Clinical and radiological evaluation of systemic lupus erythematosus, Research question: Evaluation of lupus cases in corona infection

doi:10.21203/rs.3.rs-4950731/v1

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Clinical and radiological evaluation of systemic lupus erythematosus, Research question: Evaluation of lupus cases in corona infection

https://doi.org/10.21203/rs.3.rs-4950731/v1

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Introduction: Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by periods of remission followed by acute attacks. Its diagnosis is based on several criteria, the most recent of which is the European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) criteria, which is based on clinical manifestations in addition to a positive ANA titer.

Methods: A retrospective cross-sectional study was conducted on 385 patients at Al-Mowasat University Hospital, extending retrospectively from 2020 to the last month of 2023. The study included lupus patients who had pathological radiological findings based on clinical and laboratory signs and according to the international standards adopted in 2019. The focus was on studying lupus patients who developed COVID-19 during 2021-2022, with a total of 95 cases. The sample was selected from patients with proven lupus infection with a positive COVID-PCR, while patients whose study was not fully completed were excluded.

Results: It was noted that clinical symptoms and radiological manifestations worsened in COVID patients who had a previous and chronic infection with systemic lupus erythematosus compared to COVID patients who did not have lupus. The study confirmed parenchymal infection in most cases in lupus and the appearance of typical signs in the stratified layer diagnostic of Corona, which are: the spread of glass-covered densities in the peripheral sections The background of the lungs with multiple focal condensations 92% in patients with Covid with a previous infection with lupus in addition to thickening of the diaphragm 65% with bronchiectasis 33% and enlargement of the mediastinal phlegm nodules 35%

Conclusion: Lupus is a multisystemic disease that requires accurate diagnosis and follow-up, the necessity and use of appropriate radiological methods for diagnosis, not neglecting any complaint in lupus patients, and attention to the areas of Covid in lupus patients.

Rheumatology

Lupus erythematosus

radiological diagnosis

clinical manifestations

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects multiple body systems. It is characterized by periods of remission followed by acute attacks. All genomic studies have confirmed that patients have a genetic predisposition to develop the disease, in addition to the association between genes and environmental factors with the immune response. Tissue damage results from autoantibodies or immune complex deposits in the kidneys, heart and blood vessels, central nervous system, skin, lungs, muscles and joints. [1.2]

MRI is used to detect erosions and deformities around the joint in the early stages of the disease, and it also detects synovitis with high sensitivity. Ultrasound allows for the evaluation of the joints and surrounding soft tissues in real time at a low cost and without ionizing radiation. It is more sensitive to erosions than plain radiography and can be more sensitive than clinical examination. However, MRI has the advantage over other techniques in imaging bone marrow edema (BME) and detecting any other inflammation, in addition to the ability to detect more erosions by taking advantage of multiplanar imaging. And access to all bone surfaces. [3]

A study at Al-Mowasat University Hospital extended retrospectively from 2020 until the last month of 2023 by reviewing the files of patients admitted to the internal medicine departments and diagnosed with lupus erythematosus clinically and laboratory. The focus of our study is on the radiological findings of lupus cases, where 385 patients diagnosed with lupus erythematosus were monitored based on clinical and laboratory signs and according to the international standards approved in 2019.

Inclusion criteria: Lupus patients who had various pathological radiological findings (bone-urinary-cerebral).

Exclusion criteria: Lupus patients whose radiological examinations were negative and patients whose study was not fully completed.

The type of study is retrospective, where the files were reviewed and the study was completed in the Radiology Department by reviewing the archived images in the Radiology Department on the various radiological image archiving storage station in the PACS network.

The number of patients who were monitored and diagnosed with lupus clinically and laboratory was 385 patients. The focus was on the radiological findings seen in lupus or lupus complications. The number of samples studied radiologically was 156 patients. The percentage of males was 20% and the percentage of females was 80%. The most common infection is in women and the peak infection is at the ages of 25–35 years. Women under the age of 40 years were 86%.

Statistical Analysis:

it was entered and processed using the statistical package SPSS-26. To describe the basic features of the data in the study through frequencies and percentages, the chi-square test (χ2), P-value < 0.05 was adopted as a statistically significant value.

Clinical symptoms: Their percentages only in the sample included in the study (156):

Weight loss 15%, fatigue 45%, joint pain 77%, skin rash 45%, sensitivity to light 44%, digestive symptoms 20%, neurological and psychological symptoms 10%, urinary symptoms 25%, pulmonary symptoms 37%.

