Lupus eritematoso sistémico en un paciente de 87 años / Onset of systemic lupus erythematosus in a 87-year-old man

Se expone el caso de un paciente que presentó una clínica compatible con inicio de lupus eritematoso sistémico (LES) a una edad excepcional (87 años). El LES de inicio tardío tiene unas características de presentación, como mayor benignidad y mayor retraso diagnóstico, que lo diferencian del LES de inicio en el paciente más joven. Los anticuerpos antinucleares son casi siempre positivos en el LES de inicio tardío. El hecho de tener una edad avanzada no debe eliminar la sospecha de LES y ante síntomas sugestivos deben realizarse los exámenes diagnósticos correspondientes

The case of an 87-year-old man who presented symptoms compatible with the onset of systemic lupus erythematosus (SLE) is reported. Late-onset SLE shows specific clinical features, such as a better prognosis and delayed diagnosis, which distinguish it from SLE in younger patients. Antinuclear antibodies are almost always positive in patients with late-onset SLE. Suspected SLE should not be ruled out in individuals of advanced age and specific laboratory tests should be performed when symptoms compatible with this disease are present

Lipid and lipoprotein levels in premenopausal systemic lupus erythematosus patients.

The purpose of this study was to assess the prevalence of dyslipoproteinemia and to analyze the clinical variables that are associated with it in a sample of premenopausal systemic lupus erythematosus (SLE) patients. We studied 53 premenopausal (34.5 y) SLE outpatients and 45 controls. Clinical variables studied included patient age, weight, height, body mass index (BMI), age at disease onset, disease duration, clinical activity of SLE, renal involvement and drug therapy. Total cholesterol (TC), high- and low-density lipoprotein cholesterol (HDL-C and LDL-C), and triglycerides were measured using standard enzymatic techniques. Apolipoproteins (apo) A-I and B were determined by radial immunodiffusion. Twenty-nine patients (55%) and 14 controls (30%) had dyslipoproteinemia. An increase in TC, triglycerides, HDL3-C, apo A-I and apo B, and a decrease in HDL2-C and HDL-C/TC index was found in SLE patients in comparison with controls. TC (P = 0.007), apo B (P = 0.02), LDL-C (P = 0.03) and triglycerides (P = 0.0001) were significantly correlated with proteinuria. Patients on prednisone therapy had higher triglycerides levels (P = 0.03) than untreated patients. TC (P = 0.01), LDL-C (P = 0.006) and triglycerides (P = 0.04) were also correlated with the dose of prednisone. Dyslipoproteinemia is a common feature in adult SLE premenopausal patients which is characterized by an increase in TC, triglycerides and apo B, and an abnormal distribution of HDL subclasses. Corticosteroid therapy and proteinuria are the best predictors of dyslipoproteinemia in these patients.

High disease activity at baseline does not prevent a remission in patients with systemic lupus erythematosus.

OBJECTIVE: To evaluate the utility of systemic lupus erythematosus (SLE) initial clinical manifestations and the SLE Disease Activity Index (SLEDAI) for identifying patients who will have a remission. METHODS: We studied 100 SLE patients (85 females, 15 males) and identified all patients who had remission (defined as at least one continuous year during which lack of disease activity permitted withdrawal of all treatment to suppress general lupus activity of a particular clinical manifestation). Changes in laboratory parameters without clinical activity, thus not requiring treatment, did not invalidate remission. We did not include any patient who had never required treatment. We evaluated the SLEDAI values and the main SLE manifestations at the time of diagnosis of SLE, and also every 3 months during the first year of disease. RESULTS: Twenty-four of the 100 SLE patients achieved remission that occurred a mean of 64 months after the diagnosis. They remained in remission for a mean of 55 months. There were no statistical differences in SLEDAI values and the initial manifestations (including renal and cerebral) between patients who reached remission and those who did not. The patients who have a higher SLEDAI score take longer to achieve remission. CONCLUSION: SLE patients with severe initial clinical manifestations and higher SLEDAI values may achieve clinical remission.

Mild presentation of systemic lupus erythematosus in elderly patients assessed by SLEDAI. SLE Disease Activity Index.

