Elderly-Onset Systemic Lupus Erythematosus

Risk factors associated with thrombocytopenia in systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) frequently manifests with thrombocytopenia (TP), a hematologic complication that heightens the risk of severe outcomes and increases mortality. This meta-analysis aims to evaluate the potential risk factors associated with TP in SLE patients, providing insights into the demographic features, clinical features, and laboratory findings that contribute to this condition.

METHODS

A comprehensive literature search was conducted across eight databases from inception to September 1, 2024. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis was conducted using univariate and multivariate analyses with Revman 5.3, while heterogeneity was addressed through subgroup and sensitivity analyses. Publication bias was assessed using funnel plots and Egger tests via Stata 15.0.

RESULTS

Seventeen high-quality studies meeting the inclusion criteria were incorporated into this meta-analysis. Independent risk factors for TP in SLE included age (Demographic Features), serositis, splenomegaly, blood system involvement, and renal involvement (Clinical Features), as well as cardiac involvement, anemia, leukocytopenia, low C3/C4, ACA, and CRP (Laboratory Findings). Arthritis and rash were protective factors. Subgroup analysis addressed heterogeneity caused by unit and sample size differences. Sensitivity analysis comparing the consistency between fixed-effects model (FEM) and random-effects model (REM) confirmed the reliability of the findings, and both funnel plots and Egger tests suggested no publication bias.

CONCLUSION

This meta-analysis identified several potential independent risk factors for TP in SLE. Early screening and timely intervention for patients with these risk factors are essential to reduce the likelihood of TP, prevent severe organ damage, and improve overall prognosis.

Late-onset Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a multisystem autoimmune rheumatic disease (ARD) that results from the dysregulation of multiple innate and adaptive immune pathways. Late-onset SLE (Lo-SLE) is the term used when the disease is first diagnosed after 50-65 years, though the standard age cut-off remains undefined. Defining "late-onset" as lupus with onset after 50 years is more biologically plausible as this roughly corresponds to the age of menopause. Lo-SLE comprises nearly 20% of all cases of lupus. With advancing age, the female predominance of lupus declines to nearly 4:1 to even 1.1:1. The natural history of the disease varies, with lesser major organ involvement like nephritis but higher damage accrual. The latter is possibly owed to the atypical presentation and hesitation among physicians to diagnose SLE at this age, a diagnostic delay with late treatment initiation may accelerate the damage accrual. Multimorbidity is a central issue in these patients, which includes osteoporosis, sarcopenia, accelerated atherosclerosis in the background of existing dyslipidemia, diabetes mellitus, major depression, hypertension, coronary artery disease and other thrombotic events.With the rising ages of populations worldwide, awareness about late-onset lupus is paramount, especially due to the associated diagnostic delays and higher overlap with Sjogren's disease. Also, pharmacotherapeutics must be optimized considering factors associated with ageing like declining glomerular filtration rate (GFR), sarcopenia, osteoporosis, and the associated comorbidities. Measures to minimize the exposure to long-term exposure to high-dose steroids are crucial. Beyond this, it is of essence to adopt non-pharmacological interventions as an adjunct to traditional immunosuppression to improve pain, fatigue, depression, and anxiety, improve cardiovascular health and overall better quality of life with favourable long-term outcomes.

Pitfalls and pearls in diagnosing inflammatory arthritis in older patients

Given current demographic shifts, the number of older adults continues to grow, with almost half of patients over 65 being diagnosed with some form of arthritis. Rheumatic diseases pose unique diagnostic challenges in older patients due to the convergence of physiologic changes of aging, confounding difficulties to care, and atypical disease manifestations. This review summarizes the current published evidence to guide clinicians in evaluating geriatric patients with rheumatologic concerns, focusing on inflammatory arthritis. Using the background of epidemiologic data on various musculoskeletal diseases, clinical presentations, current diagnostic tests, and known physiologic changes of aging, this review highlights five diagnostic pitfalls in inflammatory polyarthritis among older patients. The pitfalls include: 1) broader differential diagnosis; 2) atypical presentations; 3) communication, cognitive, and social impairments; 4) the role of chronological vs. biological age; and 5) anchoring bias by assuming older adults are simply "older young adults". These pitfalls are discussed in the context of geriatric principles such as the "hallmarks of aging" and the expected pathophysiologic changes of organ systems. Furthermore, the review discusses the strengths and weaknesses of diagnostic tests used in arthritis and introduces some of the geriatric assessment tools that systematically evaluate multimorbidity and geriatric syndromes. With familiarity of the potential diagnostic pitfalls, knowledge of both normal and pathologic aging processes, awareness of the difference between biological and chronological age, and the ability to use geriatric assessment tools to better characterize older patients, clinicians will be better able to diagnose and manage rheumatic conditions in this population.