Pulmonary and chest injuries in lupus patients according to our study:

Pleural effusion 50%, pericardial effusion 48%, pleural empyema 3%, chest pain with pleural effusion 65%, dyspnea with pleural effusion 72%, fever 55%, cough 30%.

The parenchymal injury seen in the CT scan is non-specific. The most important observations are:

1- Interstitial injuries 35%

2- Honeycomb view 33%

3- Thickening of the interalveolar septa 42%

Pulmonary hypertension was diagnosed radiologically based on the expansion and congestion of the pulmonary umbilicus on the chest X-ray and the CT scan. The simple chest X-ray revealed congestion in 5%, congestion and vascular dilatation appeared on the CT scan in 15%, and a radiological sign seen in cases of pulmonary hypertension, which is the pulmonary mosaic pattern, was evaluated in 25%. A pulmonary embolus was also discovered accompanying cases of pulmonary hypertension and was of the chronic type, accounting for 13% of cases. The dilated pulmonary artery exceeded 47 mm in diameter, and cardiomegaly at the expense of the right atrium with thickening of the ventricular septa in 22%. Lupus was accompanied by sepsis and pneumonia of various forms in 50% of cases. Skin manifestations were observed in 71% of all patients:

Malar rash 49%, discoid rash 26%, photosensitivity 33%, oral ulcers 43%.

The incidence of joint disorders in patients' files was high, reaching 68%, which seems lower than the rates of global studies, perhaps due to the prevalence of joint pain in our country and its neglect.

Kidney injuries based on clinical examination, urine examination and echo 27%.

Neurological disorders (radiologically) 13% and psychological disorders 14%.

Acute, chronic and non-specific joint complaints and pain 95%.

Neurological manifestations (clinically) 45%, disability 6.6% and globally the percentage is higher reaching 50%, anxiety 25%, headache 28%, stroke 15%, seizures 20%, myelopathy 9%, demyelinating lesions 4%, aseptic meningitis 2%. Neurological injury in our study was seen in 45% of patients and compared to the medical literature the percentage ranged from 15–75%.

Laboratory: ANA antibodies positive in 85% and globally reaching 99%, ds-DNA antibodies positive in 85% and globally reaching 98%, unexplained anemia 29% compared to global studies seems less as the percentage reaches 60%, thrombocytopenia 4%.

Radiological investigations used in the study of lupus erythematosus:

Plain radiographs 60% (bone and joint imaging - plain chest)
Ultrasonography 35%, especially urinary ultrasound
Computed tomography 77%
Magnetic resonance imaging 10% and imaging was done for specific indications such as (tendon study - brain MRI).

Plain radiograph:

A chest radiograph was performed in all 100% of patients and the pathological findings observed in 35% included pleural effusion, pneumonia and pulmonary artery enlargement.

Bone and joint radiographs 95% of patients and the findings were: hypocalcification around the joints 76%, swelling of the soft tissue around the joints 34%, erosion of the joint margins 35%, detection of MacLeod's deformity 30% with an anteroposterior and oblique hand (wrist) and Norgaard ball-bearing position.

Radiographic signs on plain radiographs of bones and joints were classified and monitored in addition to the previous signs:

Hypocalcification accompanied by joint narrowing (dislocation) by 25%
Non-destructive deformity (Jaccoud arthropathy) 46%
Sclerosis of the edges with articular ends 34%
Joint infection and joint effusion 14%
Muscle calcifications 7%

Echocardiography:

Joint effusion (clear, homogeneous, anechoic fluid) 23%
Joint effusion (turbid fluid) 5%
Synovial membrane thickening 25%
Synovial membrane hyperperfusion (Doppler) 44%
Joint capsule edema 33%
Tendon sheath thickening 14%

Echocardiography shows greater sensitivity than plain radiographs in assessing bone metastases, which are moderate in cases of lupus arthropathy.