OBJECTIVE: Systemic lupus erythematosus (SLE) predominantly affects young patients. SLE starting in later life has a clinical presentation different than in younger patients. We have used the SLE Disease Activity Index (SLEDAI) to explore the relationship between age of onset and disease activity. METHODS: We selected all patients controlled in our hospital at the moment of clinical diagnosis of SLE (100 patients; 85 females and 15 males). They were classified in two groups: those with early onset (>50 y) and those with late onset (>50 y) based on their age at the moment of clinical diagnosis of SLE. RESULTS: In 12 patients the onset of SLE was >50 y (10 females and two males; mean age 59 y). The early onset patients had significantly higher SLEDAI values at the presentation and during the first year of disease with respect to elderly patients. Antibodies to DNA and hypocomplementemia were detected more often in younger patients. CONCLUSION: Our results confirm using SLEDAI, that the lupus of the elderly patients is a distinct clinical subgroup with a milder course of disease.

The association of dehydroepiandrosterone sulphate levels with bone mineral density in systemic lupus erythematosus.

OBJECTIVES: To evaluate, in premenopausal systemic lupus erythematosus (SLE) patients, the possible protective role of androgens on bone mass. METHODS: Bone mineral density (BMD) was measured in the lumbar spine and femoral neck in 37 women with SLE (mean age 31.1 years) without disturbances or therapy that could interfere with bone metabolism except glucocorticoid therapy. We measured serum intact parathyroid hormone (iPTH): 2.5 +/- 1.3 pmol/L, serum testosterone: 1.6 +/- 1.1 nmol/L, salivary testosterone: 0.09 +/- 0.1 nmol/L, and serum dehydroepiandrosterone sulphate (DHEAS): 2.2 +/- 2.2 umol/L. RESULTS: BMD in the spine (L2-L4) was 0.94 +/- 0.1 g/cm2 and in the femoral neck 0.77 +/- 0.1 g/cm2. Four patients (10.8%) had osteoporosis. We found a significant positive relationship between DHEAS and BMD, a negative relationship between DHEAS and the glucocorticoid dose at the time of study, and a negative correlation between iPTH and DHEAS. CONCLUSIONS: Bone loss in corticosteroid-treated premenopausal patients with SLE may be modulated through down-regulation of the endogenous production of DHEAS.

[Risk factors of arteriopathy of the lower extremities: lipid and not lipid factors]. / Factores de riesgo de la arteriopatía de las extremidades inferiores: factores lipídicos y no lipídicos.

BACKGROUND: The role of lipoproteins as markers of peripheral arterial disease (PAD) is not well defined. METHODS: We measured both lipid and non-lipid risk factors in 51 male patients with angiographically proven PAD and in 56 control subjects. The independent association of risk factors with PAD was evaluated by means of a multiple logistic regression analysis. RESULTS: The levels of cholesterol bound to high density lipoprotein (HDLc) and to its subfraction HDL2 were lower and triglycerides were higher in patients than in control subjects (1.0 +/- 0.3 vs 1.2 +/- 0.3, p < 0.003; 0.4 +/- 0.2 vs 0.5 +/- 0.3, p < 0.03; and 1.8 +/- 1.2 vs 1.3 +/- 0.7, p < 0.02, respectively). Total cholesterol and LDLc levels were similar in both groups. In the multiple logistic regression analysis that was done with lipid parameters, a statistically significant association of triglycerides (OR = 1.73; CI95% = 1.06-2.80) and HDLc (OR = 0.15; CI95% = 0.05-0.50) with PAD was observed, while HDL subfractions and apolipoproteins were not significantly associated. In the multiple logistic regression analysis that was done with non-lipid parameters, hypertension (OR = 5.35; CI95% = 1.86-15.4) and smoking (packs-year) (OR = 1.04; CI95% = 1.10-1.06) were the only significantly associated with PAD. When lipid and non-lipid parameters were included in the regression analysis, a statistically significant association between hypertension, smoking and HDLc with PAD was observed. CONCLUSIONS: Among lipid risk factors, a low HDLc and high triglycerides, and among non-lipid risk factors hypertension and smoking, are significantly and independently associated with lower limb arteriopathy.

[Osteonecrosis in systemic lupus erythematosus. Report of 3 cases]. / Osteonecrosis en el lupus eritematoso sistémico. Presentación de tres casos.

