune cells was performed in determining the impact of immune cells on the virus mediated immunity in SLE by using ImmQuant algorithm.

RESULTS

Thirty-nine upregulated and 57 downregulated were identified in SLE patient compared to the healthy controls. Upregulated genes were significantly implicated in Gene Ontology gene sets as cytokine mediated signaling, secretion, and exocytosis in immune response pathways in 26 female SLE patients. In addition, these genes were enriched in hepatitis C, influenza A, measles, Epstein-Barr virus, and herpes simplex virus 1 infection in Kyoto Encyclopedia of Genes and Genomes pathways. Especially, FCGR1A, IRF7, OAS2, CAMP, MX1, OAS3, OAS1, DEFA3, ISG15, and RSAD2 were involved in virus mediated SLE mechanism, and the expression for OAS1, OAS2, and IRF7 was closely associated with the quantities of colony forming unit-monocyte and colony forming unit-granulocyte.

CONCLUSIONS

Identifying virus-mediated SLE genes and quantifies of immune cells were used to understand the pathological process and perform early diagnosis of female SLE, and will lead to clinical tools for treating SLE in patients. Key Points • Using gene expression-based computational methodologies, the 57 immune and viral genes were significantly upregulated in 26 SLE patients. • The identified three key  viral genes such as OAS1, OAS2, and IF7 were closely associated with colony-forming unit-monocytes and colony-forming unit-granulocytes, which affect the virus mediated immunity in SLE. • The viral genes and quantifies of immune cells are useful in understanding pathogenesis of SLE, and this will provide clinical strategies of potential treatment choices in SLE patients.

Presentation and outcome of pediatric lupus nephritis from a large single centre contemporary cohort in Eastern India

BACKGROUND

We present clinical, biochemical, and histopathological characteristics and treatment outcomes of biopsy proven childhood lupus nephritis (LN) from a low/middle income setting treated in the current era of increased use of Mycophenolate Mofetil (MMF) and biologics.

METHODS

Retrospective observational study of children (1-18 years) with biopsy proven LN treated from 01.01.2010 to 31.01.2020.

RESULTS

60 children met our inclusion criteria (80%, n = 48 were females). The median age at diagnosis was 11 (IQR: 9-12) years. The most common extra-renal manifestation was mucocutaneous (n = 54, 90%) and the most common kidney manifestation was edema (n = 50, 83.3%). The median 24-h urinary protein excretion was 1117.8 (IQR: 795.4-1941.7) mg/m2/day with 67% (n = 40) having nephrotic range proteinuria (>1000 mg/m2/day). 75% (n = 45) children had eGFR <90 mL/min/1.73 m2 (median eGFR = 71; IQR: 56-90 mL/min/1.73 m2). Anti-Nuclear Antibody was positive in all, both complement three and four were low in 82% (n = 49) and anti-double stranded DNA antibodies were positive in 63% (n = 38). 85% (n = 51) had proliferative LN with majority being class IV (57%, n = 34). All children received steroids for induction therapy. MMF was given as the sole induction agent in 48% (n = 29) and cyclophosphamide in 27% (n = 16). Rituximab was added in 17% (n = 10) as a rescue agent. Median follow up duration was 50 (IQR: 28-82) months. Six children (10%) died as a result of serious infections and none of them had shown complete response (CR). Out of the 52 children who had a follow up duration of at least 2 years, CR was achieved in 46 children (88%) and partial response (PR) or no response (NR) in three children (6%) each. Although children who were in CR/PR at last follow up had lower proteinuria, higher eGFR, and lower histopathology activity index at onset; low numbers in the NR group precluded us from subjecting them to any statistical correlation tests. 36% (n = 22) of children developed 36 episodes of renal flares with overall incidence of 0.14/person-year.

CONCLUSION

Our study on a contemporary cohort of childhood LN highlights the importance of achieving CR and its feasibility.

