Clinical features of systemic lupus erythematosus in men. Characteristics of the cutaneous manifestations

Clinical Features of Systemic Lupus Erythematosus in Tunisian Males

PURPOSE

Systemic Lupus Erythematosus (SLE) in males is rare. Clinical and biological features, as well as, the outcome may differ comparatively to female patients. The purpose of our study is to define these clinical and biological features in Tunisian male patients presenting SLE.

METHODS

A mono-centric, retrospective and descriptive study of 96 patients followed for SLE out of which 21 are males. A comparative study was then performed between male and female patients groups.

RESULTS

Sex-ratio female/male was 3.6/1, the average age at diagnosis of SLE was 37.8±14 years. The most frequently noted clinical manifestations were: skin involvement (81%), renal involvement (71.4%) and joint damage (66.7). We observed a significant difference in clinical features between male and female patients (21 males and 76 females): renal failure (52% vs. 71.4%), serositis (23.8% vs. 2.7%), peripheral neuropathy (19% vs. 4%) and lung interstitial disease (14.3% vs. 1.3%). No significant difference was found in the positivity of serum antibodies between the two groups. Fifteen male patients (71.4%) had a SLEDAI score greater than or equal to 11, referring to high/very high disease activity. Out of the 32 patients who developed infectious complications during the course of the disease, 11 were male (52.4% of males). Concerning the male group, complete remission was observed in 10 patients (47.6%), while 10 others presented persistent sequella. We observed one death in the male group secondary to infective acute respiratory failure.

CONCLUSION

SLE in male patients is rare and associated with poor prognosis. Disparity was observed in clinical and biological features as well as outcome in the different studies. In our study, we concluded that male lupus is more severe.

Chinese SLE Treatment and Research group (CSTAR) registry: V. gender impact on Chinese patients with systemic lupus erythematosus

Introduction

Many studies have shown that differences were observed between male and female lupus patients. Although systemic lupus erythematosus (SLE) affects mostly females (female:male ratio 9:1), male SLE patients show higher mortality due to kidney and neurological disease. Currently there are limited epidemiological data concerning lupus in the Chinese population. As such, the Chinese SLE Treatment and Research group (CSTAR) developed the first online registry of Chinese lupus patients in 2009, and represents a multicenter observational study that attempts to describe and compile the major clinical characteristics of lupus in Chinese patients.

Objective

To investigate the effect of gender on the phenotypes of Chinese SLE patients.

Patients and methods

Data for 2104 SLE patients were prospectively collected and included in the CSTAR registry. Patients fulfilled the 1997 American College of Rheumatology (ACR) SLE classification criteria. We conducted a cross-sectional case-control study to analyze patient clinical and laboratory data at onset and at enrollment. SLE disease activity scores (SLEDAI) were also measured at enrollment.

Results

This study included 1914 women and 190 men. Males and females showed no differences in mean ages at onset, delay of diagnosis and disease duration. Males presented more frequently with fever ( p = 0.003), while musculoskeletal involvement ( p = 0.001) and cytopenia ( p = 0.017) was more common in females as the initial manifestation at onset of SLE. For manifestations at enrollment, males presented more frequently with fever ( p = 0.005), renal disease ( p = 0.019), vasculitis ( p = 0.032) and neuropsychiatric lupus ( p = 0.007). For cumulative manifestations at enrollment, males presented more frequently with discoid rash ( p < 0.001) and neuropsychiatric lupus ( p = 0.036), while less frequently with arthritis ( p = 0.011). However, the laboratory data showed no significant differences between the two groups at enrollment. Males also had higher SLEDAI scores at enrollment ( p = 0.002).

Conclusions

Renal disease, vasculitis and neuropsychiatric lupus are more common in male SLE patients with higher SLEDAI scores compared to female SLE patients in China.

Clinical and immunological pattern of systemic lupus erythematosus in men in a cohort of 2355 patients

AIM

To investigate the impact of gender on expression of systemic lupus erythematosus (SLE) in a cohort of 2355 SLE patients as one of the largest series of cases among the present reports.

METHOD

In this retrospective study we used medical records of all patients (239 male and 2116 female) of the SLE registry of Rheumatology Research Center (RRC), Tehran University of Medical science (TUMS), Iran. Both clinical and paraclinical manifestations of SLE patients have been registered in this database since 1976 and updated during their follow-up. Chi-square test was used to compare the clinical and paraclinical manifestations in men and women at disease onset and during the disease course. We used logistic regression to compute odds ratios with 95% confidence intervals. A P-value < 0.05 was considered as statistically significant.

RESULTS

Mean age at disease onset was 25 ± 11.8 and 24.5 ± 10.3 years in men and women, respectively (P = 0.48). Comparison of clinical and immunological manifestations showed that male patients had a higher prevalence of mucocutaneous (43.5% vs. 33.7%, P = 0.005) and a lower prevalence of musculoskeletal symptoms (44% vs. 54.7%, P = 0.003) as the initial manifestation. During the disease course, discoid rash (25.9% vs. 13%, P = 0.000) and type IV lupus nephritis (23.4% vs. 18.1%, P = 0.03) were significantly more common, whereas arthritis (61.1% vs. 71.7%, P = 0.01) and leukopenia (28.5% vs. 35.8%, P = 0.024) were significantly less common in men.

