RESUMO
BACKGROUND: Acute transverse myelitis (ATM) is an infrequent but severe complication of systemic lupus erythematosus (SLE). The purpose of study was to describe clinical features and prognostic factors of patients with SLE-related ATM. METHODS: In this medical records review study, data were collected from 60 patients from 16 centers seen between 1996 and 2017 who met diagnostic criteria for SLE and myelitis as defined by the American College of Rheumatology/Systemic International Collaborating Clinics and the Working Group of the Transverse Myelitis Consortium, respectively. Objective neurological impairment was measured with American Spinal Injury Association Impairment Scale (AIS) and European Database for Multiple Sclerosis Grade Scale (EGS). RESULTS: Among patients included, 95% (n = 57) were female, and the average age was 31.6 ± 9.6 years. Myelitis developed after diagnosis of SLE in 60% (n = 36). Symmetrical paraparesis with hypoesthesia, flaccidity, sphincter dysfunction, AIS = A/B, and EGS ≥ 8 was the most common presentation. Intravenous methylprednisolone was used in 95% (n = 57), and 78.3% (n = 47) received intravenous cyclophosphamide. Sensory/motor recovery at 6 months was observed in 75% (42 of 56), but only in 16.1% (9 of 56) was complete. Hypoglycorrhachia and EGS ≥ 7 in the nadir were associated with an unfavorable neurological outcome at 6 months (p < 0.05). A relapse rate during follow-up was observed in 30.4% (17 of 56). Hypoglycorrhachia and hypocomplementemia seem to be protective factors for relapse. Intravenous cyclophosphamide was associated with time delay to relapse. CONCLUSIONS: Systemic lupus erythematosus-related ATM may occur at any time of SLE course, leading to significant disability despite treatment. Relapses are infrequent and intravenous cyclophosphamide seems to delay it. Hypoglycorrhachia, hypocomplementemia, and EGS at nadir are the most important prognostic factors.
Assuntos
Lúpus Eritematoso Sistêmico , Mielite Transversa , Adulto , Feminino , Humanos , América Latina , Lúpus Eritematoso Sistêmico/complicações , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Mielite Transversa/diagnóstico , Mielite Transversa/tratamento farmacológico , Mielite Transversa/epidemiologia , Recidiva Local de Neoplasia , Prognóstico , Adulto JovemRESUMO
BACKGROUND: Aquaporin-4 antibodies (AQP4-Ab) are associated with neuromyelitis optica spectrum disorder (NMOSD) and typically this disorder has a poor visual prognosis as a result of optic neuritis (ON). Our aim was to report the clinical features at onset and final visual outcomes at 6 months of patients with ON who were positive for AQP4-Ab vs. those who were negative for AQP4-Ab. METHODS: Retrospective cohort study. AQP4-Ab were tested by indirect immunofluorescence in 57 patients with a first episode of ON. All patients initially were referred for consideration of multiple sclerosis ON (MSON), NMOSD, or any other inflammatory central nervous system disorder during follow-up (41.31 ± 24.32 months). Our patients were diagnosed as having NMOSD, MSON, chronic relapsing inflammatory ON, and single isolated ON. Risk factors associated with visual outcomes of ON patients were assessed through an ordinal regression model. RESULTS: Positive AQP4-Ab were associated with male sex (P = 0.02), earlier age of onset (P = 0.01), and myelitis relapses (P = 0.04). Seronegative group had fewer recurrences of ON than the seropositive group (35% vs 58%, P = 0.14). Patients that were positive for AQP4-Ab did not have worse visual acuity at baseline and after 6 months. However, poor visual acuity during first attack was associated with a worse visual acuity at 6 months (odds ratio = 2.28, 95% CI [1.58-3.28], P = 0.03). CONCLUSIONS: At 6 months, positive AQP4-Ab vs negative AQP4-Ab patients no evidence of poorer visual acuity. Lower visual acuity at baseline was associated with poor visual recovery at 6 months.
