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D’Aniello S, Rustici A, Gramegna LL, Godi C, Piccolo L, Gentile M, Zini A, Carrozzi A, Lodi R, Tonon C, Dall’Olio M, Simonetti L, Chieffo R, Anzalone N, Cirillo L. The Contribution of Vessel Wall Magnetic Resonance Imaging to the Diagnosis of Primary and Secondary Central Nervous System Vasculitis. Diagnostics (Basel) 2024; 14:927. [PMID: 38732340 PMCID: PMC11083696 DOI: 10.3390/diagnostics14090927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/11/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND To describe high-resolution brain vessel wall MRI (VW-MRI) patterns and morphological brain findings in central nervous system (CNS) vasculitis patients. METHODS Fourteen patients with confirmed CNS Vasculitis from two tertiary centers underwent VW-MRI using a 3T scanner. The images were reviewed by two neuroradiologists to assess vessel wall enhancement characteristics and locations. RESULTS Fourteen patients were included (six females; average age 48 ± 19 years). Diagnoses included primary CNS vasculitis (PCNSV) in six patients and secondary CNS vasculitis (SCNSV) in eight, half of which were infection-related. Thirteen patients showed vessel wall enhancement, which was intense in eleven patients (84.6%) and concentric in twelve (92.3%), affecting the anterior circulation in nine patients (69.2%), posterior in two patients (15.4%), and both circulations in two patients (15.4%). The enhancement patterns were similar across different CNS vasculitis types. DWI changes corresponded with areas of vessel wall enhancement in 77% of patients. Conclusions: CNS vasculitis is often associated with intense, concentric vessel wall enhancement in VW-MRI, especially in the anterior circulation. The consistent presence of DWI alterations in affected territories suggests a possible link to microembolization or hypoperfusion. These imaging findings complement parenchymal brain MRI and MRA/DSA data, potentially increasing the possibility of a clinical diagnosis of CNS vasculitis.
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Affiliation(s)
- Serena D’Aniello
- Department of Advanced Biomedical Science, University of Napoli “Federico II”, 80125 Naples, Italy
| | - Arianna Rustici
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Laura Ludovica Gramegna
- Vall d’Hebron Research Institute, Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Servicio de Radiología, Unidad de Neuroradiología, Hospital del Mar, 08003 Barcelona, Spain
| | - Claudia Godi
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Neuroradiology Unit, Sant’Antonio Abate Hospital, ASST Valle Olona, 21013 Gallarate, Italy
| | - Laura Piccolo
- Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Mauro Gentile
- Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Andrea Zini
- Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Alessandro Carrozzi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40123 Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40123 Bologna, Italy
| | - Massimo Dall’Olio
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, 40139 Bologna, Italy
| | - Luigi Simonetti
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Raffaella Chieffo
- Experimental Neurophysiology Unit, IRCCS San Raffaele, Institute of Experimental Neurology (INSPE), 20132 Milan, Italy
| | - Nicoletta Anzalone
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Luigi Cirillo
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40123 Bologna, Italy
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, 40139 Bologna, Italy
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Hoshina Y, Delic A, Wong KH, Lyden S, Kadish R, Smith TL, Wright MA, Shimura D, Clardy SL. Vasculitis in the Central Nervous System: Etiology, Characteristics, and Outcomes in a Large Single-Center Cohort. Neurohospitalist 2024; 14:129-139. [PMID: 38666288 PMCID: PMC11040621 DOI: 10.1177/19418744231223283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Background and Purpose For the management of central nervous system (CNS) vasculitis, it is crucial to differentiate between primary and secondary CNS vasculitis and to understand the respective etiologies. We assessed the etiology, characteristics, and outcomes of patients with CNS vasculitis. Methods A single-center retrospective chart review was conducted at the University of Utah, Department of Neurology, between February 2011 and October 2022. Results The median age of the 44 included patients at diagnosis was 54 years; 25.0% were men. Compared to primary CNS vasculitis, secondary CNS vasculitis exhibits higher fever incidence (observed in infectious and connective tissue disorder [CTD]-associated vasculitis), low glucose levels (mostly in infectious vasculitis) and unique cerebrospinal fluid oligoclonal bands (observed in infectious and CTD-associated vasculitis). Patients with inflammatory cerebral amyloid angiopathy (CAA) were older and more commonly had microhemorrhage than primary angiitis of the CNS (PACNS). All patients with CTD-associated vasculitis had a known history of CTD at presentation. Brain biopsies were performed on 10 of 17 PACNS patients and 4 of 8 inflammatory CAA patients, confirming vasculitis in 7 and 4 patients, respectively. Intravenous methylprednisolone was the predominant induction therapy (63.6%), and cyclophosphamide was the most used adjunctive therapy. Cyclophosphamide, rituximab, azathioprine, and mycophenolate mofetil were utilized as maintenance therapy, often with concurrent prednisone. Patients with inflammatory CAA had a higher tendency for relapse rates than PACNS. Conclusions This study highlights the variations in patients' characteristics, symptoms, and treatment for CNS vasculitis. Understanding these differences can lead to more efficient diagnostic and management strategies.
