Neuropsychiatric systemic lupus erythematosus events: An Asian African cosmopolitan study in a tertiary care university hospital

Abstract

This work aimed to study neuropsychiatric (NP) events related to systemic lupus erythematosus (SLE) in an Asian African cosmopolitan cohort attending a tertiary care university hospital. Medical records of 312 adults with SLE were retrospectively revised. Patients' from 14 Asian and 13 African countries were subgrouped according to the presence of NP manifestations. Electromyography and nerve conduction studies (EMG/NCS), electroencephalogram (EEG), computerized tomography and magnetic resonance imaging brain were considered. The systemic lupus international collaborating clinics damage index (SLICC-DI) was assessed. Patients were 275 females and 37 males (7.4:1), mean age 37.5 ± 12.7 years and disease duration 5.2 ± 3.2 years. 242 were Asian (150 Saudis) and 70 African. 279 were adult-onset, 26 juvenile-onset and 7 elderly-onset. NP manifestations were present in 48.4%. In NPSLE, magnetic resonance imaging brain showed white matter lesions (11.3%), infarction (9.9%), posterior reversible encephalopathy syndrome (5.2%),brain atrophy (1.3%) and vasculitis (2.6%); electromyography and nerve conduction studies revealed polyneuropathy (11.9%) and electroencephalogram epileptical changes in 3.3%. In NPSLE, lupus nephritis, receiving rituximab, SLICC-DI and mortality were significantly higher (53%, 16.6%, 1.94 ± 1.9 and 19.2% vs 36.6%, 8.1%, 0.54 ± 1.04 and 8.7%; P = .004, P = .02, P < .0001 and P = .008 respectively). NP manifestations were similar between Asians and Africans (47.1% vs 52.9%; P = .4). SLICC-DI was significantly lower in Saudis (0.88 ± 1.28) compared to non-Saudis (1.53 ± 1.91; P = .001). NP involvement is frequent in SLE patients especially females and is related to renal affection. Damage, mortality and receiving rituximab were significantly higher in those with NP manifestations. NP events are similar between Asian and African patients and damage in Saudis was remarkably less.

Keywords: Africa; Asia; Saudi-Arabia; damage; neuropsychiatric; systemic lupus erythematosus.

Figure 1.

Magnetic resonance imaging brain showing (A) multiple nonspecific white matter small foci of high signal intensities on FLAIR sequence and (B) with no restricted diffusion in diffusion weighted images, (C) restricted diffusion involving left midbrain indicating acute infarction (D) irregularity of middle and anterior cerebral arteries with possible vasculitis on MRI angiography, (E) posterior reversible encephalopathy syndrome (PRES) on axial FLAIR sequence showing bilateral occipitotemporal high signal intensity with (F) asymmetric frontal bilateral signal intensity mainly in the subcortical areas. FLAIR = fluid-attenuated inversion recovery.

Figure 2.

Systemic lupus international collaborating clinics damage index in patients with and without NPSLE, across disease onset, geolocation and Saudi vs non-Saudis. AO = adult-onset, EO = elderly-onset, JO = juvenile-onset, NPSLE = neuropsychiatric systemic lupus erythematosus.

Figure 3.

Receiver operating characteristic curve showing the moderate predictive potential of the SLICC-DI to determine neuropsychiatric involvement in SLE patients. At a damage score >0.5 it could significantly (P < .0001) discriminate, sensitivity 78.8% and specificity 67.1% at area under the curve 0.771. SLE = systemic lupus erythematosus, SLICC-DI = systemic lupus international collaborating clinics damage index.