Systemic lupus erythematosus in São Paulo/Brazil: a clinical and laboratory overview

Age of onset influences on clinical and laboratory profile of patients with systemic lupus erythematosus

The present study aims to evaluate differences in clinical and laboratory manifestations and medication use in the different ages of disease onset in patients with systemic lupus erythematosus (SLE). This cross-sectional study consisted of 598 SLE patients (550 female and 48 male), who attended the Rheumatology Clinic of the Hospital de Clínicas de Porto Alegre between 2003 and 2015. Demographic, clinical and laboratory data were collected. The patients were classified into three groups according to their ages at disease diagnosis. Mean age of diagnosis was 33.6 ± 14.3 years, and the median (25th-75th percentile) disease duration was 13 (7-20) years. Among the patients studied, 419 (70%) were adult-onset (aSLE), 90 (14.8%) were late-onset (lSLE) and 89 (14.8%) were childhood-onset (cSLE). The female to male ratio was higher in aSLE (18:1) compared to the other groups (p = 0.001). Arthritis was predominantly found in aSLE (78.5%) when compared with lSLE (57.7%) (p < 0.001). Nephritis was more common in cSLE (60.6%) than in lSLE (26.6%) (p < 0.001). Median (25th-75th percentile) of SLE disease activity index (SLEDAI) was higher in the cSLE group [2 (0-5)] when compared to the lSLE group [0 (0-4)] (p = 0.045). Childhood-onset SLE showed a more severe disease due to the higher incidence of nephritis and needed a more aggressive treatment with immunosuppressive drugs.

Clinical and immunological aspects and outcome of a Brazilian cohort of 414 patients with systemic lupus erythematosus (SLE): comparison between childhood-onset, adult-onset, and late-onset SLE

The clinical expression of systemic lupus erythematosus (SLE) is influenced by genetic and environmental factors and therefore varies between ethnicities. Information on the epidemiology of SLE in Brazil is scarce and practically limited to studies conducted in socioeconomically developed regions (South and Southeast). The objective of this study was to describe the clinical and immunological aspects and outcome of a cohort of patients with SLE treated at a university hospital in northeastern Brazil and compare patterns related to age at onset: childhood (cSLE), adult (aSLE), and late (lSLE). A random sample of 414 records (women: 93.5%) were reviewed. The mean age at SLE onset and the mean disease duration were 28.9 ± 10.9 years and 10.2 ± 6.6 years, respectively. Most patients had aSLE (n = 338; 81.6%), followed by cSLE (n = 60; 14.5%) and lSLE (n = 16; 3.9%). The female/male ratio was 6.5:1 in cSLE and 16.8:1 in aSLE; in lSLE, all patients were female (p = 0.05). During follow-up, the cSLE group presented higher rates of nephritis (70% vs. 52.9% vs. 12.5%; p = 0.0001) and leuko/lymphopenia (61.7% vs. 43.8% vs. 56.2%; p = 0.02). No significant differences were found for anti-dsDNA, anti-Sm, and antiphospholipid antibodies. Treatment with immunosuppressants was significantly more common, and higher doses of prednisone were used, in cSLE. The prevalence of cardiovascular diseases were more frequent in lSLE (p = 0.03). No significant differences were found between the three groups with regard to mean damage accrual (SDI), remission, and mortality. Although cSLE presented higher rates of nephritis and leuko/lymphopenia, more frequent use of immunosuppressants and higher prednisone doses than aSLE and lSLE, the three groups did not differ significantly with regard to damage accrual, remission, and mortality.

A nationwide study of SLE in Japanese identified subgroups of patients with clear signs patterns and associations between signs and age or sex

We performed a nationwide study to determine the distributions of the signs and clinical markers of systemic lupus erythematosus (SLE) and identify any patterns in their distributions to allow patient subclassification. We obtained 256,999 patient-year records describing the disease status of SLE patients from 2003 to 2010. Of these, 14,779 involved patients diagnosed within the last year, and 242,220 involved patients being followed up. Along with basic descriptive statistics, we analyzed the effects of sex, age and disease duration on the frequencies of signs in the first year and follow-up years. The patients and major signs were clustered using the Ward method. The female patients were younger at onset. Renal involvement and discoid eczema were more frequent in males, whereas arthritis, photosensitivity and cytopenia were less. Autoantibody production and malar rash were positively associated with young age, and serositis and arthritis were negatively associated. Photosensitivity was positively associated with a long disease duration, and autoantibody production, serositis and cytopenia were negatively associated. The SLE patients were clustered into subgroups, as were the major signs. We identified differences in SLE clinical features according to sex, age and disease duration. Subgroups of SLE patients and the major signs of SLE exist.