Review of evidence linking exposure to environmental stressors and associated alterations in the dynamics of immunosenescence (ISC) with the global increase in multiple sclerosis (MS)

Historical survey confirms that, over the latter part of the 20th century, autoimmune-based diseases, including multiple sclerosis (MS), have shown a worldwide increase in incidence and prevalence. Analytical population studies have established that the exponential rise in MS is not solely due to improvements in diagnosis and healthcare but relates to an increase in autoimmune risk factors. Harmful environmental exposures, including non-communicable social determinants of health, anthropogens and indigenous or transmissible microbes, constitute a group of causal determinants that have been closely linked with the global rise in MS cases. Exposure to environmental stressors has profound effects on the adaptive arm of the immune system and, in particular, the associated intrinsic process of immune ageing or immunosenescence (ISC). Stressor-related disturbances to the dynamics of ISC include immune cell-linked untimely or premature (p) alterations and an accelerated replicative (ar) change. A recognised immune-associated feature of MS is pISC and current evidence supports the presence of an arISC during the disease. Moreover, collated data illustrates the immune-associated alterations that characterise pISC and arISC are inducible by environmental stressors strongly implicated in causing duplicate changes in adaptive immune cells during MS. The close relationship between exposure to environmental risk factors and the induction of pISC and arISC during MS offers a valid mechanism through which pro-immunosenescent stressors may act and contribute to the recorded increase in the global rate and number of new cases of the disease. Confirmation of alterations to the dynamics of ISC during MS provides a rational and valuable therapeutic target for the use of senolytic drugs to either prevent accumulation and enhance ablation of less efficient untimely senescent adaptive immune cells or decelerate the dysregulated process of replicative proliferation. A range of senotherapeutics are available including kinase and transcriptase inhibitors, rapalogs, flavanols and genetically-engineered T cells and the use of selective treatments to control emerging and unspecified aspects of pISC and arISC are discussed.

Early-onset lupus nephritis

Early-onset systemic lupus erythematous (SLE) is a distinct clinical entity characterized by the onset of disease manifestations during childhood. Despite some similarities to patients who are diagnosed during adulthood, early-onset SLE typically displays a greater disease severity, with aggressive multiorgan involvement, lower responsiveness to classical therapies, and more frequent flares. Lupus nephritis is one of the most severe complications of SLE and represents a major risk factor for long-term morbidity and mortality, especially in children. This review focuses on the clinical and histological aspects of early-onset lupus nephritis, aiming at highlighting relevant differences with adult patients, emphasizing long-term outcomes and discussing the management of long-term complications. We also discuss monogenic lupus, a spectrum of conditions caused by single gene variants affecting the complement cascade, extracellular and intracellular nucleic acid sensing and processing, and occasionally other metabolic pathways. These monogenic forms typically develop early in life and often have clinical manifestations that resemble sporadic SLE, whereas their response to standard treatments is poor.

Comparison of late-onset and non-late-onset systemic lupus erythematosus individuals in a real-world electronic health record cohort

Objective: Late-onset systemic lupus erythematosus (LO-SLE) is defined as SLE diagnosed at age 50 years or later. Current studies on LO-SLE are small and have conflicting results.Methods: Using a large, electronic health record (EHR)-based cohort of SLE individuals, we compared demographics, disease characteristics, SLE-specific antibodies, and medication prescribing practices in LO (n = 123) vs. NLO-SLE (n = 402) individuals.Results: The median age (interquartile range) at SLE diagnosis was 60 (56-67) years for LO-SLE and 28 (20-38) years for NLO-SLE. Both groups were predominantly female (85% vs. 91%, p = 0.10). LO-SLE individuals were more likely to be White than NLO-SLE individuals (74% vs. 60%, p = 0.005) and less likely to have positive dsDNA (39% vs. 58%, p = 0.001) and RNP (17% vs. 32%, p = 0.02) with no differences in Smith, SSA, and SSB. Autoantibody positivity declined with increasing age at SLE diagnosis. LO-SLE individuals were less likely to develop SLE nephritis (9% vs. 29%, p < 0.001) and less likely to be prescribed multiple classes of SLE medications including antimalarials (90% vs. 95%, p = 0.04), azathioprine (17% vs. 31%, p = 0.002), mycophenolate mofetil (12% vs. 38%, p < 0.001), and belimumab (2% vs. 8%, p = 0.02).Conclusion: LO-SLE individuals may be less likely to fit an expected course for SLE with less frequent positive autoantibodies at diagnosis and lower rates of nephritis, even after adjusting for race. Understanding how age impacts SLE disease presentation could help reduce diagnostic delays in SLE.

A State-of-the-Art Review on the Recent Advances of Mesenchymal Stem Cell Therapeutic Application in Systematic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease with an unknown etiology that has widespread clinical and immunological manifestations. Despite the increase in knowledge about the pathogenesis process and the increase in treatment options, however, the treatments fail in half of the cases. Therefore, there is still a need for research on new therapies. Mesenchymal stem cells (MSCs) are powerful regulators of the immune system and can reduce the symptoms of systemic lupus erythematosus. This study aimed to review the mechanisms of immune system modulation by MSCs and the role of these cells in the treatment of SLE. MSCs suppress T lymphocytes through various mechanisms, including the production of transforming growth factor-beta (TGF-B), prostaglandin E2 (PGE2), nitric oxide (NO), and indolamine 2 and 3-oxygenase (IDO). In addition, MSCs inhibit the production of their autoantibodies by inhibiting the differentiation of lymphocytes. The production of autoantibodies against nuclear antigens is an important feature of SLE. On the other hand, MSCs inhibit antigen delivery by antigen-presenting cells (APCs) to T lymphocytes. Studies in animal models have shown the effectiveness of these cells in treating SLE. However, few studies have been performed on the effectiveness of this treatment in humans. It can be expected that new treatment strategies for SLE will be introduced in the future, given the promising results of MSCs application.