Natural Killer Cell Count in Systemic Lupus Erythematosus Patients: A Flow Cytometry-Based Study

Background Natural killer cells (NK cells) are important mediators of innate immune regulation and literature has shown that they have a role in shaping the adaptive immune system. Objective The present study was undertaken to analyze the NK cell count in systemic lupus erythematosus (SLE) patients as compared to that of controls. Materials and methods Safety of Estrogens in Lupus Erythematosus National Assessment SLE Disease Activity Index (SELENA-SLEDAI) score was assessed in 32 SLE cases. CD3(-) cells were identified as NK cells on flow cytometry, and then their subsets CD56(+) and CD16(+) cells were identified compared to 30 healthy controls. Receiver Operating Characteristic (ROC) curve analysis was performed on NK cells to attempt to determine a cut-off point. Results The CD3(-) NK cells, including the percentages of CD56(+) and CD16(+), were significantly (p<0.001) reduced in SLE patients (12.35%, and 18.7%) as compared to controls (24.67%, and 46.6%). On ROC curve analysis, cut-off values <481/cumm with sensitivity of 86.7% and specificity of 84.4% for CD3(-) NK cells (p<0.001), <23% with 60% sensitivity and 75% specificity for CD56(+) NK cells (p<0.001), and <29% with sensitivity of 70% and specificity of 87.5% for CD16(+) NK cells (p<0.001) were noted. Subsets of NK cells showed no association with the clinicopathological parameters like age, sex, disease activity, anti-nuclear antibodies (ANA), dsDNA, absolute lymphocyte count, and renal involvement. Conclusion NK cells, and their subpopulations of CD56(+) and CD16(+) cells, are decreased in patients with SLE as compared to controls.

Limited Cutaneous Scleroderma: A Case Report

Scleroderma is an uncommon disease that affects the connective tissue, causing skin hardening and sometimes organ damage. There are two main forms of scleroderma: localised scleroderma, or morphea, which usually has a mild and limited course and only affects the skin and/or the tissues below it, and systemic sclerosis, which involves skin hardening and internal organ problems. The cause of localised scleroderma is unknown. Recent studies suggest that this form can have different levels of severity and can affect some organs. To avoid complications due to the high morbidity of localised scleroderma, early treatment is recommended. In this article, we present the main aspects and details of the management of patients with localised scleroderma.

A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations

This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.

Gender Disparities in Hospitalization Outcomes and Healthcare Utilization Among Patients with Systemic Lupus Erythematosus in the United States

Background Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease characterized by various clinical manifestations. Despite efforts to improve outcomes, mortality rates remain high, and certain disparities, including gender, may influence prognosis and mortality rates in SLE. This study aims to examine the gender disparities in outcomes of SLE hospitalizations in the US. Methods We conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) database between 2016 and 2020. The NIS database is the largest publicly available all-payer database for inpatient care in the United States, representing approximately 20% of all hospitalizations nationwide. We selected every other year during the study period and included hospitalizations of adult patients (≥18 years old) with a primary or secondary diagnosis of SLE using International Classification of Diseases, Tenth Revision (ICD-10) codes. The control population consisted of all adult hospitalizations. Multivariate logistic regression was used to estimate the strength of the association between gender and primary and secondary outcomes. The regression models were adjusted for various factors, including age, race, median household income based on patients' zip codes, Charlson comorbidity index score, insurance status, hospital location, region, bed size, and teaching status. To ensure comparability across the years, revised trend weights were applied as the healthcare cost and use project website recommends. Stata version 17 (StataCorp LLC, TX, USA) was used for the statistical analyses, and a two-sided P-value of less than 0.05 was considered statistically significant. Results Among the 42,875 SLE hospitalizations analyzed, women accounted for a significantly higher proportion (86.4%) compared to men (13.6%). The age distribution varied, with the majority of female admissions falling within the 30- to 60-year age range, while most male admissions fell within the 15- to 30-year age category. Racial composition showed a slightly higher percentage of White Americans in the male cohort compared to the female cohort. Notably, more Black females were admitted for SLE compared to Black males. Male SLE patients had a higher burden of comorbidities and were more likely to have Medicare and private insurance, while a higher percentage of women were uninsured. The mortality rate during the index hospitalization was slightly higher for men (1.3%) compared to women (1.1%), but after adjusting for various factors, there was no statistically significant gender disparity in the likelihood of mortality (adjusted odds ratio (aOR): 1.027; 95% confidence interval (CI): 0.570-1.852; P=0.929). Men had longer hospital stays and incurred higher average hospital costs compared to women (mean length of stay (LOS): seven days vs. six days; $79,751 ± $5,954 vs. $70,405 ± $1,618 respectively). Female SLE hospitalizations were associated with a higher likelihood of delirium, psychosis, and seizures while showing lower odds of hematological and renal diseases compared to men. Conclusion While women constitute the majority of SLE hospitalizations, men with SLE tend to have a higher burden of comorbidities and are more likely to have Medicare and private insurance. Additionally, men had longer hospital stays and incurred higher average hospital costs. However, there was no significant gender disparity in the likelihood of mortality after accounting for various factors.