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Affiliation(s)
- Yoji Hoshina
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Alen Delic
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Ka-Ho Wong
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Lyden
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Tammy L. Smith
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Melissa A. Wright
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Daisuke Shimura
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Stacey L. Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
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Li N, Liu X, Wu P, Liu J, Chen P, Zeng J. Three cases of systemic lupus erythematosus presenting with ischemic stroke as the initial symptom: Case reports and literature review. Immun Inflamm Dis 2024; 12:e1183. [PMID: 38332684 PMCID: PMC10853674 DOI: 10.1002/iid3.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Ischemic stroke constitutes a grave complication within the context of systemic lupus erythematosus (SLE), typically manifesting several years postdiagnosis of SLE. Incidents where ischemic stroke precedes and acts as an initial symptom of SLE are comparatively rare in its early stages, and such presentations are frequently misdiagnosed as ischemic cerebrovascular diseases, posing significant diagnostic challenges. CASE REPORTS This article presents three cases of young females in whom ischemic stroke emerged as the initial manifestation of SLE. It incorporates a review of 17 case reports published over the past two decades, focusing on patients with SLE where ischemic stroke was a primary symptom. This discussion encompasses the clinical presentation, outcomes, and therapeutic approaches for these patients. CONCLUSION In young patients, particularly females presenting with ischemic stroke and especially in cases accompanied by hematologic or multisystemic involvement, there should be heightened vigilance for SLE-induced ischemic stroke. Early diagnosis and treatment significantly enhance patients' quality of life and survival rates.
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Affiliation(s)
- Na Li
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Xiaoxia Liu
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Pengjia Wu
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Jun Liu
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Pengyu Chen
- Radiology DepartmentThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
| | - Jiashun Zeng
- Department of Rheumatology and ImmunologyThe Affiliated Hospital of Guizhou Medical UniversityGuiyangChina
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Isogai S, Mizuno M, Uehara K, Okita K, Naniwa T. Case report: Additional use of hydroxychloroquine in treatment-resistant recurrent cerebral infarctions with antiphospholipid antibody syndrome. Int J Rheum Dis 2024; 27:e15056. [PMID: 38334164 DOI: 10.1111/1756-185x.15056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/04/2024] [Accepted: 01/19/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Shuntaro Isogai
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Masayuki Mizuno
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Koji Uehara
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Kenji Okita
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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Jiang W, Mei S, Deng Q, Lei C, Pang A. A Case of Cerebral Large-Vessel Vasculitis Concomitant Fahr Syndrome in Systemic Lupus Erythematosus. Neurologist 2024; 29:17-21. [PMID: 37639572 PMCID: PMC10763715 DOI: 10.1097/nrl.0000000000000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a heterogenous, devastating autoimmune inflammatory disease with multiorgan involvement. A variety of neurological and psychiatric symptoms may be caused by nervous system involvement, termed neuropsychiatric systemic lupus erythematosus. CASE REPORT We describe a young man newly diagnosed with SLE who had a stroke as an initial symptom and was found to have cerebral large-vessel vasculitis and Fahr syndrome. CONCLUSIONS The novelties of this report are the extensive cerebral calcification demonstrated on head computerized tomography in a patient with SLE, and the depiction of an underlying vasculitis on high-resolution magnetic resonance vessel wall imaging. It is our aim to describe this atypical form of neuropsychiatric systemic lupus erythematosus onset and to make known the usefulness of the new magnetic resonance imaging techniques for the diagnosis of cerebral large-vessel vasculitis.