Acute Onset Rheumatoid Vasculitis With Polyarthritis and Erythema: A Case Report

We present the case of a woman in her 70s who was diagnosed with rheumatoid vasculitis (RV) after initially presenting with systemic joint pain and erythema. RV, a rare complication of rheumatoid arthritis, involves inflammation of blood vessels, leading to various skin manifestations. The patient's complaints included fever, generalized joint pain, and skin manifestations that initially resembled erythema multiforme. However, a skin biopsy revealed vasculitis, which guided the RV diagnosis. Although rheumatoid arthritis primarily affects the joints, systemic implications such as RV can arise in rare cases. This case underscores the importance of a holistic and meticulous diagnostic approach, especially in older patients, as early detection and treatment are crucial for managing disease progression and associated complications. Collaborative care involving multidisciplinary teams is vital to achieving optimal outcomes in complex cases.

Association of lipid lowering drugs and the risk of systemic lupus erythematosus: a drug target Mendelian randomization

Background and objective: An interaction between low-density lipoprotein level, lipid-lowering drugs, and systemic lupus erythematosus (SLE) was reported by previous studies. However, whether lipid-lowering drugs provided protective effect for reducing the risk of SLE was unclear. We aimed to clarify this causal relationship through a drug-target Mendelian randomization (MR) study. Methods: Genetic instruments-single nucleotide polymorphism (SNPs)-were utilized to proxy inhibition of the three genes-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), proprotein convertase subtilisin/kexin type 9 (PCSK9), and Niemann-Pick C1-Like 1(NPC1L1), which was corresponded to three lipid-lowering drugs-statins, evolocumab, and ezetimibe. Low-density lipoprotein (LDL) cholesterol was selected as the biomarker for the measurement of the inhibitors of HMGCR, PCSK9, and NPC1L1, and the genetic data were acquired from the Global Lipids Genetics Consortium, which consisted of 1.3 million participants of European ancestry and 146.5 thousand participants of East Asian ancestry. The genetic dataset of SLE was acquired from two large-scale GWAS studies; one recruited 23,210 participants (7,219 SLE cases and 15,991 controls) of European ancestry and the other one recruited 12,653 participants (4,222 SLE cases and 8,431 controls) of Chinese ancestry. The primary analysis used the inverse variance weighted (IVW) method. Four additional sensitivity analyses, colocalization analysis, and stratification analysis were performed. Results: The primary analysis showed that inhibition of PCSK9 (evolocumab) was associated with a significantly lower risk of SLE [odds ratio (OR) 0.51, 95%CI 0.34 to 0.76, p = 0.001] in the European population. The secondary analyses had similar findings. Stratification analysis demonstrated that the preventive effect of PCSK9 inhibition for SLE was similar in both males and females. However, the results were not replicated in the East Asian population. The inhibition of HMGCR (statins) and NPC1L1 (ezetimibe) did not cause a lower risk of SLE. Conclusion: Evolocumab might provide a protective effect on the risk of SLE in the European population, but statins and ezetimibe might not have the protective effect. Further research is necessary to elucidate the specific mechanisms and potential therapeutic applications of PCSK9 inhibitors (evolocumab) in the context of SLE protection.

A Case of Late-Onset Systemic Lupus Erythematosus With Systemic Symptoms Leading to Multiple Organ Failure

This case report discusses the diagnosis and management of late-onset systemic lupus erythematosus (SLE) in an elderly patient. Systemic lupus erythematosus is an autoimmune disease that affects several organs. Sex differences in incidence, especially among women in their childbearing years, have been linked to estrogen fluctuations. This study focuses on an 87-year-old male who initially presented with anorexia, a history of heart failure, pancytopenia, and elevated antinuclear antibodies. His symptoms were initially attributed to heart failure and pneumonia. However, further evaluation led to the suspicion of immune-mediated vasculitis. Treatment with prednisolone improved his condition; however, a recurrent decrease in food intake and increased inflammation prompted the consideration of late-onset SLE. The diagnosis was supported by laboratory results, including antinuclear antibodies and complement levels, in accordance with the diagnostic criteria. This case highlights the challenges in diagnosing late-onset SLE owing to its overlap with other conditions and emphasizes the importance of a multidisciplinary approach for accurate diagnosis and treatment. Early recognition and intervention are crucial for managing late-onset SLE, even in elderly patients, to prevent multiple organ failure and improve outcomes.

Safety and efficacy of belimumab in older adults with SLE: results of an integrated analysis of clinical trial data

OBJECTIVE

Assess the safety and efficacy of belimumab in older adults with SLE.

METHODS

This post hoc integrated analysis (GSK Study 116559) included safety data from six randomised, placebo-controlled belimumab trials (BLISS-76, BLISS-52, BLISS-SC, North East Asia study, LBSL02, EMBRACE; n=4170). The BASE study provided additional safety data (n=4003). Efficacy data were from five of the trials. Older adults (≥65 years) were compared with the overall populations of patients with SLE. Patients who had received ≥1 treatment dose were included.

