Seroprevalence and specificity of NMO-IgG (anti-aquaporin 4 antibodies) in patients with neuropsychiatric systemic lupus erythematosus.

Neuropsychiatric manifestations are present in 30-40% of patients with systemic lupus erythematosus (SLE). Recently, antibodies to aquaporin-4 (termed AQP4-Ab, or NMO-IgG), a water channel protein, were reported to be present in a subset of patients with SLE and neurological involvement. To evaluate the syndrome specificity and prevalence of serum NMO-IgG/anti-AQP4 antibodies in patients with neuropsychiatric systemic lupus erythematosus (NPSLE). Sera of 76 patients with SLE and neurological symptoms, 50 of whom met the ACR case definitions of NPSLE, were tested for AQP4-Ab in an indirect immunofluorescence assay employing HEK293 cells transfected with recombinant human AQP4. Only one of the examined sera was positive for NMO-IgG/AQP4-Ab. This patient suffered from TM, ranging over two vertebral segments on spinal MRI. None of the 75 NPSLE without TM was found to be seropositive for NMO-IgG/AQP4-Ab. NMO-IgG/AQP4-Ab in NPSLE were present only in a patient with TM and were not detectable in NPSLE patients with other neurological manifestations. Testing for NMO-IgG/AQP4-Ab positivity should be considered in patients presenting with SLE and TM. Non-longitudinally extensive lesions do no not exclude NMO-IgG/AQP4-Ab in patients presenting with SLE and TM.

Association of systemic lupus erythematosus with low serum bilirubin levels.

OBJECTIVE: Systemic lupus erythematosus (SLE) is accompanied by severe oxidative stress. Bilirubin has been reported as a strong negative predictor of oxidative stress-mediated diseases, such as atherosclerosis. The objective of our study was to evaluate the association between serum bilirubin levels and SLE manifestation. METHODS: The study was performed with 259 SLE patients, diagnosed according to American Rheumatism Association (ARA) criteria. A subset of these patients, having normal hepatic function (n = 218, mean age 39.5 years), was studied in greater detail to eliminate the possible confounding effects of any underlying or drug-induced liver disease on the serum bilirubin levels. Age-matched healthy subjects (n = 180) served as the control group. A standard biochemical and immunological work-up was performed on all subjects. RESULTS: Compared to the controls, substantially lower levels of serum bilirubin were detected in SLE patients (p < 10⁻5); these were inversely correlated with disease activity and extent (p < 0.05). Furthermore, each 1 µmol/L decrease in serum bilirubin was associated with a 37% increase in the odds for a positive SLE status [odds ratio (OR) 1.37, 95% confidence interval (CI) 1.28-1.47, p < 10⁻5]. Simultaneously, the odds of unconjugated hyperbilirubinaemia (a phenotypic sign of Gilbert's syndrome) were more than four times lower in SLE patients (OR 0.235, 95% CI 0.072-0.764, p = 0.016). CONCLUSION: Low serum bilirubin represented a strong predictor of the manifestation of SLE symptoms. The most likely explanation for this finding is the increased consumption of bilirubin due to the severe oxidative stress accompanying SLE. Subjects with higher serum bilirubin levels, such as those with Gilbert's syndrome, might be protected from the development of SLE.

Magnetic resonance volumetry of pathological brain foci in patients with systemic lupus erythematosus.