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Affiliation(s)
- Wen Jiang
- Departments of Neurology
- Yunnan Provincial Clinical Research Center for Neurological Disease, Kunming, Yunnan Province, China
| | - Song Mei
- Cardiovascular Surgery, The First Affiliated Hospital of Kunming Medical University
| | | | - Chunyan Lei
- Departments of Neurology
- Yunnan Provincial Clinical Research Center for Neurological Disease, Kunming, Yunnan Province, China
| | - Ailan Pang
- Departments of Neurology
- Yunnan Provincial Clinical Research Center for Neurological Disease, Kunming, Yunnan Province, China
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6
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Silverman A, Dugue R, George PM. Clinical Problem Solving: A 38-year-Old Woman With Systemic Lupus Erythematosus Presenting With Headache, Nausea, and Vomiting. Neurohospitalist 2023; 13:394-398. [PMID: 37701245 PMCID: PMC10494810 DOI: 10.1177/19418744231182285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
A 38-year-old woman with migraine headaches and systemic lupus erythematosus with recent cessation of her immunosuppressive therapy presents with prolonged headache and hypertensive emergency. Her examination is notable for a peripheral right facial palsy and stable malar rash. There are no signs of systemic infection nor systemic symptoms of a lupus flare. Initial CT head reveals bilateral hypodensities in the basal ganglia. Within 8 hours of presentation, she develops right hemiplegia and becomes encephalopathic. MRI shows multifocal acute infarcts (most notably in the left basal ganglia), enhancement of the right facial nerve, and multifocal vessel wall enhancement in the anterior and posterior circulation. We discuss the differential diagnosis, comprehensive workup, and subsequent treatment decisions in the management of this immunocompromised patient with encephalopathy, headache, and rapidly progressing focal neurologic deficits.
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Affiliation(s)
- Andrew Silverman
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
- Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rachelle Dugue
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Paul M. George
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
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7
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Ghorishi A, Alayon A, Ghaddar T, Kandah M, Amundson PK. MR and CT angiography in the diagnosis of vasculitides. BJR Open 2023; 5:20220020. [PMID: 37953869 PMCID: PMC10636354 DOI: 10.1259/bjro.20220020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 11/14/2023] Open
Abstract
Vasculitides represent the wide-ranging series of complex inflammatory diseases that involve inflammation of blood vessel walls. These conditions are characterized according to the caliber of the predominantly involved vessels. The work-up of vasculitides often includes imaging to narrow a differential diagnosis and guide management. Findings from CT and MR angiography in conjunction with a thorough history and physical exam are of utmost importance in making an accurate diagnosis. Further, imaging can be used for follow-up, in order to monitor disease progression and response to treatment. This wide-ranging literature review serves as the primary resource for clinicians looking to diagnose and monitor the progression of rare vascular inflammatory conditions. This article provides a comprehensive summary of the main findings on imaging related to each of these vasculitides. For each of the named vasculitis conditions, a thorough overview of the diagnostic modalities and their respective findings is described. Many specific hallmarks of pathology are included in this review article.