RESULTS

Sixty-three older adults (1.5%) were included in the pooled safety analysis population and 156 (3.9%) in the BASE study. At baseline, older adults had lower disease activity but more organ damage than the overall populations. In the pooled safety analysis population, five (18.5%) placebo-treated and ten (27.8%) belimumab-treated older adults experienced ≥1 serious adverse event (SAE), as did 230 (17.0%) placebo-treated and 421 (15.0%) belimumab-treated patients overall. In the BASE study, nine (11.0%) placebo-treated and six (8.1%) belimumab-treated older adults experienced ≥1 SAE, as did 222 (11.1%) placebo-treated and 220 (11.0%) belimumab-treated patients overall. No clinically relevant differences in deaths and adverse events of special interest were observed between older adults and the overall populations. Older adults' SLE Responder Index response rates favoured belimumab versus placebo, consistent with the overall population.

CONCLUSION

The safety and efficacy of belimumab in older adults were generally consistent with the overall populations, suggesting belimumab is a treatment option for older patients with SLE. Due to small numbers of older adults, findings should be interpreted with caution.

Systemic lupus erythematous after Pfizer COVID-19 vaccine: a case report

The Pfizer-BioNTech COVID-19 vaccine has been authorized by the U.S. Food and Drug Administration as it demonstrated 95% effectiveness against the SARS-CoV-2 virus. Although the initial vaccine trials showed a favorable side effect profile, there have been concerns regarding activation of aberrant immune responses, triggering autoimmunity. This is a case report of a 68-year-old woman without history of autoimmune conditions, who presented to our emergency department 7 days after receiving the Pfizer-BioNTech COVID-19 vaccine. Her initial symptoms were suggestive of polymyalgia rheumatica, and she had nearly complete response to steroids. Interestingly, she later met criteria for classified systemic lupus erythematous given the development of inflammatory arthritis, positive ANA, and positive dsDNA. The temporal relationship of her symptoms that started 2 days after vaccine administration could suggest a possible association between the Pfizer-BioNTech COVID-19 and the development of systemic lupus erythematous.

Genome-wide assessment of genetic risk for systemic lupus erythematosus and disease severity

Using three European and two Chinese genome-wide association studies (GWAS), we investigated the performance of genetic risk scores (GRSs) for predicting the susceptibility and severity of systemic lupus erythematosus (SLE), using renal disease as a proxy for severity. We used four GWASs to test the performance of GRS both cross validating within the European population and between European and Chinese populations. The performance of GRS in SLE risk prediction was evaluated by receiver operating characteristic (ROC) curves. We then analyzed the polygenic nature of SLE statistically. We also partitioned patients according to their age-of-onset and evaluated the predictability of GRS in disease severity in each age group. We found consistently that the best GRS in the prediction of SLE used SNPs associated at the level of P < 1e−05 in all GWAS data sets and that SNPs with P-values above 0.2 were inflated for SLE true positive signals. The GRS results in an area under the ROC curve ranging between 0.64 and 0.72, within European and between the European and Chinese populations. We further showed a significant positive correlation between a GRS and renal disease in two independent European GWAS (P_cohort1 = 2.44e−08; P_cohort2 = 0.00205) and a significant negative correlation with age of SLE onset (P_cohort1 = 1.76e−12; P_cohort2 = 0.00384). We found that the GRS performed better in the prediction of renal disease in the ‘later onset’ compared with the ‘earlier onset’ group. The GRS predicts SLE in both European and Chinese populations and correlates with poorer prognostic factors: young age-of-onset and lupus nephritis.

Late-onset versus early-onset systemic lupus: characteristics and outcome in a national multicentre register (RELESSER)

OBJECTIVE

The aim of the present study was to describe the demographic, clinical and immunological characteristics of patients with late-onset (≥50 years) SLE vs patients with early-onset SLE (<50 years).

METHODS

We performed a cross-sectional retrospective study of 3619 patients from the RELESSER database (National Register of Patients with Systemic Lupus Erythematosus of the Spanish Society of Rheumatology).

RESULTS

A total of 565 patients (15.6%) were classified as late-onset SLE and 3054 (84.4%) as early-onset SLE. The male-to-female ratio was 5:1. Mean (s.d.) age at diagnosis in the late-onset group was 57.4 (10.4) years. At diagnosis, patients with late-onset SLE had more comorbid conditions than patients with early-onset SLE; the most frequent was cardiovascular disease (P <0.005). Furthermore, diagnostic delay was longer in patients with late-onset SLE [45.3 (3.1) vs 28.1 (1.0); P <0.001]. Almost all patients with late-onset SLE (98.7%) were Caucasian. Compared with early-onset SLE and after adjustment for time since diagnosis, patients with late-onset SLE more frequently had serositis, major depression, thrombotic events, cardiac involvement and positive lupus anticoagulant values. They were also less frequently prescribed immunosuppressive agents. Mortality was greater in late-onset SLE (14.3% vs 4.7%; P <0.001).

CONCLUSION

Late-onset SLE is insidious, with unusual clinical manifestations that can lead to diagnostic errors. Clinical course is generally indolent. Compared with early-onset disease, activity is generally reduced and immunosuppressants are less commonly used. Long-term prospective studies are necessary to determine whether the causes of death are associated with clinical course or with age-associated comorbidities in this population.