OBJECTIVE: The aim of our study was to determine the volume of pathological foci in the brain tissue of patients suffering from systemic lupus erythematosus (SLE) with or without neuropsychiatric manifestations (NP), and also to find out if that volume depends on the study subjects' data and clinical records. Magnetic resonance (MR) scans of patients with SLE and, in particular, signs of neuropsychiatric involvement, show pathological foci in the cerebral white matter. METHODS: A total of 53 SLE patients, 29 with signs of neuropsychiatric syndromes (NPSLE), 24 without, and 16 healthy controls underwent prospective volumetric magnetic resonance imaging in a flow attenuated inversion recovery (FLAIR) sequence. The disease activity was expressed in terms of the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). RESULTS: All the patients in this study were found to have a larger volume of pathological foci in the brain tissue than the healthy controls. The NPSLE subgroup had a larger volume of pathological foci than the SLE patients without NP (p<0.001). The largest volume of such foci was found in the patients with a history of cerebrovascular disease (p<0.05). These were also noted for a correlation between the duration of the disease and the period of time elapsed from the onset of the first signs of neuropsychiatric lupus (p<0.01). Correlation with SLEDAI-rated disease activity was found statistically significant in all the patients (p<0.05) and in those with NPSLE at a level of p<0.01. CONCLUSION: We found that the lesion load was significantly larger in NPSLE than in SLE patients free from NP and controls. Our measurement revealed a positive correlation between the lesion load and SLEDAI in the whole SLE patients group, particularly in the subgroup with NP manifestation. In the future, longitudinal volumetry might conceivably facilitate the therapeutical effect rating.

Arthralgia of the temporomandibular joint and low-level laser therapy.

OBJECTIVE: This case report describes the treatment of a patient with arthralgia of the temporomandibular joint (TMJ) caused by disc displacement. BACKGROUND DATA: The goal of the treatment of TMJ arthralgia is to decrease pain by promotion of the musculoskeletal system's natural healing ability. METHODS: This report describes the complex treatment of TMJ arthralgia. Low-level laser therapy (LLLT) was chosen for its antiinflammatory and analgesic effects. Laser therapy was carried out using the GaAlAs diode laser with an output power of 400 mW, emitting radiation with a wavelength of 830 nm, and having energy density of 15 J/cm2; the laser radiation was applied by contact mode on four targeted spots in 10 sessions. Physiotherapy was recommended to this patient to prevent the injury of intraarticular tissue caused by incorrect movement during opening of the mouth. Splint stabilization and prosthetic treatment were used to reduce overloading of the TMJ, resulting from unstable occlusion and to help repositioning of the dislocated disc. RESULTS: Five applications of LLLT led to decrease of pain in the area of the TMJ on the Visual Analog Scale, from 20 to 5 mm. The anti-inflammatory effect of the laser was confirmed by thermographic examination. Before treatment, the temperature differences between the areas of the normal TMJ and TMJ with arthralgia was higher than 0.5 degrees C. However, at the conclusion of LLLT, temperatures in the areas surrounding the TMJ were equalized. CONCLUSION: This study showed the effectiveness of complex non-invasive treatment in patients with arthralgia of the TMJ. The analgesic and anti-inflammatory effects of LLLT were confirmed by infrared thermography.

Correlation of some MR findings in ankylosing spondylitis.

Results of the spinal magnetic resonance (MR) in patients with ankylosing spondylitis (AS) were evaluated prospectively in correlation with age, symptoms duration and some inflammatory tests. 20 patients with AS were prospectively examined by complex clinical and laboratory tests. All were examined with X-ray and 1,5T magnetic resonance. The visibility, margination and extent of acute and chronic pathological vertebral lesions were qualitatively and quantitatively compared statistically. The axial form of AS strongly prevailed (70%). If acute AS vertebral changes are evaluated CRP did not correlated with local vertebral changes, erythrocyte sedimentation rate and functional tests BASDAI and BASFI correlated with vertebral changes on the various significance level due to the MR sequence used. Chronic spinal changes correlated with age of the patients and duration of the symptoms. BASFI test with chronic changes did not correlate. MR is the best method for evaluating changes in vertebrae and in the adjacent soft tissues. The excellent evaluation of acute and chronic local MR changes of vertebral marrow is provided by Braun's scoring system. In acute AS changes short T1 inversion recovery (STIR) sequence showed most vertebral marrow changes, while in the chronic AS changes T1 weighted images were the statistically significantly best sequence in depicting the marrow and ligamentous pathology.

[Antiphospholipid syndrome--the description of two cases]. / Antifosfolipidový syndrom--popisy dvou prípadu.