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Affiliation(s)
- Alex Ghorishi
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Amaris Alayon
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Tarek Ghaddar
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Maya Kandah
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Per K Amundson
- School of Medicine, Indiana University, Indianapolis, United States
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8
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Kim NR, Kang JW, Nam EJ. Tumor-like Presentation of Cerebral Vasculitis in a Patient With Systemic Lupus Erythematosus: A Biopsy-confirmed Case. JOURNAL OF RHEUMATIC DISEASES 2023; 30:53-57. [PMID: 37476529 PMCID: PMC10351352 DOI: 10.4078/jrd.22.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/30/2022] [Accepted: 09/16/2022] [Indexed: 07/22/2023]
Abstract
Central nervous system (CNS) manifestations of systemic lupus erythematosus (SLE) are diverse and often difficult to distinguish from SLE-unrelated events. CNS vasculitis is a rare manifestation, which is seen in less than 10% of post-mortem studies, and lesions with multifocal cerebral cortical microinfarcts associated with small-vessel vasculitis are the predominant feature. However, CNS vasculitis presenting as a tumor-like mass lesion in SLE has rarely been reported. Herein, we report a case of cerebral vasculitis mimicking a brain tumor in a 39-year-old female with SLE. A biopsy of the brain mass revealed fibrinoid necrosis and leukocytoclastic vasculitis. The neurological deficits and systemic symptoms improved after treatment with corticosteroids and immunosuppressive agents. To the best of our knowledge, there are no reports of biopsy-proven cerebral vasculitis presenting as a brain mass in patients with SLE in Korea.
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Affiliation(s)
- Na Ri Kim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong Wan Kang
- Division of Rheumatology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Eon Jeong Nam
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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9
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Sherman MA, Botero-Calderon L, Boggs K, Patel D, Goss M, Ahn SY, Diab YA, Whitehead MT, Harrar DB, Pearl MS, Sule S. Central nervous system venulitis in childhood-onset systemic lupus erythematosus presenting with recurrent transient ischemic attacks. Lupus 2022; 31:268-269. [PMID: 35041537 DOI: 10.1177/09612033221074537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew A Sherman
- Division of Rheumatology, 8404Children's National Hospital, Washington, DC, USA
| | | | - Kaitlyn Boggs
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Devika Patel
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Margaret Goss
- Division of Neurology, 8404Children's National Hospital, Washington, DC, USA
| | - Sun-Young Ahn
- Division of Nephrology, 8404Children's National Hospital, Washington, DC, USA
| | - Yaser A Diab
- Department of Hematology/Oncology, 8404Children's National Hospital, Washington, DC, USA
| | - Matthew T Whitehead
- Department of Neuroradiology, 8404Children's National Hospital, Washington, DC, USA
| | - Dana B Harrar
- Division of Neurology, 8404Children's National Hospital, Washington, DC, USA
| | - Monica S Pearl
- Department of Radiology, 8404Children's National Hospital, Washington, DC, USA
| | - Sangeeta Sule
- Division of Rheumatology, 8404Children's National Hospital, Washington, DC, USA
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10
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Hecker C, Welponer T, Herold M, Trinka E, Broussalis E, Killer-Oberpfalzer M. Update on treatment strategies for vasculitis affecting the central nervous system. Drug Discov Today 2021; 27:1142-1155. [PMID: 34838730 DOI: 10.1016/j.drudis.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022]
Abstract
Vasculitis affecting the nervous system is a rare disease that can not only present with nonspecific initial symptoms, but also run a severe course without accurate treatment. Although improvements have been achieved, diagnosis of vasculitis remains challenging, because many classification criteria are unspecific or inconclusive with regard to central nervous system (CNS) manifestations. Currently, beside an isolated primary CNS vasculitis, several systemic types of vasculitis are known to affect the nervous system. In this review, we provide an overview of the pathophysiology, current therapeutic guidelines, and highlight novel treatment strategies for CNS vasculitis.
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Affiliation(s)
- Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria.
| | - Tobias Welponer
- Department of Dermatology and Allergology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Manfred Herold
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology, and Rheumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
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11
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Leone P, Prete M, Malerba E, Bray A, Susca N, Ingravallo G, Racanelli V. Lupus Vasculitis: An Overview. Biomedicines 2021; 9:1626. [PMID: 34829857 PMCID: PMC8615745 DOI: 10.3390/biomedicines9111626] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.