Drug-induced lupus: Traditional and new concepts

Drug-induced lupus (DIL) includes a spectrum of drug-induced reactions often characterised by a clinical phenotype similar to that of idiopathic systemic lupus eruthematosus (SLE) but usually lacking major SLE complications. Different drugs may be associated with distinct clinical and serological profiles, and early recognition is crucial. Drugs traditionally associated with DIL include procainamide, hydralazine, quinidine and others, but strong associations with newer agents, such as TNF α (TNFα) inhibitors, are increasingly recognised. The pathogenic mechanisms explaining how drugs that have heterogeneous chemical structure and function lead to autoimmunity are only partially understood. However, it is likely that traditional DIL-associated agents can boost innate immune responses, particularly neutrophil responses, with neutrophil extracellular trap (NET) formation and exposure of autoantigens. Research in the field of DIL is evolving and may provide interesting models for the study of autoimmunity.

Menopause and Rheumatic Disease

Menopause occurs naturally in women at about 50 years of age. There is a wealth of data concerning the relationship of menopause to systemic lupus erythematosus, rheumatoid arthritis, and osteoarthritis; there are limited data concerning other rheumatic diseases. Age at menopause may affect the risk and course of rheumatic diseases. Osteoporosis, an integral part of inflammatory rheumatic diseases, is made worse by menopause. Hormone replacement therapy has been studied; its effects vary depending on the disease and even different manifestations within the same disease. Cyclophosphamide can induce early menopause, but there is underlying decreased ovarian reserve in rheumatic diseases.

Late-onset systemic lupus erythematosus: Is it "mild lupus"?

Objective The objective of this paper is to investigate the clinical characteristics and prognosis of patients with late-onset systemic lupus erythematosus (SLE) using a prospective observational cohort. Methods Late-onset SLE (≥50 years old) was compared with adult-onset SLE (≥18 and <50 years old) using 1997 ACR classification criteria for SLE, autoantibodies, disease activity measured by Adjusted Mean SLE Disease Activity Index (AMS), and damage measured by Systemic Lupus International Collaborating Clinics/ACR Damage Index (SDI). The standardized mortality ratio (SMR) was calculated. Results A total of 917 patients with SLE were enrolled. The mean number of cumulative ACR criteria in late-onset SLE ( n = 32, 3.5%) was lower than that in adult-onset SLE (4.6 ± 1.2 vs. 5.5 ± 1.4, p < 0.05). The percentage of patients with low complement was lower in late-onset SLE than adult-onset SLE ( p < 0.05). AMS was also lower in late-onset SLE (2.7 ± 2.1 vs. 4.3 ± 2.6, p < 0.01), but SDI was similar between the two groups (50% vs. 43.4%, p = 0.58). The SMR of late-onset SLE was 1.58 (95% CI 0.58-3.43), while the SMR of adult-onset SLE was 3.34 (2.34-4.63). Conclusion Compared with adult-onset SLE, late-onset SLE has a lower number of ACR criteria and lower disease activity. Organ damage is not different, but prognosis and mortality are more favorable.

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.

Diffuse Bullous Eruptions in an Elderly Woman: Late-Onset Bullous Systemic Lupus Erythematosus

Vesiculobullous eruptions in the elderly represent a diverse range of varying pathophysiologies and can present a significant clinical dilemma to the diagnostician. Diagnosis requires a careful review of clinical history, attention to detail on physical and histomorphological examination, and appropriate immunofluorescence testing. We describe the case of a 73-year-old female who presented to our hospital with a painful blistering skin rash developed over 2 days. Examination of the skin was remarkable for numerous flaccid hemorrhagic bullae on a normal-appearing nonerythematous skin involving both the upper and lower extremities. Histopathology of the biopsy lesion showed interface change at the epidermo-dermal region with subepidermal blister formation, mild dermal fibrosis, and sparse interstitial neutrophilic infiltrate. Immunohistological analysis was significant for positive IgG basement membrane zone antibodies with a dermal pattern of localization on direct immunofluorescence and positive IgG antinuclear antibodies on indirect immunofluorescence. Evidence of antibodies to type VII collagen suggested the diagnosis of epidermolysis bullosa acquisita versus bullous systemic lupus erythematosus (BSLE). A diagnosis of BSLE was made based on positive American College of Rheumatology criteria, acquired vesiculo-bullous eruptions with compatible histopathological and immunofluorescence findings. This case illustrates one of many difficulties a physician encounters while arriving at a diagnosis from a myriad of immunobullous dermatoses. Also, it is important for internists and dermatologists alike to be aware of and differentiate this uncommon and nonspecific cutaneous SLE manifestation from a myriad of disorders presenting with vesiculobullous skin eruptions in the elderly.

Clinical, serologic, and immunogenetic characterization (HLA-DRB1) of late-onset lupus erythematosus in a Colombian population

INTRODUCTION

Late-onset systemic lupus erythematosus (SLE) represents a specific subgroup that is defined as onset after 50 years of age. Late-onset lupus may have a different clinical course and serological findings, which may delay diagnosis and timely treatment.

OBJECTIVES

The objective of this paper is to determine the clinical, serologic, and immunogenetic differences among Colombian patients with late-onset SLE versus conventional SLE patients.