Antiphospholipid syndrome (APS) often occurs in young people, it is defined by the presence of venous or arterial thromboses, repeated miscarriages, thrombocytopenias and increased levels of antiphospholipid antibodies. Clinical symptoms are different, there is often experienced the phlebothrombosis of lower limbs, miscarriages or neurological symptoms characterized by transient ischemic attacks (TIA). If APS is associated with other system disease, most often with systemic lupus erythematosus (SLE), it is called secondary APS. We present two cases of secondary APS in the work. In first case we describe synchronous occurrence of SLE with secondary APS, which was clinically manifested by phlebothrombosis of veins of crus. At another elder patient there was stated the diagnosis of non-differentiated disease of bonding agent with secondary APS with cardial, pneumonic and neurological clinical symptoms.

The examination of the temporomandibular joint on 1,5T magnetic resonance.

The most frequent intraarticular disorder of the temporomandibular joint (TMJ) represents the disorder of the functional relation between the articular disc and mandible condyle, i.e. dislocation of the articular disc. Magnetic resonance (MR) optimally visualizes the soft and hard articular tissues (articular disc, articular socket and condyle of the mandible) and its surroundings. The aim of the study was to evaluate findings of MR investigation of the TMJ. We investigated billateraly 26 patients with TMJ disorders during the years 1996 and 2003. All patients were examined on 1,5 T MR. Joints were studied in T1 and T2 weighted images with closed mouth and during mouth opening in dynamic study. MR verified dysfunction was observed in 48 investigated TMJ (92,3 %), hydrops of the joint was observed in 3 joints (5,8 %), arthrosis of the condylar head in 4 patients (7,6 %). Only four TMJ had normal MR finding (7,6 %). MR represents the best method for studying clinically affected joints, for the evaluation of the morphological state of TMJ and the analysis of the dynamic process during mouth opening. Method is also useful for revealing of a disorder in clinically silent joints. T2 weighted image in TSE mode brought best imaging of the joint. The fat saturation sequence was advantageous mainly in liquid storage (hydrops of the joint, edema in the adjacent bone). The dimensions of the articular cleft and bone components of the joint were well-visualized in T1 weighted images.

[Multiple sclerosis and magnetic resonance]. / Roztrousená skleróza mozkomísní a magnetická rezonance.

Multiple sclerosis is a demyelinating process presently referred to autoimmune diseases. Its diagnostics is based on clinical examination and paraclinical tests (magnetic resonance, examination of CSF and evoked potentials recording). Magnetic resonance (MR) has the highest significance, both for the diagnostics and for the monitoring of the course of disease and results of treatment. Results of magnetic resonance are not specific for the multiple sclerosis and therefore for the reliable diagnosis the McDonadl's criteria have to be fulfilled. It appears that magnetic resonance is more sensitive to progression of disease than the clinical examination. Monitoring of the course of disease requires new techniques of MR imaging. Automatic, software assisted determination of plaque volumes in T2 and T1 weighted images--so called "lesion load", is checked during the patient's treatment. Assessment of brain volume determines progression of atrophy. The aim of all the new methods of MR imaging is to search for a reliable technique of the disease monitoring and namely for the prediction of disease progression.

[Characteristics of foci of increased MR signals in the brain of patients with systemic lupus erythematosus and cerebral involvement]. / Charakteristika lozisek zvýseného MR signálu v mozku u nemocných se systémovým lupus erythematodes s postizením mozku.