Assuntos
Aquaporina 4/imunologia , Autoanticorpos/sangue , Neurite Óptica/imunologia , Acuidade Visual/fisiologia , Doença Aguda , Adulto , Idade de Início , Avaliação da Deficiência , Feminino , Técnica Indireta de Fluorescência para Anticorpo , Humanos , Masculino , Pessoa de Meia-Idade , Neuromielite Óptica/imunologia , Neurite Óptica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Estudos Soroepidemiológicos , Adulto JovemRESUMO
STUDY DESIGN: Multicenter retrospective study. OBJECTIVES: The aim was to determine the frequency and magnetic resonance imaging (MRI) features of short-segment transverse myelitis (STM) in patients with neuromyelitis optica spectrum disorders (NMOSD) during a myelitis attack. SETTING: Latin American diagnostic centres (Neuroimmunology Unit). A multicenter study from Argentina, Brazil and Venezuela was performed. METHODS: Seventy-six patients with NMOSD were included. We analyzed 346 attacks and reviewed spinal cord MRIs performed within 30 days from spinal attack onset. Sagittal and axial characteristics on cervical and thoracic MRI (1.5 tesla) were observed. Demographics, clinical, serological, and disability data were collected. RESULTS: Among the 76 patients with NMOSD, isolated STM was observed in 8% (n = 6), multisegmental lesions (longitudinally extensive transverse myelitis (LETM) + STM) in 28% (n = 21; 13 had at least one STM), LETM in 42% (n = 32), and normal spinal MRI in 22% (n = 17). However, isolated STM was increased by 10% in patients with NMOSD with spinal lesions (6 out of 59) with mean attacks of 2.5 (±0.83) and last follow-up expanded disability status scale (EDSS) of 3.1 (±2.63). Positive aquaporin 4 antibodies (AQP4-ab) were found in 50%. Upper-cervical lesion was most frequently observed (5 out of 6). Myelitis was preceded by ON in all isolated patients with STM. Only one had a positive gadolinium lesion and none of these had asymptomatic spinal cord lesion. CONCLUSION: Isolated STM does not exclude NMOSD diagnosis. Therefore, APQ4-ab testing could be useful during a myelitis attack with STM.
Assuntos
Neuromielite Óptica/diagnóstico por imagem , Medula Espinal/diagnóstico por imagem , Adulto , Vértebras Cervicais , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Vértebras TorácicasRESUMO
BACKGROUND: Antibodies against aquaporin-4 (AQP4-ab) have diagnostic and prognostic value. However, little is known to date about their utility in the first event of optic neuritis (ON). OBJECTIVE: To evaluate the utility of systematic AQP4-ab determination in a retrospective cohort of patients with a first onset of ON. PATIENTS AND METHODS: All patients (n = 42) were tested for AQP4-ab in the following context: typical ON (TON) and atypical ON (AON). Clinical, radiological and biochemical data were collected; patients with TON vs. AON and AQP4-ab positive vs. negative were compared. RESULTS: The proportion of AQP4-ab seropositive patients was 40% in the TON group vs. 40.9% in the AON group. Visual acuity (VA) at baseline was poor in AON patients (p = 0.02) and these patients were associated with worse VA outcome (p < 0.001) at 6 months compared with TON patients, with a median follow-up of 3.27 ± 1.79 years. Brain MRI with dissemination in space criteria (p < 0.001), spinal cord partial lesions (p < 0.001) and oligoclonal bands (p = 0.02) were associated with the initial stages of TON. VA severity, number of myelitis attacks and ON relapses did not differ significantly between seropositive and seronegative patients. AQP4-ab were detected only in neuromyelitis optica spectrum disorders patients. CONCLUSION: This study showed a high seropositivity for AQP4-ab in TON patients, suggesting that it could diagnostic utility at the onset of ON.