METHODOLOGY

This was a cross-sectional study in a Colombian population. Patients and their medical records were analyzed from the services of Rheumatology in Bogotá and met the criteria for SLE, according to the American College of Rheumatology (ACR) revised criteria for the classification of SLE.In a reference group of late-onset SLE patients (98 participants, with an onset after 50 years of age) and a group of conventional SLE patients (72 participants, with an onset of age of 49 years or less), multiple clinical variables (age, clinical criteria for lupus, alopecia, weight loss, fever, Raynaud's phenomenon) and multiple serological variables (blood count, blood chemistry profile, autoantibodies) were analyzed. Additionally, the HLA class II (DRB1) of all the patients was genotyped, including an additional group of patients without the autoimmune disease. Statistical analysis was performed using the STATA 10.0 package.

RESULTS

In the group of late-onset lupus, there was a higher frequency of pleurisy (p = 0.002), pericarditis (p = 0.026), dry symptoms (p = 0.029), lymphopenia (p = 0.007), and higher titers of rheumatoid factor (p = 0.001) compared with the group of conventional SLE. Late-onset SLE patients had a lower seizure frequency (p = 0.019), weight loss (p = 0.009), alopecia (p < 0.001), and Raynaud's phenomenon (p = 0.013) compared to the conventional SLE group. In late-onset SLE, HLA DR17 (DR3) was found more frequently compared with individuals without autoimmune disease (OR 3.81, 95% CI 1.47 to 10.59) (p = 0.0016).

CONCLUSION

In the Colombian SLE population analyzed, there may be a probable association of several clinical and serologic variants, which would allow the differentiation of variables in the presentation of the disease among patients with late-onset SLE vs. conventional SLE.

[Primitive Sjögren syndrome in the elderly: clinical and immunological characteristics]

Les objectifs de notre étude est d’étudier les caractéristiques cliniques et immunologiques du syndrome de Gougerot Sjogren primitif (SGSp) du sujet âgé et les comparer à une population témoin plus jeune. Nous avons analysé rétrospectivement les dossiers de 60 patients atteints de SGSp consécutifs, suivis au service de Médecine interne du CHU Taher Sfar de Mahdia, en Tunisie, durant une période de 7 ans (janvier 2007 à décembre 2013). Les patients avec SGSp étaient classés en deux groupes selon l’âge de début de la maladie: groupe de sujets âgés (≥ 65 ans) et groupe de sujets jeunes (<65 ans). Chez 18 patients (30%), le SGSp a débuté après 65 ans. Il s'agissait de 17 femmes (94,5%) et un homme (5,5%). L’âge moyen du début du SGSp était de 70,5 ans ±3,1. Le délai moyen du diagnostic était de 38,6 mois ±26,8. Les manifestations glandulaires étaient constantes. La comparaison entre le groupe du SGSp du sujet âgé et celui du sujet jeune montrait que le délai moyen du diagnostic du SGSp était significativement plus long chez les sujets âgés. Les manifestations pulmonaires étaient significativement plus fréquentes chez les sujets âgés. En revanche, les fréquences des anticorps antinucléaires, anti-SSA et anti-SSB étaient significativement plus élevées chez les sujets jeunes. Bien que le SGSp soit une maladie typique d'adultes d’âge moyen, les cliniciens ne devraient pas ignorer que cette maladie peut être diagnostiquée aussi chez les patients âgés. Notre étude montre que l’âge du début avancé influence le profil clinique et immunologique du SGSp.

Late-onset systemic lupus erythematosus in Latin Americans: a distinct subgroup?

OBJECTIVE

To examine the characteristics of patients who developed late onset systemic lupus erythematosus (SLE) in the GLADEL (Grupo Latino Americano de Estudio del Lupus) cohort of patients with SLE.

METHODS

Patients with SLE of less than two years of disease duration, seen at 34 centers of nine Latin American countries, were included. Late-onset was defined as >50 years of age at time of first SLE-related symptom. Clinical and laboratory manifestations, activity index (SLEDAI), and damage index (SLICC/ACR- DI) were ascertained at time of entry and during the course (cumulative incidence). Features were compared between the two patient groups (<50 and ≥50) using descriptive statistics and hypothesis tests. Logistic regression was performed to examine the association of late-onset lupus, adjusting for other variables.

RESULTS

Of the 1480 patients included, 102 patients (6.9 %) had late-onset SLE, 87% of which were female. Patients with late-onset SLE had a shorter follow-up (3.6 vs. 4.4 years, p < 0.002) and a longer time to diagnosis (10.1 vs. 5.8 months, p < 0.001) compared to the younger onset group. Malar rash, photosensitivity, and renal involvement were less prevalent while interstitial lung disease, pleural effusions, and sicca symptoms were more frequent in the older age group (p > 0.05). In multivariable analysis, late onset was independently associated with higher odds of ocular (OR = 3.66, 95% CI = 2.15-6.23), pulmonary (OR = 2.04, 95% CI = 1.01-4.11), and cardiovascular (OR = 1.76, 95% CI = 1.04-2.98) involvement and lower odds of cutaneous involvement (OR = 0.41, 95% CI = 0.21-0.80), number of cumulative SLE criteria (OR = 0.79, 95% CI = 0.64-0.97), use of cyclophosphamide (OR = 0.47, 95% CI = 0.24-0.95), and anti-RNP antibodies (OR = 0.43, 95% CI = 0.20-0.91). A Cox regression model revealed a higher risk of dying in older onset than the younger-onset SLE (OR = 2.61, 95% CI = 1.2-5.6).