Plasma Proteomic Patterns Show Sex Differences in Early Concentric Left Ventricular Remodeling

BACKGROUND

Concentric remodeling (cRM) can precede heart failure with preserved ejection fraction (HFpEF), a condition prevalent in women.

METHODS

Patients (n=60 593, 54.2% women) visiting outpatient clinics of Cardiology Centers of the Netherlands were analyzed for cRM, HFpEF development, and mortality risk. We studied risk factors for relative wall thickness both sex-stratified and in women and men combined. Biomarker profiling was performed (4534 plasma proteins) in a substudy involving 557 patients (65.4% women) to identify pathways involved in cRM.

RESULTS

cRM was present in 23.5% of women and 27.6% of men and associated with developing HFpEF (HR, 2.15 [95% CI, 1.51-2.99]) and mortality risk (HR, 1.09 [95% CI, 1.00-1.19]) in both sexes. Age, heart rate, and hypertension were statistically significantly stronger risk factors for relative wall thickness in women than men. Higher circulating levels of IFNA5 (interferon alpha-5) were associated with higher relative wall thickness in women only. Pathway analysis revealed differential pathway activation by sex and increased expression of inflammatory pathways in women.

CONCLUSIONS

cRM is prevalent in approximately 1 in 4 women and men visiting outpatient cardiology clinics and associated with HFpEF development and mortality risk in both sexes. Known risk factors for cRM were more strongly associated in women than men. Proteomic analysis revealed inflammatory pathway activation in women, with a central role for IFNA5. Differential biologic pathway activation by sex in cRM may contribute to the female predominance of HFpEF and holds promise for identification of new therapeutic avenues for prevention and treatment of HFpEF.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT001747.

Risk factors and a new nomogram for predicting brain metastasis from lung cancer: a retrospective study

Objective

This study aims to establish and validate a new nomogram for predicting brain metastasis from lung cancer by integrating data.

Methods

266 patients diagnosed as lung cancer between 2016 and 2018 were collected from Guangdong Academy of Medical Sciences. The first 70% of patients were designated as the primary cohort and the remaining patients were identified as the internal validation cohort. Univariate and multivariable logistics regression were applied to analyze the risk factors. Independent risk factors were used to construct nomogram. C-index was used to evaluate the prediction effect of nomogram.100 patients diagnosed as lung cancer between 2018 and 2019 were collected for external validation cohorts. The evaluation of nomogram was carried out through the distinction and calibration in the internal validation cohort and external validation cohort.

Results

166 patients were diagnosed with brain metastasis among the 266 patients. The gender, pathological type (PAT), leukocyte count (LCC) and Fibrinogen stage (FibS) were independent risk factors of brain metastasis. A novel nomogram has been developed in this study showed an effective discriminative ability to predict the probability of lung cancer patients with brain metastasis, the C-index was 0.811.

Conclusion

Our research provides a novel model that can be used for predicting brain metastasis of lung cancer patients, thus providing more credible evidence for clinical decision-making.