Assuntos
Aquaporina 4/imunologia , Autoanticorpos/sangue , Neuromielite Óptica/diagnóstico , Adulto , Autoantígenos/imunologia , Encéfalo/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuromielite Óptica/imunologia , Neuromielite Óptica/patologia , Bandas Oligoclonais , Estudos Retrospectivos , Medula Espinal/patologiaRESUMO
BACKGROUND: Multiple sclerosis (MS) has a low prevalence in Argentina. However, MS has a high burden of disease, which implies frequent neurological visits, magnetic resonance images (MRI) use and chronic MS medication during follow-up, with a high impact on the healthcare system. Therefore, MS care is essential to optimize disease management and improve patients' outcome. We aimed to evaluate the access and barriers to MS care and identified differences in treatment and management of MS patients over a period of 12 months in an Argentinean cohort. METHODS: A cross-sectional study based on a self-administered survey was carried out from August to December 2017 in 13 provinces from Argentina. MS patients (nâ¯=â¯219) were divided into three groups as follows: prepaid health insurance (PHI), social health insurance (SHI) and state-run health insurance (SRHI, Public Health Ministry) and they were assessed in order to detect differences in employment, access and barriers to MS care (neurological visit, MRI use and MS medication). RESULTS: A total of 185 (84.5%) MS patients were employed (full-time: 59%), 34 (15.5%) were currently unemployed and 15 (6.8%) retired by MS. In addition, 132 had SHI, 45 PHI and 40 SRHI. No statistical differences were found in disease severity, frequency of neurological visit, waiting time for neurological visit as well as frequency and waiting time for MRI use. MS patients with SRHI experienced a longer waiting time (first prescription and during follow-up) and inappropriate delivery of MS medication during follow-up compared to MS patients with PHI and SHI. A total of 8/45 (17.7%) in PHI, 17/40 (42.5%) in SRHI and 25/132 (18.9%) in SHI did not receive the MS medication as properly as prescribed for their neurologists. PHI was independently associated with appropriate delivery of MS medication (ORâ¯=â¯0.81, pâ¯=â¯0.01). CONCLUSION: This study showed that MS patients had access barriers to receive MS medication properly, especially those with SRHI (public sector).
Assuntos
Acessibilidade aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Esclerose Múltipla , Adolescente , Adulto , Argentina , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Brain magnetic resonance imaging (BMRI) lesions were classically not reported in neuromyelitis optica (NMO). However, BMRI lesions are not uncommon in NMO spectrum disorder (NMOSD) patients. OBJECTIVE: To report BMRI characteristic abnormalities (location and configuration) in NMOSD patients at presentation. METHODS: Medical records and BMRI characteristics of 79 patients with NMOSD (during the first documented attack) in Argentina, Brazil and Venezuela were reviewed retrospectively. RESULTS: BMRI abnormalities were observed in 81.02% of NMOSD patients at presentation. Forty-two patients (53.1%) showed typical-NMOSD abnormalities. We found BMRI abnormalities at presentation in the brainstem/cerebellum (n = 26; 32.9%), optic chiasm (n = 16; 20.2%), area postrema (n = 13; 16.4%), thalamus/hypothalamus (n = 11; 13.9%), corpus callosum (n = 11; 13.9%), periependymal-third ventricle (n = 9; 11.3%), corticospinal tract (n = 7; 8.8%), hemispheric white matter (n = 1; 1.2%) and nonspecific areas (n = 49; 62.03%). Asymptomatic BMRI lesions were more common. The frequency of brain MRI abnormalities did not differ between patients who were positive and negative for aquaporin 4 antibodies at presentation. CONCLUSION: Typical brain MRI abnormalities are frequent in NMOSD at disease onset.
Assuntos
Aquaporina 4/imunologia , Autoanticorpos/sangue , Encéfalo/patologia , Neuromielite Óptica/sangue , Neuromielite Óptica/patologia , Adulto , Argentina , Encéfalo/diagnóstico por imagem , Tronco Encefálico/diagnóstico por imagem , Tronco Encefálico/patologia , Brasil , Cerebelo/diagnóstico por imagem , Cerebelo/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuromielite Óptica/diagnóstico por imagem , Estudos Retrospectivos , Venezuela , Adulto JovemRESUMO
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects multiple systems. Myelopathy is one of 19 neuropsychiatric syndromes related to SLE defined by the American College of Rheumatology. Although infrequent, it is a severe manifestation, leading to motor and sensory deficits, and sphincter dysfunction. The pathogenesis is not clearly known, but may be related to arterial thrombosis and vasculitis. Diagnosis is based on clinical findings, laboratory tests and the use of gadolinium-enhanced magnetic resonance imaging. The standard therapy is the combination of intravenous cyclophosphamide and glucocorticoids. In refractory disease, other treatments such as plasmapheresis or rituximab have been used.