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Affiliation(s)
- Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Eleonora Malerba
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Antonella Bray
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Nicola Susca
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Giuseppe Ingravallo
- Section of Pathology, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy;
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
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12
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Abraham P, Neel I, Bishay S, Sewell DD. Central Nervous System Systemic Lupus Erythematosus (CNS-SLE) Vasculitis Mimicking Lewy Body Dementia: A Case Report Emphasizing the Role of Imaging With an Analysis of 33 Comparable Cases From the Scientific Literature. J Geriatr Psychiatry Neurol 2021; 34:128-141. [PMID: 31996085 DOI: 10.1177/0891988720901788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Neuropsychiatric symptoms occur in 30% to 40% of patients living with systemic lupus erythematosus (SLE). Brain imaging may play a pivotal role in determining the etiology as it did for the case presented here. METHODS A new case of central nervous system (CNS) SLE is presented along with an analysis of 33 comparable cases from the scientific literature. RESULTS A 70-year-old female with subacute cutaneous lupus presented to a university-based geropsychiatry program after 1 year of benign visual hallucinations and several months of shuffling gait, recurrent falls, and forgetfulness. These symptoms were highly suggestive of Lewy body dementia; however, the patient's history of basal ganglia infarct, cognitive testing demonstrating inattention and executive dysfunction, and follow-up brain imaging, which did not reveal acute findings, aligned with cerebral pathology previously attributed to vasculitis and supported the diagnosis of subcortical dementia due to SLE-CNS vasculitis. Oral prednisone 20 mg daily resolved her symptoms. Over the next 19 months, her prednisone was tapered completely and her symptoms did not return. A systematic literature search identified 33 comparable cases. CONCLUSION An analysis of previously published cases suggests that extending the duration of the prednisone taper beyond 1 year may decrease the risk of later occurring neuropsychiatric symptoms in this patient population.
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Affiliation(s)
- Peter Abraham
- Department of Psychiatry, 8784University of California, San Diego, CA, USA
| | - Ian Neel
- Department of Internal Medicine, 8784University of California, San Diego, CA, USA
| | | | - Daniel D Sewell
- Department of Psychiatry, 8784University of California, San Diego, CA, USA
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Carrión-Barberà I, Salman-Monte TC, Vílchez-Oya F, Monfort J. Neuropsychiatric involvement in systemic lupus erythematosus: A review. Autoimmun Rev 2021; 20:102780. [PMID: 33609799 DOI: 10.1016/j.autrev.2021.102780] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/31/2020] [Indexed: 02/07/2023]
Abstract
The neuropsychiatric involvement in systemic lupus erythematosus (NPSLE) is a challenge for clinicians, both at a diagnostic and therapeutic level. Although in 1999 the American College of Rheumatology (ACR) proposed a set of definitions for 19 NPSLE syndromes, with the intention of homogenizing the terminology for research purposes and clinical practice, the prevalence of NPSLE varies widely according to different series and is estimated to be between 37 and 95%. This is due to multiple factors such as the unalike definitions used, the diverse design of the studies, type of population, race, type and severity of symptoms, and follow-up of the different cohorts of patients with SLE. In recent years, some authors have tried excluding minor neuropsychiatric manifestations in order to try to reduce this wide variation in the prevalence of NPSLE since they are very prevalent in the general population; others authors have developed various models for the attribution of neuropsychiatric events to SLE that can assist clinicians in this diagnostic process, and finally, some authors developed and validated in 2014 a new algorithm based on the definitions of the ACR that includes the evaluation of the patient's lupus activity together with imaging techniques and the analysis of cerebrospinal fluid (CSF), with the aim of trying to differentiate the true neuropsychiatric manifestations attributable to SLE. In 2010, the European League Against Rheumatism (EULAR) developed recommendations for the management of NPSLE. We found abundant literature published later where, in addition to the recommendations for the management of the 19 NPSLE syndromes defined by the ACR, additional recommendations are given for other neurological and/or psychiatric syndromes, conditions, and complications that have been associated to SLE in recent years. We review below the diagnostic and therapeutic management of the different entities.
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Affiliation(s)
| | | | - F Vílchez-Oya
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar-IMIM, Spain.
| | - Jordi Monfort
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar-IMIM, Spain.