CONCLUSION

Late-onset SLE in Latin Americans had a distinct disease expression compared to the younger-onset group. The disease seems to be mild with lower cumulative SLE criteria, reduced renal/mucocutaneous involvements, and less use of cyclophosphamide. Nevertheless, these patients have a higher risk of death and of ocular, pulmonary, and cardiovascular involvements.

Pregnancy outcomes among African-American patients with systemic lupus erythematosus compared with controls

Objective

In a study of Gullah African–Americans, we compared pregnancy outcomes before and after systemic lupus erythematosus (SLE) diagnosis to controls to test whether there is a predisease state that negativelyaffects pregnancy outcomes.

Design

Cases and controls reporting at least one pregnancy were included. Controls were all Gullah African-American females. We collected demographic, socioeconomic and pregnancy data. We modelled pregnancy outcome associations with case status using multiple logistic regression to calculate ORs.

Results

After adjustment for age, years of education, medical coverage and pregnancy number, compared with controls, cases were more likely to have any adverse outcome (OR 2.35, 95% CI 1.78 to 3.10), including stillbirth (OR 4.55, 95% CI 1.53 to 13.50), spontaneous abortion (OR 2.05, 95% CI 1.40 to 3.00), preterm birth (OR 2.58, 95% CI 1.58 to 4.20), low birth weight (OR 2.64, 95% CI 1.61 to 4.34) and preeclampsia (OR 1.80, 95% CI 1.08 to 3.01). The odds of adverse pregnancy outcomes all increased after SLE diagnosis compared with before diagnosis, even after adjustment for age, years of education, pregnancy number and medical coverage.

Conclusion

From a large cohort of African–American women, our findings suggest there may be a predisease state that predisposes to adverse pregnancy outcomes.

Rare cause of seizures, renal failure, and gangrene in an 83-year-old diabetic male

We report an 83-year-old diabetic male who presented with acute-onset renal failure, seizures, psychosis, pneumonia, and right foot gangrene. Investigations revealed thrombocytopenia, CSF lymphocytosis, ANA and dsDNA positivity, hypocomplementemia, and pneumonitis following which he was treated with pulse methylprednisolone. He was treated for Pseudomonas-related ventilator-associated pneumonia, candiduria, and E. coli-related bedsore infection prior to discharge. He was discharged at request and died 17 days later due to a respiratory infection.

Survival analysis of late-onset systemic lupus erythematosus: a cohort study in China

The aim of this study is to explore the survival rate and risk factors of mortality in patients with late-onset systemic lupus erythematosus (SLE) in a large cohort. Clinical presentations, disease activity, organ damage scores, autoantibody profile, and mortality data were obtained retrospectively from late-onset SLE patients (onset age ≥50 years) diagnosed between 1995 and 2009. The risk factors of organ damage were evaluated by the chi-square test and logistic regression. The cumulative rate of survival was calculated by Kaplan-Meier method, and factors predictive of mortality were studied by Cox proportion hazard regression model. A total of 158 patients (132 female and 26 male) were studied. The average onset age was 58.66 ± 6.38 years and mean disease duration was 63.85 ± 48.17 months. One hundred and four patients had organ damage at the time of data analysis. Hematological system and kidney involvement were most common. Central nervous system involvement was relatively rare. In univariate logistic analysis, associations were found between SLE disease activity index (SLEDAI) at diagnosis (OR = 1.133, P = 0.001); renal involvement (OR = 2.441, P = 0.009) and edema (OR = 2.812, P = 0.003) were associated with organ damage. And SLEDAI at diagnosis (OR = 1.103, P = 0.034) was independent factor for organ damage in multivariate logistic regression. During the follow-up, 64 patients (51 female and 13 male) died. Five-, 10-, and 15-year survival rates were 80.4, 56.5, and 31.7 %, respectively. Median survival time was 123 months. The analysis of Cox proportion hazard regression model showed that age at disease onset (OR = 1.069, P = 0.002), compliance of medical care (OR = 3.282, P = 0.001), and SLEDAI at diagnosis (OR = 1.091, P = 0.003) were independent risk factors of mortality. Late-onset SLE has a poor long-term prognosis. Infection is the major cause of death in patients with late-onset lupus. Disease activity, medical care, and onset age are strongly related to death of late-onset SLE.

Late-onset systemic lupus erythematosus in Northwestern Spain: differences with early-onset systemic lupus erythematosus and literature review