We present three cases of patients with systemic lupus erythematosus (SLE) and osteonecrosis or avascular necrosis (AV). Although, the pathogenesis of osteonecrosis is controversial and multifactorial, the glucocorticoids therapy is the most important factor contributing to the lesion. We report the clinical presentation of the three patients. We comment the characteristics of AV, the diagnosis and the treatment of this uncommon complication in SLE patients.

Clinicopathological correlations and prognostic factors in lupus nephritis.

OBJECTIVE: To define prognostic factors at the moment of the diagnosis in lupus nephritis, and to assess the contribution of renal histologic data. PATIENTS AND METHODS: Sixty-two patients with systemic lupus erythematosus (SLE) and histologic evidence of nephritis were studied for renal outcome. Correlations between clinical or biological and histological data were carried out as an indicator of the utility of the renal biopsy. RESULTS: There were no significant differences in creatinine between the different histologic classes at the moment of the diagnosis, although the WHO classification correlated well with proteinuria and immunologic activity. There was a strong correlation between clinical and histological activity as measured by the activity index in proliferative glomerulonephritis, mainly with creatinine and proteinuria, but not with haematuria or immunological activity. Young age at the time of renal biopsy, proliferative classes III and IV, and the chronicity index were associated with a poorer renal prognosis. CONCLUSIONS: High immunologic activity, mainly elevated anti-DNA titers and decreased levels of CH100, is highly suggestive of proliferative glomerulonephritis. Proliferative classes III and IV and high chronicity indexes are associated with a worse prognosis in lupus nephritis.

Bone mineral density and hormonal status in men with systemic lupus erythematosus.

A loss in bone mass was reported in premenopausal systemic lupus erythematosus (SLE) women, but this problem has not been studied in SLE males. We evaluated bone mineral density (BMD) in SLE males and the relationship between prolactin (PRL) and testosterone with BMD. We also studied the controversial effect of steroid therapy on BMD in these patients. We measured BMD in the lumbar spine and at the hip in 20 SLE men (mean age 37 y) and in the controls (n = 40). We measured PRL and testosterone in serum and saliva. The mean dose of prednisone at the time of study was 11.6 mg; and cumulative dose was 17.6 g. No significative decrease in BMD was detected in SLE males vs controls; either in the lumbar spine (1.00 +/- 0.1 vs 1.05 +/- 0.1 g/cm2) or in the femoral neck (0.84 +/- 0.1 vs 0.87 +/- 0.1 g/cm2). No patient or control had osteoporosis or fractures. We did not find any relationship between BMD and cumulative dose and baseline dose of corticosteroids. The mean values of PRL and testosterone (serum and salivary) were in the normal range. We did not find any correlation between BMD, PRL and androgens. This study did not show a loss in bone mass in SLE men on corticosteroid therapy.

[Antiphospholipid antibodies and epilepsy in patients with systemic lupus erythematosus]. / Anticuerpos antifosfolípido y epilepsia en los pacientes con lupus eritematoso sistémico.

OBJECTIVE: To verify the possible relationship between the presence of antiphospholipid antibodies (APLA) and the presence of epileptic seizures in patients with systemic lupus erythematosus (SLE). METHODS: A total of 168 patients with SLE were studied. Fifteen patients had antecedents of epilepsy which were non attributable to a cause other than SLE. Epilepsy was diagnosed on clinical and electroencephalographic grounds. Antibodies to cardiolipin (CLa) and lupus anticoagulant (LA) were measured. RESULTS: Epileptic seizures were generalized in 13 and partial in two patients. The lupus anticoagulant was positive in 40% of patients with epilepsy compared to 32% in the control group; CLa IgG in 53.5% compared to 65.6%, and CLa IgM in 40% compared to 35.2%. Differences were never statistically significant. Neither when patients with moderate/high CLa levels were studied. Seven patients (40%) had some of the classical manifestations of antiphospholipid syndrome. CONCLUSIONS: No association was found between positive APLA and epilepsy in patients with SLE.

[Bone mineral density in female patients with systemic lupus erythematosus treated with high glucocorticoid doses]. / Densidad mineral ósea en enfermas con lupus eritematoso sistémico tratadas con dosis altas de glucocorticoides.

