Systemic lupus erythematosus induced by psychotropic drugs

Psychiatric symptoms before systemic lupus erythematosus is diagnosed

Psychiatric symptoms are rarely reported as an initial feature of systemic lupus erythematosus (SLE). Nevertheless, many patients have the feeling that psychiatric symptoms occurred before they were diagnosed as having SLE. This feeling was confirmed by an enquiry among members of the Dutch Lupus Patients Society: half of them had experienced psychiatric complaints before SLE was diagnosed. Two-thirds of these patients searched for professional help for these complaints. This motivated us to study whether SLE patients were admitted into psychiatric hospitals without being diagnosed as having SLE. Sera from 2121 patients admitted to a psychiatric hospital and from 500 controls matched for sex and age were tested for the presence of antinuclear antibodies (ANA) and antibodies to DNA. ANA were found in 3% of patients, as well as controls. Anti-DNA antibodies were found in 1% of both patients and controls. Two out of 114 patients psychiatric patients with ANA and/or anti-DNA antibodies had SLE and/or Sjögren's syndrome. We concluded that SLE is not an important cause of admission to psychiatric hospitals. Routine tests for the determination of antinuclear and anti-DNA antibodies on admissions in these hospitals thus would not seem useful. To study whether patients with another chronic disease also had psychiatric complaints before being diagnosed, we performed the same enquiry among members of the Dutch Sarcoidosis Patients Society. The results were almost equal to those of the enquiry of the members of the Dutch Lupus Patients Society. Why members of both societies so often report psychiatric symptoms before their disease is diagnosed should be a subject of further studies.

Autoantibodies to DNA in multicase families with schizophrenia

In an attempt to define the autoimmune status of members of multicase families with schizophrenia, sera of both patients and healthy relatives from 28 such cases were tested for antinuclear antibodies, anti-double-stranded DNA, and anti-single-stranded DNA autoantibodies. These autoantibodies were significantly more frequent in both schizophrenic patients and healthy relatives than in normal subjects. Immunoglobulin (Ig) M anti-DNA antibodies were more common in patients, whereas in healthy relatives, IgG anti-DNA antibodies were more common. No significant differences were found between schizophrenic patients and their healthy relatives. The data indicate that an autoimmune process may be involved in the etiology of a subset of patients with schizophrenia.

Late-onset atypical psychosis: a case involving neuroleptic drug toxicity and autoimmune serological abnormalities

Serious or significant neuroleptic toxicity (Kurlan et al. 1984; Lazarus 1985; Levenson 1985; Pearlman 1986) may complicate the diagnosis and management of patients who develop acute medical problems while under treatment with neuroleptics (Levenson and Simpson 1986). We have found that in some cases it is difficult, if not impossible, to determine whether neuroleptics have contributed to the cause of an acute medical illness, or if the occurrence of acute medical problems precipitated the signs of neuroleptic toxicity by altering the disposition or the pharmacologic effects of the drugs.

Neuroleptic-associated autoantibodies. A prevalence study

Antinuclear antibodies (ANA), antiphospholipid antibodies (APA), rheumatoid factor (RF), and immunoglobulin (Ig) M levels were determined in 184 male chronic psychiatric patients on long-term therapy with neuroleptics, and in 35 age-matched normal male controls. The prevalence of one or more of these autoantibodies was 70% in the neuroleptic-treated patients and 9% in the normal controls. Polyclonal IgM elevation was frequently seen among patients treated with phenothiazines. There was a significant correlation between the presence of ANA, APA, and RF; ANA and APA were more frequently associated with CPZ therapy, but the prevalence of RF was high in all treatment groups. These findings suggest that antibodies against the Fc fragment of IgG are the most common autoantibody associated with neuroleptics. Alternatively, the presence of RF could be a common finding in patients with neuropsychiatric disorders.

Phenothiazine-induced systemic lupus erythematosus with superior vena cava syndrome: case report and review of the literature

Phenothiazine-induced lupus with circulating anticoagulant (CAC) has been reported infrequently, and is rarely associated with significant symptoms. We describe a patient who we suspect had perphenazine-induced lupus erythematosus with CAC. She had recurrent episodes of venous thrombosis and ultimately developed superior vena cava syndrome. The relationships among phenothiazine-induced lupus, CAC, and thrombosis are discussed.

