Neurology -- Correspondence for Ainiala et al., 57 (3) 496-500

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Correspondence published:

Reply to Letter to the Editor: Hanna Ainiala (15 March 2002)

The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus: Ignacio Casas Parera, Sara Malagold (15 March 2002)

Reply to Letter to the Editor 15 March 2002

Hanna Ainiala
Tampere University Hospital Tampere Finland
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Re: Reply to Letter to the Editor

jukkaps{at}koti.tpo.fi Hanna Ainiala

We thank Dr Malagold for her interest in our paper. Malagold et al. and our group have studied the prevalence of neuropsychiatric syndromes in SLE patients. We believe that the main reason for differences in the results is caused by different patient selections. Our study was based on a population-based cohort of patients. As a result, the number of patients with a milder form of SLE was considerable (mean activity index ECLAM was only 1.6; only 54% of patients were receiving glucocorticoids vs all patients in Dr Malagold`s study). Also in former studies, the prevalence rates have ranged widely reflecting differences in selection of patients for study, and therefore there has been a need for a population- based study. [1, 2] Patient selection for Dr Malagold`s study was not described in the correspondence, but we assume that the patients had been recruited from the academic referral centers only.
Dr Malagold was also interested in what kind of neuropsychological tests were used in our study. Because the length of the article was limited, the tests were not described, but they are available on the Neurology website (www.neurology.org).
References
1.Mc Cune WJ, Golbus J. Neuropsychiatric lupus. Rheum Dis Clin North Am 1988;14:149-167.
2.Hanly JG, Liang MH. Cognitive disorders in systemic lupus erythematosus: epidemiologic and clinical issues. Ann NY Acad Sci 1997;823:60-68.

The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus 15 March 2002

Ignacio Casas Parera
Buenos Aires Argentina,
Sara Malagold
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Re: The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus

escabio08{at}yahoo.com Ignacio Casas Parera, et al.

We have read with interest the article by Ainiala et al. [1] describing the prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neuropsychiatric syndrome may be present in SLE patients (more than 50%) and not only throughout serious manifestations such as seizures and psychosis but in more other subtle ways, as cognitive impairment and mood disorder, even in neurologic or psychiatric asymptomatic patients. [2,3] In this study, only 14 of 37 patients (38%) tested with cognitive dysfunction had cognitive problems. We had studied 15 SLE women in a control group, with a mean age of 27.8 ± 6.35, mean disease duration since diagnosis of SLE of 4.8 ± 3.5 years and mean level of education of 11.7 � 6.3 years. [4] At the time of the study all patients were receiving low dose of prednisone (10-15 mg daily). In our experience, in a small sample size study, all patients with no cognitive or depressive complaints have shown abnormalities in cognitive ability in several domains and depressive diagnosis according to neuropsychological standardised testing. This high prevalence of cognitive impairment and depressive manifestation in SLE patients, without neuropsychiatric symptomatology, provides evidence of sub-clinical CNS involvement in SLE.
Moreover, we find a high correlation between depression and patient�s history of psychosocial stressors experience. Seventy per cent of the patients in this study classified as having mild cognitive impairment (only one or two had cognitive domain dysfunction) and 80% of patients with mild depression required no medication. The results of our study suggest a prevalence of severe cognitive impairment (declination in three or more domains) and moderate depression. It would have been convenient to describe the neuropsychological tests you used in order to discriminate and deepen the cognitive dysfunction. Compared to Ainiala�s et al. study, ours showed a higher evidence of CNS involvement according to the cognitive deficits we found. Our patients showed 2SD declination in Executive Functioning (abstract reasoning: WAIS-R and set shifting/suppressing response: Stroop Test), Language (verbal fluency: FAS) and Memory (Verbal: BVSRLT, Visual: BVLT and Logical: WMS). Focalised auditive attention (Digit Span Test), divided concentration (Trail Making Test A&B), comprehension and nomination (Boston Naming Test), general praxias (WAB) and constructional praxia (Wechsler Intelligence Scale) were also tested. No significant differences were observed between both groups. Mood disorder records showed a 73.3% of patients (11/15) with depressive disorder, 53.3% mild depression and 20% moderate depression. Therefore, we conclude that cognitive and depressive symptoms that had remained unnoticeable to the clinical eye appeared to be severe enough, even to anticipate brain lesions in a CT or MRI. We agree with Ainiala et al. that more work must be done in order to determinate the effects of long lasting medication, even in low dose, on CNS functioning and neuropsychiatric manifestations.
References:
1. Ainiala H, Loukkola J, Peltola J, Korpela M, Hietaharju A. The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neurology 2001;57:496-500.
2. Ferstl R, Niemann T, Biehl G, Hinrichsen H, Kirch W. Neuropsycological impairment in autoimmune disease. Eur J Clin Invest 1992;22(Suppl1):16-20.
3. Hanly JG, Fisk JD, Sherwood G, Jones E, Jones JV, Eastwood B. Cognitive impairment in patients with systemic lupus erythematosus. J Rheumatol 1992;19:562-567.
4.Malagold S. Compromiso neuropsicol�gico en pacientes con lupus eritematoso sist�mico (LES) neurol�gicamente asintom�ticos. Rev Neurol Arg 1996;21(Suppl II):43.