To further investigate into the epidaemiology of systemic lupus erythematosus (SLE) in Southern Europe, we have assessed the incidence, clinical spectrum and survival of patients diagnosed with late-onset SLE (age ≥ 50 years) according to the 1982 American College of Rheumatology (ACR) classification criteria at the single hospital for a well-defined population of Lugo, Northwestern (NW) Spain. Between January 1987 and December 2006, 51 (39.3%) of the 150 patients diagnosed as having SLE fulfilled definitions for late-onset SLE. The predominance of women among late-onset SLE (4:1) was reduced when compared with that observed in early-onset SLE (7:1). However, the incidence of late-onset SLE was significantly higher in women (4.2 [95% confidence interval (CI): 3.1–5.6] per 100,000 population) than in men (1.3 [95% CI: 0.6–2.2] per 100,000 population) ( p < 0.001). As observed in early-onset SLE, the most frequent clinical manifestation in patients with late-onset SLE was arthritis (71.2%). Renal disease was less common in late-onset SLE (13.5%) than in early-onset SLE (26.4%); p = 0.07). In contrast, secondary Sjögren syndrome was more commonly found in the older age-group (27.1% versus 12.1%; p = 0.03). A non-significantly increased incidence of serositis was also observed in late-onset SLE patients (33.9% versus 22.0%; p = 0.13). Hypocomplementaemia (72.9% versus 91.2%) and positive results for anti-DNA and anti-Sm (49.2% and 6.8% versus 68.1% and 23.1, respectively) were significantly less common in late-onset SLE patients than in early-onset SLE. The probability of survival was reduced in late-onset SLE ( p < 0.001). With respect to this, the 10-year and 15-year survival probability were 74.9 % and 63.3% in the late-onset SLE group and 96.3% and 91.0% in patients with early-onset SLE, respectively. In conclusion, our results confirm that in NW Spain SLE is not uncommon in individuals 50 years and older. In keeping with earlier studies, late-onset SLE patients from NW Spain have some clinical and laboratory differences with respect to those individuals with early-onset SLE. Our data support the claim of a reduced probability of survival in the older age-group of SLE patients.

Late onset lupus nephritis in Chinese patients: classified by the 2003 International Society of Nephrology and Renal Pathology Society system

AIM

The aim of this study was to assess clinicopathological characteristics and outcomes of a cohort of Chinese patients with late onset lupus nephritis.

METHODS

Clinical, pathological and outcome data for patients with late onset lupus nephritis (onset at age ≥50 years) and early onset lupus nephritis (onset at age ≤40 years) were retrospectively analyzed and compared.

RESULTS

Among 271 patients with renal biopsy-proven lupus nephritis, 30 were identified as having late onset lupus nephritis and 241 were identified as having early onset lupus nephritis. Lower female predominance was observed in the late onset patients (p = 0.06). The interval between presentation of lupus nephritis and diagnosis was significantly longer in the late onset group than in the early onset group (p = 0.003). In comparison with early onset group, patients in the late onset group had significantly lower scores for endocapillary hypercellularity (p = 0.041), subendothelial hyaline deposits (p = 0.022) and glomerular leukocyte infiltration (p = 0.032), but had significantly higher scores for tubular atrophy (p = 0.037) and interstitial fibrosis (p = 0.018). Regarding long-term survival and renal outcome, there was no significant difference between the two groups, although it seemed that the early onset group had a poorer renal outcome (p = 0.077, hazard ratio (HR) = 3.909, 95% CI: 0.862-17.726).

CONCLUSIONS

Patients with late onset lupus nephritis were usually diagnosed later; they had milder active lesions and more severe chronic lesions in renal pathology. However, the renal outcome was similar between late and early onset patients.

Clinical Features and Prognosis of Late-onset Systemic Lupus Erythematosus: Results from the 1000 Faces of Lupus Study

Objective.

There is controversy whether older-onset systemic lupus erythematosus (SLE) is associated with a different, more benign disease course than in younger-onset SLE. Our objective was to characterize the clinical features and prognosis of late-onset SLE in a large, multicenter cohort.

Methods.

We studied adult-onset lupus in the 1000 Canadian Faces of Lupus cohort (n = 1528) of whom 10.5% had onset at age ≥ 50 years versus a control group with onset at < 50 years.

Results.

Disease duration was different in early- and late-onset groups (15 yrs in early vs 9.3 yrs in late; p < 0.001). Caucasians were represented more in the later-onset SLE group (55.6% vs 74.5%), while Asians and Blacks were more prevalent in the younger group. Younger-onset SLE subjects fulfilled more American College of Rheumatology criteria for SLE (< 50 yrs: 5.98 ± 1.68; ≥ 50 yrs: 5.24 ± 1.44; p < 0.0001). Despite an equal prevalence of anti-dsDNA, the younger-onset group more often had positive anti-Smith autoantibody, ribonucleoprotein, and hypocomplementemia, and more nephritis, rash, and cytopenias than the older-onset group. However, disease activity and damage accrual were higher in the older-onset group. The older patients received less prednisone and immunosuppressives (current and ever-use). As expected, comorbidity was higher in the older-onset SLE group.

Conclusion.

This study suggests that older age-onset SLE is not benign. There may be an interaction between lupus and age in which, although there is less lupus nephritis in the elderly, more disease activity and damage are present.

Systemic Lupus Erythematosus: A Therapeutic Update

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with variable clinical manifestations that is characterized by flares and periods of relative quiescence. The disease occurs approximately 10 times more frequently in women and is more prevalent among certain ethnic groups. The etiology is complex and dependent upon an interaction of genetic, hormonal, and environmental factors. Corticosteroids and immunosuppressive agents have transformed the outlook for patients with lupus. Unfortunately, the increased lifespan unmasked an accelerated process of atherosclerosis and cardiovascular disease. Early mortality is usually attributable to active lupus, but deaths late in the disease process are often secondary to thrombotic events. Advancements in the understanding of molecular and cellular mechanisms involved in the pathogenesis have resulted in development of novel therapies. Immunomodulatory drugs developed for other diseases are being investigated for use in specific manifestations of lupus. Individualization of treatment and lifelong monitoring are required in most patients.