CONCLUSION

This study reveals gender influence on some manifestations of SLE. Considering sex differences is recommended in diagnostic and therapeutic features of the disease.

Lupus erythematosus. Part II: clinical picture, diagnosis and treatment

Lupus erythematosus (LE) is an important dermatologic autoimmune disease. In many respects, it may be regarded as a model autoimmune disease due to its spectrum of autoimmune antibodies and involvement of different organ systems, as well as response to immunosuppressive agents which target B cells and T cells and their cytokines. A recently published article in this Journal summarized the most important knowledge about epidemiology, genetics, and immunology of LE. Here, the different clinical manifestations, diagnostic procedures and current therapeutic approaches will be described. Special emphasis is placed on different cutaneous manifestations of LE. In regard to treatment, the classic treatment approaches such as corticosteroids, methotrexate, chloroquine and hydroxychloroquine will be described. Lastly, new therapeutic approaches with specific monoclonal antibodies which are currently used in systemic LE, such as belimumab (Benlysta®), will be addressed. The most recent developments in this area could have implications even for purely cutaneous forms of LE.

Effect of gender on clinical presentation in systemic lupus erythematosus

The incidence of SLE is markedly increased in females of child-bearing age. Although males are protected in terms of incidence of disease, it is unclear whether a distinct phenotype of male lupus exists in those who do develop SLE. We sought to explore through a detailed literature review whether gender exerts an influence on the clinical presentation and outcome of SLE. We found that males experience less of the typical mucocutaneous and musculoskeletal symptoms commonly present at diagnosis in women. On the other hand, there is limited evidence to support a negative prognostic association between male gender and disease activity or mortality.

Kutaner Lupus erythematodes

Cutaneous lupus erythematosus (CLE) is a heterogenous disorder with a wide range of skin manifestations. Therefore, it has been difficult to develop a unifying concept for classifying CLE from the dermatologic perspective in the past. In 2004, the classification system was updated and includes now acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), and intermittent CLE (ICLE). Additional rarely described variants are not listed as separate entities but are included in the classical forms. Diagnosis of the different subtypes of CLE is made by considering genetic, clinical, histopathologic, and immunoserologic findings, with a systematic analysis of individual criteria. In the past years, the etiology and pathogenesis of CLE has been subject of intensive research and it has been shown by several groups that exogenous factors, such as ultraviolet light and drugs, can induce CLE. The first part of this review will enable the reader to identify the various clinical manifestations of CLE and to employ characteristic criteria to assess differential diagnostic considerations.

Gender differences in systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is known to be much more prevalent in females than in males, but the cause of this sexual predilection is not established. In addition, much controversy surrounds the differences in manifestations of SLE in both sexes.

OBJECTIVE

This article reviews the possible etiologies of the greater prevalence of SLE in females, as well as the differences in the clinical presentation of the disease in both sexes.

METHODS

Relevant studies were identified through a PubMed search for articles published between 1960 and 2001; no language restrictions were applied. Search terms included lupus, SLE, and gender differences. Books and online resources were also consulted.

RESULTS

Potential causes of the female predilection for SLE included the effects of estrogen and its hydroxylation, decreased androgen levels, hyperprolactinemia, and differences in gonadotropin-releasing hormone (GnRH) signaling. Clinical manifestations of SLE included females having more frequent relapses, but the incidence of severe relapses was the same in both sexes. Raynaud phenomenon, arthritis, and leukopenia were more common in women, whereas skin manifestations, serositis, and renal involvement were more common in men. For neurologic manifestations, females with SLE experienced more psychiatric symptoms and headaches, whereas males with SLE experienced more seizures and peripheral neuropathy. Males with SLE also tended to have more severe renal disease and cardiorespiratory involvement.

CONCLUSIONS

The increased frequency of SLE among women may be attributed to differences in the metabolism of sex hormones and/or GnRH. Though less common in men, when it does occur SLE tends to run a more severe course-an important consideration in the diagnosis and follow-up of male patients with SLE.

Pyrexia of unknown origin, the age-old dilemma

Images

Cutaneous lupus mucinosis: a review of our cases and the possible pathogenesis

Cutaneous lupus mucinosis (CLM) is a rare variant of lupus erythematosus eruptions. Our 5 cases with CLM were reviewed. All were men with systemic lupus erythematosus (SLE). CLM occurred as asymptomatic cutaneous papules, nodules, or plaques on the trunk, upper and lower extremities, and face. Histopathology of CLM mainly revealed abundant mucin deposits among splayed collagen bundles throughout the dermis. However, some CLM lesions showed discoid lupus erythematosus-like epidermal and dermal changes and/or lupus profundus. Vasculitis was also revealed in the CLM lesions of 2 cases. The pathogenesis of CLM may be closely related to its two important features, the male preponderance and the association with SLE. Vasculopathy may also be involved in the development of CLM.