Cardiovascular involvement in autoimmune diseases

Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.

Concomitance of IgM and IgG anti-dsDNA Antibodies Does Not Appear to Associate to Active Lupus Nephritis

Previous reports proposed that the IgM anti-dsDNA antibody is protective for lupus nephritis. In this cross-sectional study, we aimed to compare clinical features of systemic lupus erythematosus (SLE) patients positive for IgG anti-dsDNA alone with those presenting both IgG and IgM anti-dsDNA. Anti-dsDNA antibodies, urinary examination and complement levels were assessed in the day of appointment. IgG and IgM anti-dsDNA antibodies were detected by indirect immunofluorescence. Fifty-eight SLE patients (93.1% female, 81% European-derived, mean age 42.8±14.7 years, mean duration of disease 10.9±8 years) positive for IgG anti-dsDNA entered the study. Of those, 15 were also positive for the IgM anti-dsDNA isotype. The group with both isotypes showed significant less frequency of active nephritis (sediment changes and proteinuria) when compared to patients with IgG anti-dsDNA alone (6.7% versus 34.9%, p=0.046). These data suggest a nephroprotective role for IgM anti-dsDNA and a distinct biologic behavior for this isotype in SLE.

Cardiovascular disease in latin american patients with systemic lupus erythematosus: a cross-sectional study and a systematic review

Objective. This study was performed to determine the prevalence of and associated risk factors for cardiovascular disease (CVD) in Latin American (LA) patients with systemic lupus erythematosus (SLE). Methods. First, a cross-sectional analytical study was conducted in 310 Colombian patients with SLE in whom CVD was assessed. Associated factors were examined by multivariate regression analyses. Second, a systematic review of the literature on CVD in SLE in LA was performed. Results. There were 133 (36.5%) Colombian SLE patients with CVD. Dyslipidemia, smoking, coffee consumption, and pleural effusion were positively associated with CVD. An independent effect of coffee consumption and cigarette on CVD was found regardless of gender and duration of disease. In the systematic review, 60 articles fulfilling the eligibility criteria were included. A wide range of CVD prevalence was found (4%-79.5%). Several studies reported ancestry, genetic factors, and polyautoimmunity as novel risk factors for such a condition. Conclusions. A high rate of CVD is observed in LA patients with SLE. Awareness of the observed risk factors should encourage preventive population strategies for CVD in patients with SLE aimed at facilitating the suppression of cigarette smoking and coffee consumption as well as at the tight control of dyslipidemia and other modifiable risk factors.

Clinical and immunological features of 888 Brazilian systemic lupus patients from a monocentric cohort: comparison with other populations

Epidemiological studies with systemic lupus erythematosus (SLE) patients have been reported worldwide but, until now, a large evaluation had not been performed in Brazil. Therefore, we determined the clinical and immunological features of 888 SLE patients followed at our service from 2008 to 2012. The mean age at SLE onset and the mean disease duration were 29.9 ± 9.5 years old and 14.5 ± 8.4 years, respectively. A predominance of female gender (91.9%) and Caucasian ethnicity (69.9%) were observed. Cumulative mucocutaneous manifestations (90.7%) were most commonly identified (malar rash (83.2%), photosensitivity (76.9%)) followed by articular (87.4%), hematological (44.0%) and renal (36.9%) involvements. Antinuclear antibody was detected in all patients, followed by anti-dsDNA (35.1%), anti-Sm (21.8%) and anti-ribosomal P protein antibodies (19.8%). Additional comparison of clinical and laboratory features between genders revealed that malar rash was observed more in female SLE patients (84.5% vs. 69.4%, p = 0.001). Male lupus patients presented a higher frequency of anti-dsDNA (45.8% vs. 34.2%, p = 0.047) and a trend of more nephritis (47.2% vs. 36.0%, p = 0.059). In conclusion, we identified a high prevalence of mucocutaneous manifestations in this Brazilian SLE cohort compared to other countries, mainly malar rash that was most commonly observed in female patients. Anti-dsDNA and other specific SLE autoantibodies were also identified in a higher frequency, predominantly in the male gender.