Disentangling the Pathogenesis of Systemic Lupus Erythematosus: Close Ties between Immunological, Genetic and Environmental Factors

Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease that attacks various organ systems with a variety of clinical implications, ranging from mild skin and mucosal manifestations to severe central nervous system manifestations and death. Cases of SLE have been documented nearly two centuries ago when scholars used the terms 'erythema centrifugum' and 'seborrhea congestiva' to describe the discoid skin lesions and the butterfly or malar rash in SLE. Since then, knowledge about this disease has developed rapidly, especially knowledge related to the underlying pathogenesis of SLE. To date, it is known that immune system dysregulation, supported by genetic and environmental predisposition, can trigger the occurrence of SLE in a group of susceptible individuals. Various inflammatory mediators, cytokines and chemokines, as well as intra- and intercellular signaling pathways, are involved in the pathogenesis of SLE. In this review, we will discuss the molecular and cellular aspects of SLE pathogenesis, with a focus on how the immune system, genetics and the environment interact and trigger the various clinical manifestations of SLE.

Patient-reported disease impact of systemic lupus erythematosus with active joint symptoms: Results from the systemic lupus erythematosus-update survey

BACKGROUND

Many people with systemic lupus erythematosus (SLE) experience joint pain, swelling, and stiffness. These joint symptoms are associated with problems in physical functioning and work disability. We used survey data from adults with SLE to explore the burden and impact of joint symptoms.

METHODS

SLE-UPDATE was a 2019 cross-sectional US survey of adults with SLE. We compared respondents with "currently active" joint symptoms' and those "without currently active" joint symptoms. The active joint cohort comprised survey respondents who self-reported current "stiffness in joints" or "pain/swelling in joints" and who had moderate to severe joint pain (Worst Joint Pain Numeric Rating Scale [NRS] score ≥ 4). Respondents not fulfilling these criteria were included in the non-active joint cohort. Outcomes included frequency and severity of pain, patient-reported outcomes (LupusPRO™ and Work Productivity and Activity Impairment: Lupus [WPAI-Lupus]), satisfaction with current treatments, and importance of different treatment goals.

RESULTS

More respondents in the active joint cohort (N = 285) than in the non-active joint cohort (N = 215) reported pain most or all the time over the preceding 7 days (77.5% vs. 32.1%, p < .0001), fibromyalgia (45% vs. 12%, p < .0001), and higher (worse) mean scores on the Worst Pain NRS (6.5 vs. 4.8, p < .0001) and Worst Joint Pain NRS (6.7 vs. 4.5, p < .0001). Mean Lupus PRO health-related quality of life (HRQoL) total score was lower (worse) in the active joint cohort (48.9 vs. 64.1, p < .0001). WPAI-Lupus scores indicated greater work productivity losses and activity impairment in the active joint cohort. More respondents in the active joint cohort than in the non-active joint cohort were neutral or not satisfied with current treatments and rated reducing pain as a "very important" treatment goal (26.7% vs. 18.1%).

CONCLUSIONS

Respondents with SLE and active joint manifestations in addition to having more pain report lower HRQoL and were less satisfied with their current treatments. Comorbid fibromyalgia may play a role in joint symptoms in patient with SLE joint manifestations. There is an unmet need for new therapeutic options to reduce joint symptom burden among patients with SLE.

Gut microbiota in SLE: from animal models to clinical evidence and pharmacological perspectives

Systemic lupus erythematosus (SLE) is a multifactorial autoimmune disease driven by complex interactions between genetics and environmental factors. SLE is characterised by breaking self-immune tolerance and autoantibody production that triggers inflammation and damage of multiple organs. Given the highly heterogeneous nature of SLE, the treatments currently used are still not satisfactory with considerable side effects, and the development of new therapies is a major health issue for better patient management. In this context, mouse models significantly contribute to our knowledge of the pathogenesis of SLE and are an invaluable tool for testing novel therapeutic targets. Here, we discuss the role of the most used SLE mouse models and their contribution to therapeutic improvement. Considering the complexity of developing targeted therapies for SLE, adjuvant therapies are also increasingly proposed. Indeed, murine and human studies have recently revealed that gut microbiota is a potential target and holds great promises for successful new SLE therapies. However, the mechanisms of gut microbiota dysbiosis in SLE remain unclear to date. In this review, we propose an inventory of existing studies investigating the relationship between gut microbiota dysbiosis and SLE to establish microbiome signature that may serve as a potential biomarker of the disease and its severity as well as a new potential therapy target. This approach may open new possibilities for early diagnosis, prevention and therapeutic perspectives of SLE based on gut microbiome.

