Antonio Fraga

Acute Abdomen in Systemic Lupus Erythematosus: The Importance of Early Laparotomy

BACKGROUND Acute abdomen (AA) in systemic lupus erythematosus (SLE) is a challenging diagnostic and therapeutic problem. Most patients are on steroid and/or immunosuppressive treatment and mortality is high. METHODS We assessed the relationship between the causes of AA in SLE and the SLE disease activity index (SLEDAI). RESULTS Of 51 patients with SLE and AA, 36 had active disease (Group 1) and 15 inactive disease (Group 2). Group 1 included 19 patients with vasculitis (mean SLEDAI 15.4, range 13 to 24). Three patients with intraabdominal thrombosis and high titers of anticardiolipin antibodies (mean SLEDAI 18.3) and 14 patients with non-SLE-related AA (SLEDAI 8.2, range 5 to 11). Group 2 consisted of 15 inactive SLE patients (mean SLEDAI 1.7, range 0 to 4). Mortality was high in the active group (14 patients) compared with inactive SLE (2 cases). A delay in surgical exploration (39.3 vs 178.6 hours) had a negative influence on the prognosis. CONCLUSIONS In SLE patients with AA, a SLEDAI score below 5 is indicative of non-SLE-related AA. Elevated aCL were found in patients with intraabdominal thrombosis. AA in inactive SLE is non-SLE-related and has low mortality, provided an appropriate surgical treatment is given. Early laparotomy influences positively the prognosis of SLE patients with AA.

Prolactin, immunoregulation, and autoimmune diseases

Cells of the immune system synthesize prolactin and express mRNA and receptors for that hormone. Interleukin 1, interleukin 6, gamma interferon, tumor necrosis factor, platelet activator factor, and substance P participate in the release of prolactin. This hormone is involved in the pathogenesis of adjuvant arthritis and restores immunocompetence in experimental models. In vitro studies suggest that lymphocytes are an important target tissue for circulating prolactin. Prolactin antibodies inhibit lymphocyte proliferation. Prolactin is comitogenic with concanavalin A and induces interleukin 2 receptors on the surface of lymphocytes. Prolactin stimulates ornithine decarboxylase and activates protein kinase C, which are pivotal enzymes in the differentiation, proliferation, and function of lymphocytes. Cyclosporine A interferes with prolactin binding to its receptors on lymphocytes. Hyperprolactinemia has been found in patients with systemic lupus erythematosus. Fibromyalgia, rheumatoid arthritis, and low back pain patients present a hyperprolactinemic response to thyrotropin-releasing hormone. Experimental autoimmune uveitis, as well as patients with uveitis whether or not associated with spondyloarthropathies, and patients with psoriatic arthritis may respond to bromocriptine treatment. Suppression of circulating prolactin by bromocriptine appears to improve the immunosuppressive effect of cyclosporine A with significantly less toxicity. Prolactin may also be a new marker of rejection in heart-transplant patients. This body of evidence may have an impact in the study of rheumatic disorders, especially connective tissue diseases. A role for prolactin in autoimmune diseases remains to be demonstrated.

Infections in outpatients with systemic lupus erythematosus: a prospective study

The objective of this study was to assess the incidence and risk factors of infections in 200 SLE outpatients. All outpatients with active or inactive SLE without infections in the previous month were included. They were assessed every 3 months. Major infections were those requiring hospitalization and parental antibiotic therapy; minor infections required oral or topical therapy. Sociodemographic, disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), therapy and laboratory variables were evaluated. After a follow-up of 22 7 months, 65 (32%) patients had infections; 35% of those were major. The most common sites for infection were urinary (26%), skin (23%), systemic (12%), and vaginal (9%). At infection onset, 50 of 65 patients (77%) had disease activity, with a mean SLEDAI score of 6.1. The variables signifycantly associated with infection in the univariate analyses were the presence of disease activity, SLEDAI score, renal activity, prednisone dose, and IV cyclophosphamide. The only variable associated with infection in the multivariate analyses was a SLEDAI score of 4 or higher. Most infections in SLE outpatients were single, minor, non-life threatening, and associated with disease activity independently of sociodemographic and therapeutic factors.

Measurement of damage in 210 Mexican patients with systemic lupus erythematosus: relationship with disease duration

The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index is a validated instrument specifically designed to ascertain damage in SLE; this instrument has been applied mainly to Caucasians and African-American SLE patients. The objective of this study was to assess damage using the SLICC/ACR Damage Index in Mexican SLE patients. The SLICC/ACR Damage Index was applied to 210 consecutive SLE patients with disease of variable duration. The SLICC/ACR Damage Index was assessed by review of hospital clinical records, interview and physical examination. One hundred and seventeen (55.5%) patients had some damage. The proportion of patients with damage increased significantly with disease duration (33% at 1–60 months, 66% at 61–120 months and 70% at ≥121 months, P < 0.001). The main organ systems involved were musculoskeletal (osteonecrosis), neuropsychiatric (neuropathy, seizures), gonadal (amenorrhea prior to age 40 years), ocular (cataracts), renal (glomerular filtration < 50%) and peripheral vascular (permanent damage by venous thrombosis). Damage was frequent, increased over time, particularly for ocular, renal, musculoskeletal and gonadal. Patients who experienced damage were older, had a longer disease duration, a greater number of ACR criteria at diagnosis, and were more likely to have renal involvement and antibodies to dsDNA. The damage occurred in many different domains and started to develop early after disease onset. Mexican patients had more peripheral vascular and gonadal involvement compared with published data from non-Hispanic SLE populations.