Assuntos
Imunossupressores/uso terapêutico , Lúpus Eritematoso Sistêmico/complicações , Mielite/etiologia , Terapia Combinada , Ciclofosfamida/uso terapêutico , Diagnóstico Diferencial , Feminino , Glucocorticoides/uso terapêutico , Substância Cinzenta/diagnóstico por imagem , Substância Cinzenta/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , Mielite/diagnóstico por imagem , Mielite/tratamento farmacológico , Mielite/fisiopatologia , Neuromielite Óptica/diagnóstico , Neuromielite Óptica/etiologia , Plasmaferese , Guias de Prática Clínica como Assunto , Prognóstico , Rituximab/uso terapêutico , Substância Branca/diagnóstico por imagem , Substância Branca/fisiopatologiaRESUMO
Clinical, neuroimaging, and laboratory features are not specific enough to establish the etiological diagnosis of the acute inflammatory myelitis (AIM). Longitudinally extensive transverse myelitis (LETM) seen on magnetic resonance imaging (MRI) has been associated with a poor functional prognosis. The aim of this study was to assess the functional outcomes of a first AIM event comparing patients with LETM vs. no LETM on MRI and to report the differential diagnosis. Clinical, radiological, biochemical aspects were collected, and Winner-Hughes Functional Disability Scale (WHFDS) was performed after 3 and 6 months. Centromedullary lesions were associated with LETM, lateral lesions with partial lesion (PL), and brain MRI lesions with multiple sclerosis and acute encephalomyelitis disseminated. LETM patients were associated with a worse functional outcome as the need of a wheelchair after 3 and 6 months (OR = 7.61 p = 0.01; OR 4.8 p = 0.04, respectively), a walker or cane (OR = 11.0 p = 0.002, OR = 4.3 p = 0.03, respectively). In addition, we found a correlation between LETM and acute complete transverse myelitis and PL with acute partial transverse myelitis (83.3 and 90.9%, respectively; p < 0.0001). In conclusion, AIM is a heterogeneous syndrome from an etiological point of view and LETM patients had worse functional prognosis compared with PL after 3 and 6 months.
Assuntos
Imageamento por Ressonância Magnética/tendências , Mielite Transversa/diagnóstico por imagem , Mielite Transversa/etiologia , Recuperação de Função Fisiológica/fisiologia , Adulto , Anti-Inflamatórios/farmacologia , Anti-Inflamatórios/uso terapêutico , Encefalomielite/complicações , Encefalomielite/diagnóstico por imagem , Feminino , Humanos , Masculino , Metilprednisolona/farmacologia , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Esclerose Múltipla/complicações , Esclerose Múltipla/diagnóstico por imagem , Mielite Transversa/tratamento farmacológico , Neuromielite Óptica/complicações , Neuromielite Óptica/diagnóstico por imagem , Recuperação de Função Fisiológica/efeitos dos fármacos , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: To report the impact of multiple sclerosis (MS) on patients' quality of life (QoL) compared to systemic lupus erythematosus (SLE) using the 36-Item Short Form (SF-36) health questionnaire in Argentina. PATIENTS AND METHODS: Cross-sectional study. All consecutive MS patients, SLE and healthy controls (HC) were included. Demographics, clinical and radiological aspects, EDSS and SF-36 were assessed. RESULTS: A total of 191 subjects were included (MS=74, SLE=30 and HC=87). When we compared, using 2 standard deviations below the normal mean, the SF-36 subscales scores between MS and SLE, we found that MS patients experienced significant deterioration in general health (p<0.0001), vitality (p=0.009), current health (p<0.0001) and previous year health perception (p=0.003). Additional evaluated areas did not show significant differences. MS patients scored significantly lower in all categories compared to HC, except for bodily pain. An inverse correlation between EDSS and SF-36 total (R2=0.59, ß -11.08, p<0.0001) and subscale scores was observed after applying regression analysis. CONCLUSION: MS behaves as a systemic disease from the functional point of view. Patient-reported QoL scales scores provide comprehensive additional prognostic information beyond the EDSS score. Therefore, adding the SF-36 questionnaire in clinical practice might be useful for the assessment and follow-up of MS patients.