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Abstract
A 47-year-old woman, who was diagnosed to have systemic lupus erythematosus (SLE), was admitted because she suffered a severe ischemic stroke three weeks after experiencing a transient attack of aphasia. Diffusion-weighted MRI revealed high intensity at the borderzone of the middle cerebral artery (MCA), while the proximal portion of the left MCA was occluded with its vascular wall enhanced by gadolinium. Intravenous methylprednisolone and heparin were administrated without any symptomatic benefit. She developed severe right hemiparesis with aphasia. Isolated cerebral vasculitis in the large vessel has been rarely reported in SLE patients. The presence of an enhanced vascular wall in the MRI with gadolinium could support the diagnosis.
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Affiliation(s)
- Sho Takeshita
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
| | - Toshiyasu Ogata
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
| | - Jun Tsugawa
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
| | - Yoshio Tsuboi
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
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Prabhat N, Chakravarty K, Pattnaik SN, Takkar A, Ray S, Lal V. Systemic lupus erythematosus with autoimmune neurological manifestations in a carrier of chronic granulomatous disease - a rare presentation. J Neuroimmunol 2020; 343:577229. [PMID: 32247876 DOI: 10.1016/j.jneuroim.2020.577229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/15/2020] [Accepted: 03/25/2020] [Indexed: 12/24/2022]
Abstract
Chronic granulomatous disease (CGD) is an uncommon genetic immunodeficiency disorder affecting neutrophil function, characterized by recurrent bacterial and fungal infections. X-linked carriers of CGD have an increased risk of autoimmune disorders, in particular lupus like disorders. We describe the case of a 37 years old female carrier of X-linked CGD, who presented with clinical features and serology consistent with a definite diagnosis of Systemic lupus erythematosus (SLE), with rare immune mediated neurological manifestations including secondary central nervous system (CNS) vasculitis and Longitudinally extensive transverse myelitis (LETM), responsive to immunomodulation. These neurological manifestations have not been described previously in carriers of CGD. We recommend early diagnosis of these immune mechanisms, especially in X-linked carriers of CGD, and appropriate immunomodulation in order to improve life expectancy and improve neurological outcome.
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Affiliation(s)
- Nandita Prabhat
- Department of Neurology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India
| | - Kamalesh Chakravarty
- Department of Neurology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India.
| | - Shiv Narayan Pattnaik
- Department of Neurology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India
| | - Aastha Takkar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India
| | - Sucharita Ray
- Department of Neurology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India
| | - Vivek Lal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India
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Markousis-Mavrogenis G, Mitsikostas DD, Koutsogeorgopoulou L, Dimitroulas T, Katsifis G, Argyriou P, Apostolou D, Velitsista S, Vartela V, Manolopoulou D, Tektonidou MG, Kolovou G, Kitas GD, Sfikakis PP, Mavrogeni SI. Combined Brain-Heart Magnetic Resonance Imaging in Autoimmune Rheumatic Disease Patients with Cardiac Symptoms: Hypothesis Generating Insights from a Cross-sectional Study. J Clin Med 2020; 9:jcm9020447. [PMID: 32041234 PMCID: PMC7074384 DOI: 10.3390/jcm9020447] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Autoimmune rheumatic diseases (ARDs) may affect both the heart and the brain. However, little is known about the interaction between these organs in ARD patients. We asked whether brain lesions are more frequent in ARD patients with cardiac symptoms compared with non-ARD patients with cardiovascular disease (CVD). METHODS 57 ARD patients with mean age of 48 ± 13 years presenting with shortness of breath, chest pain, and/or palpitations, and 30 age-matched disease-controls with non-autoimmune CVD, were evaluated using combined brain-heart magnetic resonance imaging (MRI) in a 1.5T system. RESULTS 52 (91%) ARD patients and 16 (53%) controls had white matter hyperintensities (p < 0.001) in at least one brain area (subcortical/deep/periventricular white matter, basal ganglia, pons, brainstem, or mesial temporal lobe). Only the frequency and number of subcortical and deep white matter lesions were significantly greater in ARD patients (p < 0.001 and 0.014, respectively). ARD vs. control status was the only independent predictor of having any brain lesion. Specifically for deep white matter lesions, each increase in ECV independently predicted a higher number of lesions [odds ratio (95% confidence interval): 1.16 (1.01-1.33), p = 0.031] in ordered logistic regression. Penalized logistic regression selected only ARD vs. control status as the most important feature for predicting whether brain lesions were present on brain MRI (odds ratio: 5.46, marginal false discovery rate = 0.011). CONCLUSIONS Subclinical brain involvement was highly prevalent in this cohort of ARD patients and was mostly independent of the severity of cardiac involvement. However, further research is required to determine the clinical relevance of these findings.