Monozygotic twins with Klinefelter's syndrome discordant for systemic lupus erythematosus and symptomatic myasthenia gravis

Monozygotic twins with Klinefelter's syndrome were evaluated for two distinct illnesses. One subject had clinical and serologic evidence of systemic lupus erythematosus and no symptoms of muscle weakness. His identical twin had typical symptoms and laboratory evidence of myasthenia gravis. Antibodies to acetylcholine receptors were present in both subjects. These patients are discussed in relation to genetic, hormonal, and immunologic mechanisms involved in the pathogenesis of these two disorders.

A chlorpromazine-induced inhibitor of blood coagulation

An inhibitor of blood coagulation was detected in the plasma of four schizophrenic patients receiving long-term chlorpromazine therapy. The partial thromboplastin time (PTT) was prolonged in all four patients and the prothrombin time (tpt) was prolonged in one. The inhibitor which resembled in many respects that seen in patients with systemic lupus erythematosus (SLE), was shown to be associated with the tigM-rich fractions of the serum. None of the patients manifested a clinical bleeding tendency and in two, discontinuation of the chlorpromazine was followed by a decrease in the activity of the anticoagulant. While three of the patients had a positive antinuclear antibody test (ANA) and the fourth a false positive serology for syphilis, no further evidence for SLE was found.

Antinuclear antibodies (ANA): immunologic and clinical significance

The methods currently used for the detection of ANA have been analyzed, with emphasis on their practical application to the diagnosis of the CTD. The use of the indirect IF-ANA test was recommended as a screening procedure to detect ANA. The need to standardize the technique using a single substrate and fluorescent conjugates with uniform F/P ratios was stressed. Most importantly, the value of titrating ANA for the diagnosis of the CTD was discussed. ANA titers higher than 1/500 are usually very significant clinically, often found in spontaneous or drug-induced SLE and few other CTD. The immunologic aspects of ANA and their potential value as aids in the diagnosis and management of the CTD were discussed. Anti-nDNA antibodies have been found to have a high degree of specificity for SLE and high titers of these antibodies correlate well with low levels of serum complement and severity of kidney involvement. The spectrum of ANA in the sera from patients with SLE has been expanded with the finding of anti-Sm antibodies which, when detected by gel precipitation with prototype serum, have been found so far only in SLE. Some of these antibodies have been found to have prognostic significance. Patients with MCTD and a group of patients with SLE have high titers of serum ANA with specificity for an RNase-sensitive component of ENA. The group of SLE patients defined by the presence of these antibodies (anti-Mo) have a better prognosis and in general develop only mild nephritis or have no kidney involvement at all. High titers of pure antinucleolar antibodies probably are found almost exclusively in the sera of patients with scleroderma. Some ANA have organ specificity, and GS-ANA have been found in all patients with Felty's syndrome and in a large proportion of patients with RA. One of the great advances in the field has been the recognition that ANA can be induced in the human and in experimental animals by the use of a number of therapeutic agents. Some of these agents can also induce a clinical picture resembling spontaneous SLE, though kidney involvement does not occur or is extremely mild. It is interesting that the whole spectrum of ANA can be found in drug-induced LE except anti-nDNA antibodies which have been associated to the pathogenesis of immune complex nephritis in spontaneous SLE. There is no doubt that research on ANA has contributed a great deal to the understanding of the CTD and will continue to be a valuable tool for the clinician and the investigator.

Recent observations on central nervous system lupus erythematosus

The recent literature on CNS-SLE has been reviewed. An improved prognosis is noted that is thought to be due to the use of high-dose corticosteroids. The frequencies of the various neurologic and psychiatric findings are discussed, and a distinction is noted between organic psychoses and functional psychiatric complaints. The question of corticosteroids versus cerebral vasculitis as the cause of the neuropsychiatric symptomatology in SLE is examined, and the necessity of clear psychiatric diagnosis and treatment is stressed. Recent observations on HL-A antigens, complement, immunoglobulins, virus, and immunocomplexes suggest that the latter are prominent in CNS-SLE, but that an infectious agent may be etiologic in the genesis of SLE. Fifty-four patients not previously reported are discussed. Thirty-eight of them had neuropsychiatric manifestations. The treatment of CNS-SLE with cytotoxic agents, in addition to corticosteroids, is considered, and the experience of the authors with such treatment is presented.