The frequency and size of MR hypersignal foci in the white and grey matter in T2 weighted images were evaluated in 50 patients with the definite diagnosis of systemic lupus erythematosus (SLE) with neuropsychiatric symptomatology (neuropsychiatric lupus--NPSLE) and in 50 healthy persons in this study. The lesions were divided according to the size to lesions smaller than 3 mm, lesions of 3-6 mm size and ones greater than 6 mm. Their total and relative number in the brain, the number in cerebral supra- and infratentorial regions and in all cerebral lobes was evaluated. Further their occurrence in the brain in the mediolateral and craniocaudal direction of MR investigation was determined. The study showed that the focal pathology manifests itself in NPSLE patients in 100% of cases with pronounced white matter predominance; the supratentorial occurrence of lesions and their subcortical localization significantly prevailed. As the lesions size is concerned in all patients, the lesions up to 3 mm significantly prevailed, lesions of 3-6 mm size were solitary and lesions greater than 6 mm were present up to 10% of cases. The significant predominance of all size lesions number in frontal and parietal lobes was observed in both groups of investigated persons. The statistically significant difference (p < 0.01) between both followed groups (SLE patients and controls) was found as in absolute and relative numbers of supratentorial lesions up to 3 mm, as in the total brain and in single cerebral lobes. The significant difference was recorded in the same parameters in 3-6 mm lesions and in ones greater than 6 mm. Lesions greater than 6 mm were never observed in controls. This specification of cerebral MR finding in NPSLE patients significantly supports the clinical diagnosis of NPSLE, even though it is not specific.

[EEG findings in patients with systemic lupus erythematosus]. / EEG nálezy u nemocných se systemovým lupus erythematosus.

We have examined electroencephalography (EEG) and Mini-Mental State Examination (MMSE) in 38 patients with verified diagnosis of systemic lupus erythematosus (SLE). In the clinical neurological finding there were epileptic attacks in 9 patients, 10 patients suffered from stroke, 15 patients from lupus headache, 4 patients from psychosis, in 15 patients cranial neuropathy was present, in one person extrapyramidal syndrome. EEG findings were in 12 patients normal (32%), in 26 patients abnormal (66%). In 3 cases there were focal abnormalities (8%), in 19 cases episodic ones (48%), four times abnormalities were diffuse (10%). Diffuse abnormalities correlated in EEG findings with case history of GM attacks.

[Differential diagnosis of expansive lesions in the sellar region using magnetic resonance imaging]. / Differenciální diagnostika expanzivních lézí v selární krajine v obraze magnetické rezonance.

Diagnosis of the type of expansive pathological lesion in the sellar region is of fundamental importance. Magnetic resonance is an imaging method which proved dominant and provides most information from the sellar region. Although no sign in the MR image is quite specific for a certain lesion, the substrate diagnosis can be assessed with a considerable probability. The presented paper gives an account of the authors experience supplemented by literature on the problem.

[Antiphospholipid antibodies in patients with neurologic diseases]. / Antifosfolipidové protilátky u pacientu s vybranými neurologickými chorobami.

In a series of patients with neuroinfection, Lyme disease, Guillain Barré syndrome, demyelinization, partial or generalized, epilepsy, we have investigated antiphospholipid antibodies of IgG and IgM subtypes, together with anticoagulant factors, member of thrombocytes, sedimentation rate of erythrocytes. Coagulant factor disorder in primary acute inflammatory processes (attack of demyelinization, neuroinfection, acute viral respiratory infection) and primary thrombocyte disorder (focal epilepsies) may be a result of cross reaction of antiphospholipid antibodies with negative polarized phospholipids in membranes of central nervous system, endothelium of cerebral and extracranial vessels and in the inner thrombocyte membranes connected with prostaglandin production disorder.

CT findings in cerebral metastases.

In a series of 120 patients presenting a CT image of a cerebral tumor metastasis an analysis of 88 verified cases has been performed aiming at a determination of the morphological criteria which might enable us to speculate on the site of the primary lesion. The following properties have been studied: the location, size and shape of the lesions, their number, the extent of the surrounding edema and their postcontrast enhancement. Lung cancer participated as a source in 30.8% of the disclosed metastases, in 15.8% it was breast cancer, in 11.7% renal cancer, in 9.2% malignant melanoma and the remaining 32.5% were miscellaneous others. Our results demonstrated a certain degree of probability of identifying some of those sources of the CT detected metastases which had hitherto been unknown. Their degree of malignancy might be deduced from their size and shape.