OBJECTIVE: To study the bone mineral density (BMD) in premenopausal women with systemic lupus erythematosus receiving glucocorticoids (GL) and at 6 months, when the dose of GL was decreased to a level below half of the initial dose. METHODS: Twelve premenopausal women with SLE were prospectively studied after initiating prednisone therapy at a dose > or = 0.5 mg/kg/day. A densitometric study was performed (Hologic 1000 QDR) of the lumbar spine and femoral neck. Levels of osteocalcine (BGP), catacalcine (PDN-21), testosterone in plasma and saliva, and dehydroepiandrosterone sulphate (DHEAS) were measured. Measurements were repeated after 6 months. RESULTS: The initial mean dose of prednisone was 40 +/- 10.2 mg/day (0.66 mg/kg/day) with an accumulated dose of 27.6 +/- 23 g. Lumbar and femoral BMD were 1 +/- 0.13 and 0.831 +/- 0.07 g/cm2, respectively. A significant increase was observed in BGP an adrogen levels studied after a 6 months when the dose of GL was decreased to a mean dose of 13.9 +/- 7.5 mg/day (0.23 mg/kg/day), whereas no differences were found in BMD values. In none of the two phases of the study were osteoporosis, correlations between BMD and BGP, between PDN-21 and androgens or with the accumulated or punctual doses of GL documented. CONCLUSIONS: No decrease in BMD was observed after 6 months of therapy with high doses of GL. In contrast, an increase in BGP and androgenic status was observed when the GL dose was decreased.

PDN-21 in premenopausal women with systemic lupus erythematosus treated with glucocorticoids.

OBJECTIVE: To determine if there were changes in PDN-21 and calcitonin levels in women with systemic lupus erythematosus (SLE) treated with glucocorticoids. METHODS: Concentrations of PDN-21 and calcitonin were studied in 52 premenopausal women with SLE treated with glucocorticoids. Bone mineral density analysis was performed by dual energy x-ray absorptiometry. RESULTS: The values of PDN-21 in the SLE group were 354.6 +/- 230.6 pg/ml, significantly higher than healthy women (66.7 +/- 56.8 pg/ml) (p < 0.001). There was no difference in calcitonin values between the SLE and control groups. CONCLUSION: Glucocorticoid therapy in patients with SLE causes increases of PDN-21, probably due in part to the effect on the gastric mucosa of this treatment and subsequent secretion of gastrin.

[Herpes-zoster virus infection in patients with systemic lupus erythematosus]. / Infección por virus del herpes zoster en pacientes con lupus eritematoso sistémico.

The prevalence of infection with VZV in 145 patients with SLE was investigated, with a mean follow-up of 7.6 years; its relationship with different variables, particularly with therapy of the underlying disease, was analyzed. Twenty episodes of VZV infection in 19 patients were diagnosed (13.1%). In no case was the therapeutic regime changed nor was worsening of SLE observed. There was neither dissemination of herpes nor superinfection. An increase in the number of VZV infections was observed in patients with SLE under corticosteroid therapy (p = 0.04) and particularly when drug administration was on a daily basis (p = 0.00006). Cytotoxic agents also favored the infection (p = 0.0014). VZV infection is of a benign nature in SLE and its emergence is favored by immunosuppressive agents. The risk is lower if corticosteroid administration is on alternate days. There is no need to decrease therapy for SLE.

Loss of bone mineral density in premenopausal women with systemic lupus erythematosus.

OBJECTIVE: To evaluate bone mineral density (BMD) in premenopausal patients with systemic lupus erythematosus (SLE). METHODS: We measured BMD by dual energy x ray absorptiometry at lumbar vertebrae L2-4 and at the right femoral neck in 74 premenopausal white patients (mean age 30.8 years) with SLE who were receiving glucocorticoid therapy, and in a control group. RESULTS: The mean cumulative dose of prednisone was 32.5 (SD 28) g. The mean dose at the time of absorptiometry was 13.7 (6.9) mg. BMD was significantly reduced at the spine and at the femoral neck in SLE patients when compared with the control group: L2-4 = 0.943 (0.1) g/cm2 v 1.038 (0.1) g/cm2 (p < 0.001); femoral neck = 0.766 (0.09) g/cm2 v 0.864 (0.1) g/cm2 (p < 0.001). Nine patients (12.1%), but none of the control group, had a BMD less than the reference range. CONCLUSION: BMD in premenopausal patients with SLE was less than that in a control group and less than the reference range of values defining the presence of osteoporosis in 12.1%. We did not find a relationship between BMD and either cumulative or baseline dose of corticosteroid therapy.