Clinical problem‐solving: ‘persistent knee arthritis and prolonged fever in a lupus patient’

Salmonella infections occur more frequently among immunocompromised patients such as those with systemic lupus erythematosus (SLE), with high propensity for extra‐intestinal, including osteoarticular, involvement. Hemarthrosis following trauma, typhoid fever and septic arthritis of the knee developed in a 20‐year‐old female lupus patient with pulmonary hypertension, maintained on corticosteroids and warfarin. This article takes the reader through the clinical problem‐solving process with an SLE patient whose illness is confounded by prolonged fever, with manifestations indistinguishable from that of either lupus activity and/or an infection. Early diagnosis, appropriate antibiotics, and if necessary, surgical intervention are essential principles of management to improve prognosis and prevent long‐term disabilities such as destructive arthropathy.     

A 1‐year study of two doses of steroid in combination with methotrexate and chloroquine in the treatment of patients with mild and moderate systemic lupus erythematosus

Aim: This is a retrospective study on the efficacy and adverse effects of treating mild or moderate systemic lupus erythematosus without major organ involvement using small dosage prednisone combined with MTX and chloroquine (PMC). Methods: As a retrospective 1‐year follow‐up study, clinic outpatients (Rheumatology Department, Renji Hospital, Shanghai, China) were divided by predinisone dose (Group A, prednisone ≤ 0.2 mg/kg/d; Group B prednisone 0.5–0.6 mg/kg/d). All patients (N = 30 per group) were also administered methotrexate (7.5–10 mg/week) and chloroquine (250 mg/d). Efficacy and adverse effects of the two protocol drug regimens were compared. Results: The OUT Score of Group A was reduced from 2.10 ± 1.45 to 0.94 ± 0.73, and Group B from 2.93 ± 2.26 to 1.3 ± 1.29. The treatment was successful and there was no significant difference of efficacy between these two groups. However, the infection rate was much higher in Group B than in Group A (P < 0.001). Most infections occurred in the lung, while infections of the skin were recorded. There were also three patients who presented with Cushing syndrome in Group B. Aseptic necrosis of the femoral head was noted in Group B, but none in Group A. Conclusions: Systemic lupus erythematosus patients with mild or moderate activity, and without major organ involvement, can be controlled well with PMC. Otherwise, it was noted that higher doses of prednisone leads to more infections.     

Risk of new-onset glaucoma in patients with systemic lupus erythematosus: A nationwide,population-based cohort study

To explore the relationship of systemic lupus erythematosus (SLE) and subsequent glaucoma incidence. Patients with SLE were defined as those newly diagnosed by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 710.0 in at least 3 outpatient visits or 1 hospitalization during 2000–2012 by using the National Health Insurance Research Database. We selected a non-SLE comparison cohort at a 1:1 ratio by propensity score matching on age, gender, index date, comorbidities and medications. We identified outcome as the incident glaucoma in patients with SLE. Multivariate Cox regression analysis was used to calculate the adjusted hazard ratio (aHR) in 2 groups. Kaplan- Meier analysis was performed to estimate the cumulative incidence rate between both groups. There were 1743 patients who were included in the SLE group and non-SLE group. The aHR of glaucoma was 1.56 (95% CI = 1.03–2.36) in the SLE group, compared to non-SLE controls. Subgroup analysis showed that SLE patients present greater risk of glaucoma, especially in males (aHR = 3.76; 95% CI, 1.5–9.42), and the P for interaction between gender and risk of glaucoma was 0.026. This cohort study showed that patients with SLE have 1.56-fold risk of glaucoma development. Gender acted as an effect modifier between SLE and the risk of new-onset glaucoma.     