Severe osteoarthritis of the elbow in foundry workers.

Foundry workers who used tongs for lifting and twisting metal rods develop severe osteoarthritis (OA) of the elbows. The main symptom was limitation of motion with an average loss of 45° for extension, 60° for flexion, 20° for pronation, and 10° for supination. Spontaneous pain was characteristically absent, and radiological changes were those of degenerative joint disease. A new mechanism of OA of the elbow is proposed: an increase in the length of the arm lever renders it less efficient and requires greater force which results in increased tangential (shearing) friction on the joint cartilages, and leads to early and progressive derangement of the joint. This should be considered an occupationally related disability.

Submicroscopic alterations in capillaries of skeletal muscles in polymyositis

Abstract Electron microscopic changes in capillaries of muscle are described in four patients with polymyositis. Marked thickening and lamination of basement membrane and various degrees of endothelial swelling, to the point of causing obstruction of the lumen, were found when compared to control subjects.

Renal biopsy in systemic lupus erythematosus: significance of glomerular thrombosis. Analysis of 108 cases.

We investigated the frequency and distribution of glomerular thrombosis (GT) in 108 renal biopsies of lupus patients and correlated this finding with the presence of anticardiolipin antibodies (ACLA). GT was present mainly in the diffuse proliferative form. The activity index was higher in those patients with GT (12.9 ± 4.7 vs 5.4 ± 4.1, P < 0.01). The more severe histologic features, necrosis and extracapillary proliferation were also related with GT. In 18 cases with repeated biopsy the best predictors for the subsequent development of glomerular sclerosis were fibrinoid necrosis (P < 0.01), glomerular infiltration (P < 0.01) and an activity index of 10 or more (P < 0.05). GT also showed to be an important prognostic factor for sclerosis, although no statistically significant. ACLA were investigated in 36 patients at the time of renal biopsy. There were nine positive cases and in three of them this finding was related to GT. We can conclude that GT is a relevant feature showing active lupus nephritis and that it is not related to the presence of ACLA.

Ultrastructure of muscle in polymyositis

Abstract The present observations on the ultrastructure of muscle fibers in polymyositis offer little basis for classification of different subtypes. Except for the lymphocytic and plasma cell infiltrates seen in a case associated with Sjogrens syndrome, the muscle lesions appeared much the same irrespective of the clinical type of polymyositis or its association with malignancy or some other connective tissue disease.

Gastro-intestinal bleeding in patients with rheumatoid arthritis: the effects of azapropazone treatment.

A comparative study was carried out, using the Cr51 red blood cell labelling method, to assess the amount of gastro-intestinal blood loss in 20 rheumatoid arthritis patients taking either 600 mg. or 1200 mg. azapropazone daily. The results demonstrate that azapropazone does not produce greater than normal gastro-intestinal bleeding, that the volume of faecal blood loss is not dose-related, and there would not appear to be any correlation between blood loss and the occasional mild gastro-intestinal side-effects reported in a few patients. These results compared favourably with those obtained previously by the investigators in a similar group of patients taking 3 g. aspirin per day.

Factores de riesgo relacionados con lupus eritematoso sistémico en población mexicana

Objetivo. Evaluar los factores de riesgo asociados con el desarrollo de lupus eritematoso sistemico en poblacion mexicana. Material y metodos. Estudio de casos y controles, efectuado en junio de 1996 en el Departamento de Reumatologia del Hospital de Especialidades del Centro Medico Nacional Siglo XXI (HE CMN), del Instituto Mexicano del Seguro Social, de la Ciudad de Mexico. Se estudiaron 130 pacientes (casos) que presentaban cuatro o mas criterios de clasificacion de lupus eritematoso sistemico (LES) y con una evolucion de la enfermedad menor de cinco anos. Los controles fueron pacientes hospitalizados por enfermedades agudas no autoinmunes. Fueron pareados 1:1 por edad y sexo; ambos grupos se evaluaron a traves de una entrevista directa y la aplicacion de un cuestionario estructurado. Se estudiaron los siguientes factores de riesgo: geneticos (historia familiar de LES o enfermedad de tejido conjuntivo), sociodemograficos (raza, lugar de residencia, educacion, ingreso mensual); hormonales (anticonceptivos orales, terapia hormonal de remplazo y ginecobstetricos); ambientales (productos para el cabello, cohabitacion con perros, infecciones, alergias). El analisis estadistico fue hecho con razon de momios (RM) IC 95% y regresion logistica. Resultados. El analisis estadistico multivariado mostro asociacion con el antecedente familiar de LES (RM 4.2, IC 95% 1.17-15.2) u otra ETC (RM 2.6, IC 95% 1.15-4.5), uso de anticonceptivos orales por mas de un ano (RM 2.1, IC 95% 1.13-4.3), faringoamigdalitis de repeticion (RM 2.1, IC 95% 1.18 - 3.6) y farmacos (RM 5.0, IC 95% 1.62 - 21.6). No hubo relacion con factores socieconomicos, el uso de productos para el cabello, con asma o con antecedentes alergicos. Conclusiones. Factores geneticos como el antecedente heredo-familiar de LES o enfermedad de tejido conjuntivo en familiares de primer grado continuan siendo factores importantes en el desarrollo de LES. Otros factores de riesgo como el uso de farmacos, uso de anticonceptivos orales, faringitis de repeticion, posiblemente interactuan en un huesped geneticamente susceptible para el desarrollo de la enfermedad.