[Autoantibodies in systemic lupus erythematosus: spectrum and clinical associations]

We have analysed the clinical features and autoantibody profile of 84 tunisian patients with newly diagnosed systemic lupus erythematosus (SLE). Antinuclear antibodies (ANA) were detected by an immunofluorescence method, anti-dsDNA and anti-cardiolipin (aCL) antibodies by ELISA, antinucleosome and anti-extractible nuclear antigens (or anti-ENA: anti-Sm, anti-RNP, anti-SSA and anti-SSB) by immunodot. The mean age of the patients was 29,9 years and the sex-ratio F/M was 6. The most common initial features were haematological (80%), rheumatological (78%) and cutaneous (75%) disorders. 59% of the patients had glomerular nephropathy. ANA were detected in 97.6%, antinucleosome in 78.6%, anti-dsDNA in 75%, anti-histones in 44%, anti-Sm in 36.9%, anti-RNP in 32.1%, anti-SSA in 54.8% and anti-SSB in 14.3% of patients. IgG and IgM aCL were detected in 45 and 40% of the patients respectively. The significant clinical associations were those of nephropathy and disease activity with anti-dsDNA and antinucleosome antibodies. Our results confirm the clinical polymorphism of SLE, the high frequency of antinucleosome antibodies at time of diagnosis and the predominance of anti-SSA among anti-ENA antibodies.

Le lupus érythémateux systémique en Tunisie. Étude multicentrique nationale. À propos de 295 observations

PURPOSE

Systemic lupus erythematosus (SLE) is an autoimmune disease with a great clinical polymorphism. Wide variety of genetic, hormonal, immunological and environmental contributes to release the disease. Our objective was to describe and precise the epidemiological, clinical and immunological profile of this disease in Tunisia.

METHOD

It is a retrospective study conducted by the Tunisian society of internal medicine during the period from January 1990 to December 1999. All patients fulfilled at least four of the revised American Rheumatism Association's criteria for SLE.

RESULTS

Two hundred and ninety-five SLE have been examined (271 women, 24 men). The most frequent clinical manifestations were: articular 90%, malar rash 62%, photosensitivity 46%, seritis 32% and glomerulonephritis 56%, dominated by WHO class III and IV: 60 cases (renal biopsy was performed in 95 patients). Neurological features were observed in 14.5%. The abnormal laboratory findings were leucocytopenia 45%, lymphopenia 47%, thrombocytopenia 16% and hemolytic anemia in 6.7%. Antinuclear antibodies, anti-ds DNA and anti-Sm were at 92%, 74% and 57%, respectively. Eighty-three percent of patients were treated by steroids, and in 52 cases (18%), we added immunosuppressive drugs. Two hundred and eighteen patients were followed up with a mean follow-up duration of 51 months. Twenty-eight percent were in complete remission and in 60%, the SLE was active. In contrast, death occurred in 29 cases.

CONCLUSION

Our study confirmed the clinical polymorphism of SLE, the great similarity with other studies apart the world, the gravity of renal and cardiac features and the infectious complications induced by corticosteroids.

Mucocutaneous disease in Arabs with systemic lupus erythematosus: clinical expression and relevance to autoantibodies

Both criterial and non-criterial mucocutaneous manifestations of 42 Arabs with systemic lupus erythematosus are reviewed. Photosensitivity occurred in 40.5%, malar rash in 35.75% and oral ulcers in 26% of patients. Subcutaneous nodules and subcutaneous lupus erythematosus (SCLE) were not seen, and there were few cases of discoid rash (DLE), Raynaud's phenomenon, livedo reticularis and SLE-related sicca and anticardiolipin syndromes. In the clinical relevance of autoantibodies in these patients, there was a significant association between anti-Sm antibodies and oral ulcers (P= 0.033) and, interestingly, between anti-cardiolipin (aCL) antibodies and lack of photosensitivity (P = 0.014). The report also reviews previously presented data on mucocutaneous LE in Arab and non-Arab patients and emphasises the presence of intra- and inter-racial variations of SLE expression including the clinical relevance to autoantibodies.

