Cognitive dysfunction in patients with systemic lupus erythematosus: The challenge in diagnosis and management

Cognitive dysfunction is one of the five psychiatric syndromes recognised by the American College of Rheumatologists neuropsychiatric lupus nomenclature committee. Cognitive dysfunction affects 20%–80% of systemic lupus erythematosus patients with and without overt central nervous system involvement. Specific cognitive dysfunction associated with systemic lupus erythematosus includes impairment in attention, memory and visuospatial process. Besides disease activity and vascular risk factors, the neuropathology behind cognitive dysfunction in systemic lupus erythematosus is a result of dysfunction involving the immune cells, cytokines, chemokines and autoantibodies (Abs), as well as volume reduction in the white matter and grey matter. In this review, we will discuss the challenges of using traditional neuropsychological assessment to assess cognitive function in clinical practice, the limitations of conventional neuroimaging methods, the controversies of using corticosteroids, other pharmacological treatments and non-pharmacological interventions to treat cognitive dysfunction associated with systemic lupus erythematosus.

Glucocorticoid-induced osteoporosis in systemic lupus erythematosus

Improvement in survival of systemic lupus erythematosus has been brought about with new advancement in treatment. However, glucocorticoids remain the sole cornerstone and as patients live longer, there is a need to address long-term complications brought by long-term glucocorticoid use such as osteoporosis. In this review, glucocorticoid-induced osteoporosis in systemic lupus erythematosus will be extensively discussed. This would include prevalence of osteoporosis in systemic lupus erythematosus patients, the difficulties in measuring fracture risk and pitfalls in using conventional methods such as bone mineral density. In addition, the mechanism of actions of glucocorticoids and evidence for glucocorticoids in the treatment of specific systemic lupus erythematosus manifestations would be explored and we also discussed specific pathophysiological mechanisms in the development of glucocorticoid-induced osteoporosis in systemic lupus erythematosus. We also reviewed the latest guidelines in the treatment of glucocorticoid-induced osteoporosis and the evidence for various osteoporosis medications. Finally, we recommend an approach in monitoring bone health and the treatment of osteoporosis specifically in systemic lupus erythematosus patients.

Demographic features and clinical aspects of Behçet’s disease in Omani patients

Objectives: Behçet’s disease is a chronic, relapsing, multisystem vasculitis of unknown etiology. Few reports support the hypothesis that Behçet’s disease has a primarily hereditary basis. It complicated diversified clinical features predominantly involving oral and genital ulcers, and ocular and cutaneous lesions. The clinical features of this disease have been described to be different according to geographical areas and gender. The objective of the study is to explore the demographic features and clinical aspects of Behçet’s disease in Omani patients and to compare the results with those of various reports in the region. Methods and results: In total, 56 Behçet’s disease patients were recruited, and clinical data parameters were recorded including age, sex, age at diagnosis, duration of symptoms till diagnosis, disease characteristics such as oral and genital ulcers, ocular manifestations, the presence of arthritis, and cutaneous lesions such as papulopustular lesions and erythema nodosum. Furthermore, other systemic involvement was studied including gastrointestinal, neurological, renal, and vascular manifestations. Laboratory tests of Behçet’s disease and treatment used were recorded in each patient. The onset was between 6 and 74 years with a male predominance. Oral ulcers were the most common manifestation, followed by genital ulcers, ocular lesions, and arthritis. Vascular lesions and gastrointestinal manifestations were less common. Cutaneous manifestations were rare in patients with Behçet’s disease. The frequency of neurological involvement was significantly high. There were no reported cardiac or urogenital manifestations. Conclusion: Behçet’s disease’s demographic features and clinical aspects in Omani patients showed quite significant geographical and gender differences which are comparable to other data in the area.

Comparison of structural magnetic resonance imaging findings between neuropsychiatric systemic lupus erythematosus and systemic lupus erythematosus patients: A systematic review and meta-analysis

Introduction: Neuropsychiatric systemic lupus erythematosus is often clinically challenging to diagnose, treat and monitor. Although brain magnetic resonance imaging is frequently performed before lumbar puncture in neuropsychiatric systemic lupus erythematosus, it is not clear from the literature whether specific brain magnetic resonance imaging findings are associated with distinct clinical features of neuropsychiatric systemic lupus erythematosus. Methods: We conducted a systematic review and meta-analysis on published studies of neuropsychiatric systemic lupus erythematosus including brain magnetic resonance imaging and the 1999 American College of Rheumatology-defined clinical neuropsychiatric systemic lupus erythematosus syndromes to determine their relationship. Pooled prevalence and risk ratio for distinct neuropsychiatric systemic lupus erythematosus associations were determined with 95% confidence intervals. Results: Of 821 studies screened, 21 fulfilled inclusion criteria. A total of 818 participants were evaluated (91% female) with 1064 neuropsychiatric systemic lupus erythematosus episodes assessed. Neuropsychiatric systemic lupus erythematosus features included headache (24%), seizures (19%), cerebrovascular disease (18%), cognitive dysfunction (15%) and acute confusional state (14%). Normal magnetic resonance imaging was significant for anxiety disorder (risk ratio: 9.00; 95% confidence interval: 2.40, 33.79), autonomic disorder (risk ratio: 7.00; 95% confidence interval: 0.51, 96.06) and plexopathy (risk ratio: 5.00; 95% confidence interval: 0.81, 31.00). Highest risk ratio of neuropsychiatric systemic lupus erythematosus syndrome with abnormal magnetic resonance imaging was observed for cerebrovascular disease (risk ratio: 0.15; 95% confidence interval: 0.10, 0.24) and demyelination (risk ratio: 0.11; 95% confidence interval: 0.02, 0.72). Conclusion: Normal magnetic resonance imaging in neuropsychiatric systemic lupus erythematosus was the most significant correlate from our meta-analysis for psychological symptoms including anxiety and peripheral nerve features of autonomic disorder and plexopathy. The main abnormal brain magnetic resonance imaging correlates included cerebrovascular disease and demyelination. Brain magnetic resonance imaging correlates poorly with neuropsychiatric systemic lupus erythematosus features, and specific clinical symptoms should be the main determinants of performing magnetic resonance imaging rather than presence of neuropsychiatric systemic lupus erythematosus per se.