Survival rate among Thai systemic lupus erythematosus patients in the era of aggressive treatment

Background: The major cause of death in systemic lupus erythematosus (SLE) is due to the disease activity itself or infection. It is uncertain whether the treatment approach during the last decade prolonged survival in SLE. Objective: Our objective was to identify the causes of death and the factors predictive of mortality and to calculate the survival rate among SLE patients. Method: We conducted a retrospective study of SLE patients followed up at Srinagarind Hospital, Khon Kaen University, Thailand, between January 1, 1996 and August 31, 2005. Cox regression analysis was used to estimate the probability of survival and assessing factors associated with death. The medical records of 749 SLE patients were reviewed; 66 patients died during the follow‐up period. Results: The mortality rate was 1.2 per 100 person‐years. The 5‐ and 10‐year survival rate among our SLE patients was 93% and 87%, respectively. The mean age at death was 34.08 ± 11.75 years and the median disease duration was 48 (1–336) months. One‐third of the cases were referred from a local hospital more than 1 month after onset and were associated with a significantly higher risk of mortality than cases referred earlier (P = 0.047). The most common causes of death were opportunistic pulmonary infections and neuropsychiatric lupus. Factors predictive of mortality included: (i) major organ flare more than four times per year; (ii) age at onset > 50 years; (iii) high‐dose steroid use and/or immunosuppressive therapy at onset and within 2 weeks prior to death; and (iv) concomitant diabetes mellitus. Protective against mortality was antimalarial use.     

Estimation of monocyte‐chemoattractantprotein‐1 (Mcp‐1) level in patients with lupus nephritis

Aim: To evaluate the use of non‐invasive estimation of CP‐1 in urine as a good indicator for lupus nephritis activity. Methods: The study was conducted on 30 patients with systemic lupus erythematosus (SLE) (group I): 15 of these patients were selected without renal involvement (group I [A]), and the other 15 were selected with evidence of renal involvement (group I [B]). Further 10 age‐ and sex‐matched healthy subjects were taken as a control group (group II). The SLE disease activity index (SLEDAI) was applied. Laboratory investigations done for the studied group of patients included: renal function tests (antinuclear antibody) titer, (anti‐double‐stranded DNA) titer, and monocyte chemotactic protein 1 (MCP‐1) level in serum and urine samples. Results: Serum MCP‐1 was significantly higher in SLE patients with nephritis than in the control group, while no significant difference was found between SLE patients without nephritis and the control group. Urinary MCP‐1 in patients with active lupus nephritis (LN) were significantly higher than both patients with inactive LN and control the group. Urinary MCP‐1 in SLE patients with nephritis was significantly higher than both group I (A) and group II. Urinary MCP‐1 correlated positively with proteinuria, and negatively with creatinine clearance and hemoglobin; thus, urinary MCP‐1 correlates with the severity of nephritis. Conclusion: Urinary and not serum MCP‐1 is a useful invasive technique for the assessment of renal disease activity in patients with LN.     

A 35‐year follow‐up of a large cohort of patients with primary biliary cirrhosis seen at a single centre

Background: The natural history of primary biliary cirrhosis (PBC) is still debated. Aims: To evaluate: (i) long‐term survival in a large cohort of PBC patients observed prospectively at a single centre and (ii) mortality in relation to baseline characteristics and ursodeoxycholic acid (UDCA) treatment. Methods: We considered all consecutive patients between 1973 and 2007 (327 subjects; 310 females, 17 males). Results: The mean follow‐up was 9.1±7.7 years. The patients' age at diagnosis for representative periods (1973–1980, 1981–1990, 1991–2000, 2001–2007) increased progressively from 47.7±1.5 to 53.2±1.2, to 65.2±2.1 and then 63.6±2.9 years. The proportion of asymptomatic patients at diagnosis increased from 30 to 48% in the last decade, while associated symptoms of extrahepatic autoimmunity remained unchanged. Eighty patients (24.4%) died, 74 of them because of liver failure (12 patients developed hepatocellular carcinoma); nine patients underwent liver transplantation. From 1988 onwards, all patients were treated with UDCA (n=288). The mean age at death for the sample as a whole was 67.2±1.3 years. The survival probability at 20 years was 82% for patients with histological stages I–II at entry, 64% for those with stage III and 42% for those with stage IV (P=0.0007). Mortality was significantly reduced in patients treated with UDCA (P=0.012), whereas it was independently associated with oesophageal varices (P=0.015). Patients treated with UDCA had a better prognosis than those untreated, irrespective of the histological stage. Early treated subjects with a good response to UDCA have an 85% chance of survival at 20 years. Conclusions: The clinical presentation of PBC has been changing over the years. Its early detection and early treatment improve the related survival rates.