Overlap Syndrome in a Male Presenting With Progressive Lower Limb Weakness: A Case Report

Overlap syndrome refers to a large group of inflammatory rheumatic conditions characterized by the co-existence of clinical manifestations that include different organ systems and meet the criteria of more than one rheumatic disease. Overlap syndromes are less common compared with the conditions they encompass, for example, the global prevalence of systemic lupus erythematosus (SLE) is estimated to be 43.7 per 100,000 persons, of which only around 3.4-6.3% present with SLE-myositis overlap. Although rare, overlap syndromes commonly include lupus, rheumatoid arthritis, scleroderma, and myositis. Because overlap syndrome can manifest in several ways and has an unpredictable course, it poses a challenge to multidisciplinary teams that examine and treat patients. Therefore, we must not disregard any signs and symptoms as they might have a huge impact on the progression of the disease and the overall outcome of the treatment. We present a rare case of SLE-myositis overlap syndrome in a 44-year-old male. He initially presented with gradual weakness in the proximal muscles of the bilateral lower limb. This patient was diagnosed as having SLE with positive 5g protein/24 hours, anti-nuclear, low C3, anti-U1RNP, anti-Ro, and anti-La antibodies, as well as membranous lupus nephritis evident by the results of renal biopsy. The diagnosis of myositis was also made according to the history and evaluation of the patient, the high titer of muscle enzymes creatine kinase level, and MRI result. Although the patient tested positive for anti-U1RNP, he did not meet the criteria of mixed connective tissue disease. Eventually, the patient was found to have overlap syndrome. The prevalence of overlap between SLE and myositis is relatively rare and varies from 3.4% to 6.3%. To our knowledge, no study has discussed or reported its prevalence among males.

Double-Stranded RNA Induces Mortality in an MDA5-Mediated Type I Interferonopathy Model

Gain-of-function mutations in the viral dsRNA sensor melanoma differentiation-associated protein 5 (MDA5) lead to autoimmune IFNopathies, including Singleton-Merten syndrome (SMS) and Aicardi-Goutières syndrome. However, much remains unclear regarding the mechanism of disease progression and how external factors such as infection or immune stimulation with vaccination can affect the immune response. With this aim, we generated mice with human MDA5 bearing the SMS-associated mutation R822Q (hM-R822Q). hM-R822Q transgenic (Tg) mice developed SMS-like heart fibrosis, aortic valve enlargement, and aortic calcification with a systemic IFN-stimulated gene signature resulting in the activation of the adaptive immune response. Although administration of the viral dsRNA mimic polyinosinic-polycytidylic acid [poly(I:C)] did not have remarkable effects on the cardiac phenotype, dramatic inflammation was observed in the intestines where IFN production was most elevated. Poly(I:C)-injected hM-R822Q Tg mice also developed lethal hypercytokinemia marked by massive IL-6 levels in the serum. Interrupting the IFN signaling through mitochondrial antiviral signaling protein or IFN-α/β receptor alleviated hM-R822Q-induced inflammation. Furthermore, inhibition of JAK signaling with tofacitinib reduced cytokine production and ameliorated mucosal damage, enabling the survival of poly(I:C)-injected hM-R822Q Tg mice. These findings demonstrate that the MDA5 R822Q mutant introduces a critical risk factor for uncontrollable inflammation on viral infection or vaccination.