Systemic lupus erythematosus in India

The first case of systemic lupus erythematosus (SLE) was reported from India in 1995 followed by two more case reports and further, a series of eight cases, till 1969. Since the establishment of a clinical immunology laboratory at a major teaching institution in New Delhi in 1968, SLE was extensively studied and reported from that centre. From mid-1980 onwards several other centres in different regions in India including Chennai (old name Madras), Mumbai (old name Bombay), Calcutta and Hydrabad, also published their regional experience on SLE. Based on these data, the present report describes the clinical and laboratory characteristics of 1366 SLE patients seen in different regions of India. Arthritis, rash, photosensitivity, seizures and psychosis were seen in comparable proportions to other racial groups. Similarly, ANA and anti-DNA antibody positivity was also within the range seen in other racial groups. When compared with other series, however, alopecia, renal lupus, oral ulcers and neurological involvement was seen in higher proportions, reaching statistically significant figures in comparison to some racial groups. In contrast, haematological manifestations were seen in significantly less proportions in comparison to some of the racial groups. Serositis and discoid lesions were also seen in lower proportions than in most of other races. The proportion of those with anti-Sm antibodies was in between two extremes of highest among Africans and Israelis and lowest among Chinese and Europeans. Other manifestations were comparable to most other racial groups. Compared to North American and European reports, significantly low 5 and 10 year survival was observed among patients from India. This could be related to the general public health situation in the country including less than optimal management facilities in hospitals, delay in diagnosis due to lack of awareness of the disease, referral bias where only serious patients reach major city hospitals, or a truly severe disease among Indians, or a combination of these genetic, environmental and/or sociocultural factors. The Main causes of death were irreversible renal damage, infections and neurological involvement. Despite a comparable prevalence of anticardiolipin antibodies (aCL) and lupus anticoagulants (LAC), clinical antiphospholipid syndrome was significantly less common. Genetic studies showed appreciable increase of HLA DR4 (37.5%) among patients compared with controls (18%). Additionally the haplotype B8-DR3 was encountered frequently in the patient group.

Serological characteristics of systemic lupus erythematosus from a hospital-based rheumatology clinic in Kuwait

Thirty-one consecutive patients with SLE were screened for antinuclear antibody (ANA), anti-DNA antibodies, extractable nuclear antigen antibodies (anti-ENAs) including anti-Sm, anti-RNP, anti-SSA (anti-Ro), anti-SSB; (anti-La), anti-Scl-70, rheumatoid factor (RF), C-reactive protein (CRP), C3 and C4 levels, anti-cardiolipin antibodies (aCL), biologically false positive serological test for syphilis (BF-STS) using VDRL test and Coombs' test. The age of the patients ranged from 11 to 52 year with a median of 29 year; female to male ratio of 5:1. There were 21 Kuwaitis, four Egyptians, three from the Indian subcontinent, two Filipinos and one Syrian. Main clinical categories of SLE were: mild cutaneous SLE in 12 (38.7%), clinical antiphospholipid syndrome (APS) secondary to SLE in 8 (25.8%), haematological manifestations of SLE in 5 (16.1%), renal lupus in four (12.9%), neuropsychiatric in three (9.7%), others (6.4%). Clinical features overlapped in several patients. ANA was positive in 96.8% (mean value 891.61 units/ml), anti-DNA in 35.5% (mean value 56.4 units) that was lower than expected and could be due to selection bias as the patients were from a rheumatology clinic, anti-ENA in 42%, anti-Sm 13% that was lower than other non-Caucasian populations, anti-RNP 13%, anti-SS-A in 35.5%, anti-SS-B in 19.4%, Scl-70 in 13%, CRP in 71% (moderate 58%, very high 13%); C3 mean 1.52 mg/ml (3.2% low levels), C4 mean 0.35 mg/ml (32% low levels), anticardiolipin mean GPL 35.35 units (high 58%), mean MPL 10.61 units (high 26%), BF-STS in 6%, Coombs' test in 6%, RF positive in 36%. The only significant positive clinical associations observed were those of renal involvement with anti-DNA antibodies (P = 0.042), and clinical antiphospholipid antibody syndrome with aCL antibodies (P = < 0.05).

Ethnic differences in the clinical expression of systemic lupus erythematosus: a comparative study between African-Americans and Latin Americans

Since ethnic differences in the disease expression of systemic lupus erythematosus (SLE) have been recognized, we compared the clinical and serological features in two different ethnic groups of patients with SLE. The study population consisted of 222 African-American and 300 Latin American (Colombian) SLE patients. Clinical, demographic, and laboratory data were obtained by chart review using a standard data collection form. African-American patients more commonly manifested discoid skin lesions, pulmonary fibrosis, and pleuritis, and less commonly manifested photosensitivity, livedo reticularis, and vascular thrombosis than did Latin Americans. In addition, there was a higher frequency of anti-Sm, anti-RNP, and anti-Ro positivity among African-American patients compared with Latin Americans. These results are additional evidence for the presence of ethnic differences in the clinical expression of SLE.

Systemic lupus erythematosus in males. A study of 107 Latin American patients

Clinical and laboratory features were analyzed in 107 Latin American male patients with systemic lupus erythematosus (SLE) who were compared with a group of 1,209 Latin American female patients with SLE to determine the presence of gender-associated differences. Males had an increased prevalence of renal disease, vascular thrombosis, and the presence of anti-dsDNA antibodies, as well as the use of moderate to high doses of corticosteroids, compared with female SLE patients. Although there was no difference in mortality from all causes, SLE-related mortality was higher in the male group. All these findings are consistent with a more severe disease in Latin American males than in female patients from the same region.