Assuntos
Lúpus Eritematoso Sistêmico/diagnóstico , Esclerose Múltipla/diagnóstico , Qualidade de Vida , Inquéritos e Questionários , Adulto , Estudos Transversais , Diagnóstico Diferencial , Feminino , Humanos , Lúpus Eritematoso Sistêmico/diagnóstico por imagem , Masculino , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Longitudinally extensive transverse myelitis (LETM) is a frequent manifestation of neuromyelitis optica spectrum disorder (NMOSD). However, it can also occur in other immune-mediated diseases of the central nervous system (CNS). Positive aquoporin-4 antibodies (AQP4-ab) predict higher relapse rate after LETM. OBJECTIVE: To assess clinical and brain/spinal cord magnetic resonance imaging (MRI) features of LETM immune-mediated at onset and to compare AQP4-ab negative (N-LETM) with AQP4-ab positive (P-LETM) patients. METHODS: Thirty LETM patients remitted for consideration of inflammatory CNS diseases were included. Demographics, clinical, serological, disability and neuroimaging features at onset we reviewed retrospectively and divided into two groups according to serological status. AQP4-ab were tested using indirect immunofluorescence. RESULTS: Twenty-one patients were N-LETM. We did not find significant differences between both groups as regards gender, age at onset, dysfunction (motor, sensory, bladder/bowel) or disability. However, recurrences (p=0.04) of myelitis and number of relapses (p=0.03) were associated to P-LETM. N-LETM was associated with normal brain MRI (p=0.04) at onset. AQP4-ab positive were only observed in NMOSD patients. N-LETM (24%) and P-LETM (56%) patients had relapses of optic neuritis (ON) during the follow-up. CONCLUSION: LETM at onset is a heterogeneous syndrome with similar clinical and neuroimaging features between both groups. N-LETM displayed a lower relapse rate of myelitis and ON.
Assuntos
Mielite Transversa/imunologia , Neuromielite Óptica/imunologia , Adulto , Aquaporina 4/imunologia , Autoanticorpos/sangue , Encéfalo/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Mielite Transversa/diagnóstico por imagem , Mielite Transversa/etiologia , Mielite Transversa/terapia , Neuromielite Óptica/complicações , Neuromielite Óptica/diagnóstico por imagem , Neuromielite Óptica/terapia , Recidiva , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Myelopathy is one of the neuropsychiatric lupus syndromes. In this article, an original series of related lupus myelitis is reported and analyzed. We employed a retrospective chart review and identified all patients who were admitted to a general hospital in Buenos Aires, Argentina, with SLE and myelitis during the period 2007-2014. Five patients were observed, all women. The mean age was 25.4 years (19-39). In three of five cases, myelitis was one of the initial SLE manifestations. The SLE Disease Activity Index was variable (3/5 with high activity). Time to nadir ranged from 6 to 72 h. All had severe impairment, with motor deficit, sensory level and urinary retention. Magnetic resonance imaging was abnormal in all cases, 3/5 presented a longitudinally extensive myelitis. Serum analysis revealed positive antinuclear antibodies at a high titer in all patients, 4/5 had low complement levels and 3/5 had anti-phospholipids positive. The treatment (methylprednisolone and, in some cases, cyclophosphamide, anticoagulation and/or plasmapheresis) produced partial improvement or no benefits. One patient died due to sepsis. The others showed significant disability at 6 months (European Database for Multiple Sclerosis grading scale=6-8). In view of these results, myelitis associated with lupus shows heterogeneity of the clinical, radiological and serological features. In our experience, the cases were severe and with poor response to treatment. Further studies are required to understand this disease and establish a more efficient treatment.