A pregnancy hormone-cell death link promotes enhanced lupus-specific immunological effects

Women of reproductive age demonstrate an increased incidence of systemic lupus erythematosus, and reproductive hormones have been implicated in disease progression. Additionally, pregnancy can be associated with disease "flares", the reasons for which remain obscure. While apoptotic bodies are believed to provide an autoantigenic trigger in lupus, whether autoantigenic constituents vary with varying cellular insults, and whether such variations can be immunologically consequential in the context of pregnancy, remains unknown. As assessed by antigenicity and mass spectrometry, apoptotic bodies elicited by different drugs demonstrated the differential presence of lupus-associated autoantigens, and varied in the ability to elicit lupus-associated cytokines from lupus splenocytes and alter the phenotype of lupus B cells. Immunization of tamoxifen-induced apoptotic bodies in lupus-prone mice generated higher humoral autoreactive responses than did immunization with cisplatin-induced apoptotic bodies, and both apoptotic bodies were poorly immunogenic in healthy mice. Incubation of lupus splenocytes (but not healthy splenocytes) with the pregnancy hormone human chorionic gonadotropin (hCG) along with tamoxifen-induced apoptotic bodies (but not cisplatin-induced apoptotic bodies) induced increases in the secretion of lupus-associated cytokines and in the up-modulation of B cell phenotypic markers. In addition, levels of secreted autoantibodies (including of specificities linked to lupus pathogenesis) were enhanced. These events were associated with the heightened phosphorylation of several signaling intermediates. Observations suggest that hCG is a potential disease-promoting co-stimulant in a lupus-milieu; when combined with specific apoptotic bodies, it enhances the intensity of multiple lupus-associated events. These findings deepen mechanistic insight into the hormone's links with autoreactive responses in lupus-prone mice and humans.

Hypercholesterolemia promotes autoantibody production and a lupus-like pathology via decreased DNase-mediated clearance of DNA

Hypercholesterolemia exacerbates autoimmune response and accelerates the progression of several autoimmune disorders, but the mechanistic basis is not well understood. We recently demonstrated that hypercholesterolemia is associated with increased serum extracellular DNA levels secondary to a defect in DNase-mediated clearance of DNA. In this study, we tested whether the impaired DNase response plays a causal role in enhancing anti-nuclear antibody levels and renal immune complex deposition in an Apoe^-/- mouse model of hypercholesterolemia. We demonstrate that hypercholesterolemic mice have enhanced anti-ds-DNA and anti-nucleosome antibody levels which is associated with increased immune complex deposition in the renal glomerulus. Importantly, treatment with DNase1 led to a decrease in both the autoantibody levels as well as renal pathology. Additionally, we show that humans with hypercholesterolemia have decreased systemic DNase activity and increased anti-nuclear antibodies. In this context, our data suggest that recombinant DNase1 may be an attractive therapeutic strategy to lower autoimmune response and disease progression in patients with autoimmune disorders associated with concomitant hypercholesterolemia.

Sex-dependent Lupus Blautia (Ruminococcus) gnavus strain induction of zonulin-mediated intestinal permeability and autoimmunity

Imbalances in the gut microbiome are suspected contributors to the pathogenesis of Systemic Lupus Erythematosus, and our studies and others have documented that patients with active Lupus nephritis have expansions of the obligate anaerobe, Blautia (Ruminococcus) gnavus (RG). To investigate whether the RG strains in Lupus patients have in vivo pathogenic properties in a gnotobiotic system, we colonized C57BL/6 mice with individual RG strains from healthy adults or those from Lupus patients. These strains were similar in their capacity for murine intestinal colonization of antibiotic-preconditioned specific-pathogen-free, as well as of germ-free adults and of their neonatally colonized litters. Lupus-derived RG strains induced high levels of intestinal permeability that was significantly greater in female than male mice, whereas the RG species-type strain (ATCC29149/VPI C7-1) from a healthy donor had little or no effects. These Lupus RG strain-induced functional alterations were associated with RG translocation to mesenteric lymph nodes, and raised serum levels of zonulin, a regulator of tight junction formation between cells that form the gut barrier. Notably, the level of Lupus RG-induced intestinal permeability was significantly correlated with serum IgG anti RG cell-wall lipoglycan antibodies, and with anti-native DNA autoantibodies that are a biomarker for SLE. Strikingly, gut permeability was completely reversed by oral treatment with larazotide acetate, an octapeptide that is a specific molecular antagonist of zonulin. Taken together, these studies document a pathway by which RG strains from Lupus patients contribute to a leaky gut and features of autoimmunity implicated in the pathogenesis of flares of clinical Lupus disease.