A study was conducted on cases of lupus patients who developed COVID infection. Cases were mentioned and monitored during 2021 and 2022. The number of cases mentioned in the patients' files was 95. The sample was selected from patients who had proven lupus infection with a positive COVID PCR and positive radiological signs. Typical signs were observed in the CT scan that diagnoses Corona, which are: the spread of ground-glass densities in the peripheral and posterior sections of the lungs with multiple focal densities. The following chart shows a comparative study between the radiological signs in the CT scan in COVID patients and the radiological signs in lupus patients infected with COVID:

Comparing our study with the global study where Lagnocco and his group conducted a prospective study on 62 lupus cases and focused on MTP joint involvement, the study was published in Radiology in 2023, cases of joint effusion, synovial hypertrophy and swelling, and synovitis were seen in 72.6%. In comparison with our study, the percentages seem close.

Following Lagnocco's study, cases of synovitis were more common and more common with hypertrophy and were seen alone in 80% and using Power Doppler, they were seen in 10%. In comparison, the results of our study with the echo appear to be lower than global studies. When the supervisor was asked, he answered that the sensor used had a frequency of 7.5 MHz, and there is a sensor specific to the joints with a frequency of 12 MHz (disabled), which limits the results. In general, the findings of the echo are non-specific because they are seen in other joint injuries such as: rheumatoid arthritis and psoriatic arthritis, and various pathological events are observed in the context of the infection, as the joints and soft tissues around them are affected by the disease and findings are observed in the early stages.

When searching the medical literature, we found the results of our study on lupus arthritis consistent with an old study conducted in 2017 by Coccarellia and published in Arthritis & Rheumatology, issue (42).

Cases of renal disease in lupus were evaluated by echography with a convex probe at a frequency of 3.5 MHz. The sensitivity of the echo is 92% globally and 82% in our study.

The observed echo signs:

♣ Disturbance in kidney size (nephromegaly 34% - micronephropathy 15%).

♣ Cortical-pulpal deficiency 82%.

According to Pubmed articles, the sensitivity exceeded 95%.

The results of the study were compared with the echo study conducted by Kasr Al-Aini University in Cairo, where the Egyptian study stated that the percentage of renal infection in lupus is 60%, and the study was applied by Doppler and blood flow study and the use of the normal resistance index of 0.6–0.7 in lupus, the resistance index in the renal arteries exceeded 0.6 in most patients, and the Egyptian study was consistent with the study of Al-Mowasat Hospital. The medical and international literature was reviewed, which confirmed the exacerbation of clinical symptoms and radiological manifestations in Covid patients who have a previous and chronic infection with systemic lupus erythematosus, studies confirmed parenchymal infection in most cases in lupus, and according to the study of Lie et al published in the Radiologic Society of North America (RSNA) (2023), it confirmed mentioning the radiological manifestations in lupus separately, which are: (clouded glass - lung in the form of a honeycomb - subpleural lines - thickening of the diaphragms) and their percentage was 66.6%. Pleural effusion in lupus is 61.5% and in corona it exceeds 80%, parenchymal injury includes condensation and macular infiltrates 25%, pulmonary hypertension 75%. By reviewing Pubmed articles on lupus and corona infections, 24 articles were identified, the average age of infection is 41 years, lupus nephropathy was mentioned in patients with severe Covid infections, as an article published in 2021 at Kebangsaan University in Malaysia was mentioned, and other articles by Clendelien and Mostero showed a rate of lupus nephropathy of 30%, and according to our study, the rate of lupus nephropathy with corona reaches 10% with kidney cases accompanied by pulmonary fibrosis. From a review of the medical literature from the National Library and Pubmed sources, it was found that the cases in which lupus appeared after Covid developed over a period of time estimated at one month. From the medical literature in Iran, Italy and America, the period of time was mentioned as approximately one month, and the diagnosis was adopted according to the EOLAR/ACR/2019 criteria.

Ethical approval:

Ethical approval was obtained from the hospital's systematic review board.

Consent for publication:

Not applicable.

Conflict of interest:

The authors declare that they have no Conflict of interest:

Funding:

This research received no specie grant from ASPU or any other funding agency in the public, commercial or nonprofit sectors.

Acknowledgments:

We are thankful to the management of AL-Sham Private University for their support in the eld of medical training and research. We would also like to thank Dr. Khalid Khattab for his help and supervision in the paper.

Availability of data and materials:

All data produced in the present work are contained in the manuscript

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The authors declare no competing interests.

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Clinical and radiological evaluation of systemic lupus erythematosus, Research question: Evaluation of lupus cases in corona infection

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Introduction

Methods and materials

Statistical Analysis:

Results

Discussion

Declarations

Conflict of interest:

Funding:

Acknowledgments:

Availability of data and materials:

References

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