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Affiliation(s)
| | - Dimos D. Mitsikostas
- First Neurology Department, National and Kapodistrian University of Athens, 10679 Athens, Greece;
| | | | - Theodoros Dimitroulas
- Department of Rheumatology, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Gikas Katsifis
- Rheumatology Department, Naval Hospital, 11521 Athens, Greece;
| | - Panayiotis Argyriou
- MRI Unit, Mediterraneo Hospital, 16675 Athens, Greece; (P.A.); (D.A.); (S.V.)
| | - Dimitrios Apostolou
- MRI Unit, Mediterraneo Hospital, 16675 Athens, Greece; (P.A.); (D.A.); (S.V.)
| | - Stella Velitsista
- MRI Unit, Mediterraneo Hospital, 16675 Athens, Greece; (P.A.); (D.A.); (S.V.)
| | - Vasiliki Vartela
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (V.V.); (D.M.); (G.K.)
| | - Dionysia Manolopoulou
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (V.V.); (D.M.); (G.K.)
| | - Maria G. Tektonidou
- First Department of Propaedeutic and Internal Medicine, Laikon Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.G.T.); (P.P.S.)
| | - Genovefa Kolovou
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (V.V.); (D.M.); (G.K.)
| | - George D. Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester M13 9PT, UK;
| | - Petros P. Sfikakis
- First Department of Propaedeutic and Internal Medicine, Laikon Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.G.T.); (P.P.S.)
| | - Sophie I. Mavrogeni
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (V.V.); (D.M.); (G.K.)
- Correspondence: ; Tel./Fax: +30-210-98-82-797
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Shaban A, Leira EC. Neurological Complications in Patients with Systemic Lupus Erythematosus. Curr Neurol Neurosci Rep 2019; 19:97. [PMID: 31773306 DOI: 10.1007/s11910-019-1012-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE) is commonly associated with neurological manifestations. Rapid recognition and treatment of these complications may improve outcomes. In this article, we review the neurological conditions associated with SLE, their diagnosis and management strategies. RECENT FINDINGS Recent meta-analysis showed that patients with neuropsychiatric manifestations of SLE were more likely to have positive antiphospholipid, antiribosomal P, and antineuronal antibodies. Another meta-analysis showed an association between SLE and antiphospholipid antibodies with cognitive impairment. Two large retrospective studies have shown that the peripheral nervous system is commonly involved in SLE frequently alongside the central nervous system. Neurological manifestations occur in most of SLE patients. Antiphospholipid antibodies are common in patients with SLE and increase the odds of neurological complications. Management typically involved a combination of treatments directed toward the neurological complication and therapies directed toward SLE itself. The efficacy of these treatment protocols, however, has not been rigorously studied and deserves further investigation.
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Affiliation(s)
- Amir Shaban
- Department of Neurology, Carver College of Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA.
| | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA.,Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
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Felten R, Scher F, Sibilia J, Chasset F, Arnaud L. Advances in the treatment of systemic lupus erythematosus: From back to the future, to the future and beyond. Joint Bone Spine 2018; 86:429-436. [PMID: 30243784 DOI: 10.1016/j.jbspin.2018.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/06/2018] [Indexed: 12/30/2022]
Abstract
There have been many advances in the diagnosis and therapeutic management of systemic lupus erythematosus (SLE) over the past decades. Following more than eleven centuries of therapeutic uncertainty, the discovery of the therapeutic properties of glucocorticoids is without any doubt one of the most significant advance in the field of autoimmune diseases. The many progresses made by rapidly growing chemical industry of the 19th century chemistry have allowed the identification of valuable therapeutic compounds such as anti-malarials, cyclophosphamide, azathioprine, cyclosporine and later mycophenolate mofetil, which have all profoundly changed the face of the disease. A very visible consequence of this is the profound improvement in the prognosis of the disease, with 10-year survival rates of more than 90% in most dedicated centres. Following the development of biotherapies in rheumatoid arthritis, the late 20th century has slowly opened a new era for the treatment of SLE, that of targeted therapies. With the approval of belimumab in 2011 and 74 targeted therapies in clinical development, we may expect great changes in the therapeutic management of SLE. Those molecules target inflammatory cytokines or chemokines and their receptors, B cells or plasma cells, intracellular signalling pathways, B/T cells co-stimulation molecules, interferons, plasmacytoid dendritic cells, as well as various other targets of interest. Current challenges are now slowly shifting from whether some new drugs will be available to how to select the most adequate drug (or drug combination) at the patient-level.
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Affiliation(s)
- Renaud Felten
- Service de rhumatologie, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France; Université de Strasbourg, centre national de référence RESO-Lupus, 67000 Strasbourg, France; Laboratoire d'immunologie, immunopathologie et chimie thérapeutique, institut de biologie moléculaire et cellulaire (IBMC), CNRS UPR3572, 67000 Strasbourg, France.
| | - Florence Scher
- Service de pharmacie-stérilisation, hôpitaux universitaires de Strasbourg, 67000 Strasbourg, France
| | - Jean Sibilia
- Service de rhumatologie, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France; Université de Strasbourg, centre national de référence RESO-Lupus, 67000 Strasbourg, France; Laboratoire d'immunorhumatologie moléculaire, Inserm UMR_S1109, 67000 Strasbourg, France
| | - François Chasset
- Sorbonne université, faculté de médecine, Sorbonne université, 75013 Paris, France; Service de dermatologie et allergologie, hôpital Tenon, AP-HP, 75020 Paris, France
| | - Laurent Arnaud
- Service de rhumatologie, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France; Université de Strasbourg, centre national de référence RESO-Lupus, 67000 Strasbourg, France; Laboratoire d'immunorhumatologie moléculaire, Inserm UMR_S1109, 67000 Strasbourg, France
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Matusik PS, Matusik PT, Stein PK. Cardiovascular reflex tests in patients with systemic lupus erythematosus: clinical performance and utility. Lupus 2018; 27:1759-1768. [DOI: 10.1177/0961203318783052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background This review summarizes current knowledge about cardiovascular reflex tests (CVRTs) and other selected autonomic nervous system (ANS) assessment tests in systemic lupus erythematosus (SLE) patients and assesses their clinical utility in this group of patients. Methods The PubMed database was searched for terms associated with CVRTs and SLE. Only papers available in full text and published in English were considered. Ultimately, 13 were selected and analyzed. Results In most of the studies CVRTs results were reported more likely to be abnormal in patients with SLE when compared with controls. The reported prevalence of ANS dysfunction in SLE, diagnosed using CVRTs, ranged from 23.5% to 82.7% of patients, likely because of different definitions of ANS dysfunction, variability in methods of performing CVRTs, and potential confounding factors. In general CVRTs results did not correlate with SLE activity or disease duration, but some CVRTs results correlated with some peptides associated with ANS function, including neuropeptide Y and vasoactive intestinal peptide. Conclusion Patients with SLE generally have abnormal or borderline results of CVRTs, which indicate prevalent abnormalities of the ANS in SLE. Performance of CVRTs requires good standardization of test conditions and familiarity with the proper administration and interpretation of these tests.
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Affiliation(s)
- P S Matusik
- Department of Radiology, University Hospital, Kraków, Poland
| | - P T Matusik
- Department of Electrocardiology, The John Paul II Hospital, Kraków, Poland
- Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - P K Stein
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
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