Endomyocardial biopsies in the diagnosis of myocardial involvement in systemic lupus erythematosus

BACKGROUND

Endomyocardial biopsy (EMB) is considered the gold standard for diagnosing myocardial involvement in most inflammatory conditions, including systemic lupus erythematosus (SLE). However, EMBs are rarely performed, and most of the myocardial histopathology reports in SLE consist of postmortem data. We therefore sought to describe the histopathologic findings of contemporary EMBs in SLE performed in clinical practice.

METHODS

A retrospective review of histopathology reports from SLE patients who underwent EMB from 1994 to 2017 was performed. A total of 41 SLE patients had cardiac pathology reports. Of these, 11 histopathology reports were EMBs, and the remaining were valvular specimens.

RESULTS

A total of 11 SLE EMBs were reviewed. It was found that 45% of the patients had hypertension, 27% had coronary artery disease, 9% had hyperlipidemia, and 36% had end-stage renal disease. None had diabetes or smoked. The mean left ventricular ejection fraction was 37%. On histopathology, 10 had mild interstitial fibrosis, 9 had myocyte hypertrophy, 3 had organized blood clots, and 3 had a mild infiltration of lymphocytes and macrophages without clear evidence of myocarditis. None had vasculitis, endocarditis, ischemia, amyloid deposition, or lamellar or curvilinear inclusions.

CONCLUSION

EMBs are rarely performed in SLE. In this case series, nonspecific interstitial fibrosis and myocyte hypertrophy were the most common findings, suggesting EMBs have limited value in the diagnosis of cardiac involvement in SLE and rather rule out competing conditions. These data support the need for diagnostic methods with high sensitivity and specificity for SLE heart disease.

Association between hydroxychloroquine levels and disease activity in a predominantly Hispanic systemic lupus erythematosus cohort

OBJECTIVES

Hydroxychloroquine (HCQ) is a key therapy in systemic lupus erythematosus (SLE). Medication non-adherence is reported in up to 80% of lupus patients and results in increased morbidity, mortality, and health care utilization. HCQ levels are a sensitive and reliable method to assess medication adherence. Our study evaluated the role of HCQ level measurement in routine clinical care and its association with disease activity in a predominantly Hispanic population.

METHODS

SLE patients from the Columbia University Lupus cohort treated with HCQ for ≥ 6 months and reporting medication adherence were included. HCQ levels were measured by whole blood high performance liquid chromatography. Non-adherence was defined as an HCQ level <500 ng/ml. The association between HCQ levels and disease activity measured by Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) was evaluated.

RESULTS

One hundred and eight patients were enrolled; the median age was 38 years, 91% were female, and 63% were Hispanic. The median SLEDAI-2K was 4.3 (0-20). Forty-one percent of patients had an HCQ level <500 ng/ml consistent with non-adherence, of which 19% had undetectable levels. A higher SLEDAI-2K score was associated with low HCQ levels (p = 0.003). This association remained significant after adjusting for depression (p = 0.0007).

CONCLUSION

HCQ levels < 500 ng/ml were associated with higher disease activity and accounted for 32% of the SLEDAI-2K variability. HCQ blood measurement is a simple and reliable method to evaluate medication adherence in SLE. Reasons for non-adherence (levels < 500 ng/ml) should be further explored and addressed.

Damage accrual in systemic lupus erythematosus in Dominicans in New York City and the Dominican Republic

Objectives Hispanics with systemic lupus erythematosus (SLE) in the United States have more severe disease and damage accrual compared with whites. Data on Hispanics of similar ancestry in geographically different locations is limited but essential in defining genetic and environmental factors for SLE. This study evaluates SLE disease burden in two Dominican communities, Washington Heights in New York City (NYC) and Santiago in the Dominican Republic (DR). Methods Disease activity (SLE Disease Activity Index 2000 (SLEDAI-2K)) and damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI)) were cross-sectionally measured in 76 Dominican SLE patients from the Columbia University Lupus Cohort in NYC and compared with 75 Dominican SLE patients living in Santiago in the DR. Results Mean (±SD) age was 40 (±14) and 36 (±11) years for NYC and DR patients, respectively. Median disease duration was 8 years. Disease activity was mild in both groups (SLEDAI-2K of 3 in NYC versus 4 in the DR). NYC Dominicans had more discoid lesions, positive anti-dsDNA, and anti-SSB antibodies. Dominicans in the DR used more corticosteroids, had less medical insurance, lower educational level, and were more likely to be unemployed, whereas more Dominicans in NYC smoked. NYC patients had a higher SDI compared with SLE patients in the DR (0.96 versus 0.24, p < 0.0001). Statistical significance was maintained in adjusted analysis (1.26 versus 0.57, p < 0.0001). Conclusion SLE Dominican patients in NYC had a higher SDI than those in the DR. Longitudinal studies are needed to ascertain whether this difference is due to biological, environmental factors, immigration patterns or a survival bias.

A Stepwise Approach to Laparoscopic Enucleation and Excision of Retroperitoneal Cysts

STUDY OBJECTIVE

To show a step-by-step approach to laparoscopic enucleation and excision of retroperitoneal cysts using a technical video.

DESIGN

A technical video (Canadian Task Force classification III).

SETTING

A benign gynecology department at a university hospital.

INTERVENTION

Laparoscopic enucleation and excision of retroperitoneal cysts.

CONCLUSION

Retroperitoneal cysts are rare lesions associated with numerous complications including compression on neighboring organs, infection, rupture, and malignant transformation. Excision of retroperitoneal cysts can be challenging, and dissection of the retroperitoneal space is associated with bowel and vascular injury [1]. Laparoscopic drainage and fenestration have been promoted to prevent visceral injury [2]. Such approaches are ineffective, with increased recurrences and fluid accumulation requiring repeat surgical procedures [3,4]. Successful laparoscopic excision of retroperitoneal cysts has been reported although there are no published videos of the technique [5]. In this video, we use 2 separate cases to show our step-by-step laparoscopic approach to enucleate and excise retroperitoneal cysts. Various methods to safely enter retroperitoneal spaces to avoid inadvertent damage to surrounding structures are detailed. A combination of careful blunt and sharp dissection is used to find specific planes to separate the cyst from the overlying peritoneum and underlying pelvic sidewall structures such as the ureter, vasculature, and nerves. We minimize energy use, and, when it is used, we are mindful regarding active blade positioning of the ultrasonic dissector to prevent inadvertent cyst rupture and injury to the surrounding structures. Keeping the cysts intact aids in leverage and prevents inadvertent spillage of potentially malignant contents. The cysts are retrieved laparoscopically by contained bag decompression.