He lupus Is a chronic autoimmune disease that is associated with great morbidity, due to organic damage (immunosuppression, disability and deterioration of quality of life) and mortality (Díaz-Cortés et al., 2015).
It presents with a clinical picture that can affect in a general way all the organs and systems of body: heart, blood vessels, lungs, kidneys, liver, skin, joints, central nervous system, etc. (Lavalle, 2012).
The immune system in our body is designed and prepared to combat all foreign substances or foreign to our system: viruses, bacteria, tumor cells, etc. (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014).
When a person has lupus, their immune system will exhibit an abnormal activity so it will attack and affect all healthy cells and tissues of the body, causing inflammation and even necrosis (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014).
This generalized systemic affectation will give rise to a high probability of central nervous system (CNS) compromise. When lupus causes damage at the neurological level, several psychiatric and neurological manifestations will occur (Díaz-Cortés et al., 2015), among which are confusional pictures, cognitive deficits or depressive-type pictures (Soneira, 2005) .
Prevalence of lupus
The prevalence of Lupus is estimated at approximately 10,150 cases per 100,000 population, affecting women more frequently than men, at a ratio of 9: 1. In addition, it presents a 10-year survival rate with 70% (Díaz-Cortés et al., 2015).
In the case of Spain, it is thought that approximately 1% of the population may suffer from Lupus, of which 90% are women between the ages of 15 and 55 (FELUPUS, 2015).
The most frequent situation is that the lupus present in a young woman who is of reproductive age (approximately between the 20 and 45 years of age), although it is possible that it appears from the 5 years until in old age. In addition, the younger the disease, the more frequent the manifestations of renal, haematological and central nervous system (Lavalle, 2012).
One of the variants of this disease, the Systemic lupus erythematosus ( THEM ), Is the most frequent autoimmune pathology in the pediatric area, appearing before the age of 16 in 20% of cases (Zúñiga, 2013).
Causes of Lupus
Currently the explicit causes that trigger this type of autoimmune disease are unknown. However, different lines of research show that genetic factors play a prominent role in many cases (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014).
Equally, the Spanish Federation of Lupus (FELUPUS, 2015) highlights the lack of knowledge of the cause of the disease, although there is a high implication Of genetic, hormonal, infectious and even viral factors.
Symptomatology and clinical picture
Lupus is characterized by the loss of tolerance to Antigens The production of pathogenic antibodies and, consequently, damage to multiple organs and systems (Díaz-Cortés et al., 2015). In addition, the clinical picture is defined by phases of symptom remission and phases of relapse in the form of outbreaks (Díaz-Cortés et al., 2015).
Because it can affect the whole body in general and therefore, because it presents a broad clinical course with a wide variety of symptoms and signs, we can distinguish several types of lupus:
- Systemic lupus erythematosus ( THEM ): It is the most prevalent subtype of lupus and can affect systemically diverse organs; Skin, joints, kidneys, liver, arms, heart, lungs and nervous system. Establishing your diagnosis is extremely complicated, can present more than 100 different clinical pictures and can simulate many other acute, chronic, benign or malignant diseases (Lavalle, 2012).
- Discoid lupus erythematosus : The affectation is limited to the skin, it generates inflammatory lesions, like rashes. It causes permanent injuries, atrophying the skin or causing changes of coloration. If it affects the skull it can cause hair loss (Lavalle, 2012).
- Subacute cutaneous lupus erythematosus : Affects the skin producing sores on different parts of the body that are exposed to the sun (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014).
- Drug-Induced Lupus / Lupus : Appears as a consequence of the use of some medications: antiarrhythmics, antihypertensives, Antipsychotics , Anticonvulsants, anti-inflammatories and diuretics. Generally, the symptoms that appear have to diminish and disappear some time after the suspension of treatment (Lavalle, 2012).
- Neonatal lupus : Appears in newborn babies as a result of a passage of antibodies from the mother (with SLE) through the placenta . However, only 1% of newborns with maternal antibodies in the blood develop clinical aspects of the disease. When they appear, they are usually limited to skin lesions (Lavalle, 2012).
Physical symptoms
Because of this variety of lupus subtypes, the symptoms will vary from one to another. However, the most common symptoms are (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014; FELUPUS, 2015):
- Pain and inflammation of the joints.
- Kidney problems.
- Muscle pain.
- Fever without explainable etiology.
- Inflammation of the tissues lining the internal organs.
- Red skin rash.
- Hematological problems ( anemia ).
- Headaches or migraines .
- You erect on the cheeks.
- Pain when breathing deeply.
- Hair loss.
- Fingers of the hands and feet pale or purple.
- Sensitivity to the sun.
- Swelling of the contour of the eyes and legs.
- Mouth ulcers .
- Flu-like symptoms and / or nocturnal sweating.
- Fatigue And extreme fatigue.
Neuropsychological manifestations
In the different diagnostic criteria of lupus we can find several neuropsychiatric alterations, however they are heterogeneous in their form of presentation (Soneira, 2005). These types of alterations, will impact negatively on the quality of life of the person or life expectancy.
In addition, in the case of pediatric patients, these alterations will affect cognition, academic performance, interpersonal relationships and their functional prognosis in adulthood (Zúñiga, 2013).
In systemic lupus erythematosus ( THEM ), The Central Nervous System (CNS) is one of the main causes of morbidity and mortality. Thus, in this subtype of lupus, it is estimated that approximately 30% to 40% of individuals present with neuropsychiatric symptoms and alterations (Díaz-Cortés et al., 2015). In the case of the pediatric population, between 25% and 95% of cases (Zúñiga, 2013).
The appearance of this type of manifestations will depend on multiple factors, secondary damages in the central nervous system may appear by various pathological mechanisms of the disease or by pharmacological action.
Different studies through the use of the neuroimaging have shown alterations of the type diffuse cortical atrophy; Lesions suggestive of cortical infarcts; Regions with increased gray and white matter volume. Structural images are abnormal in 46-85% of patients with neuropsychiatric lupus. In addition, functional images can be affected up to 85-100% (Zúñiga, 2013).
Due to the wide heterogeneity of the neuropsychiatric manifestations in this pathology, the American College of Rheumatology (ARC) has defined 19 clinical syndromes that may appear within these manifestations. Of these, 12 are CNS-specific and include aseptic meningitis, Cerebrovascular disease , Demyelinating syndromes, headaches (migraine and endocranial hypertension), movement disorders ( Korea ), Myelopathy , Convulsions, confusional state of acute type, anxiety disorder , Cognitive dysfunction, mood disorder and psychosis (Díaz-Cortés et al., 2015).
On the other hand, ARC includes the appearance of the following deficits within the manifestations of cognitive dysfunction: attention, memory, visuospatial processing, language, reasoning, psychomotor speed and / or executive function (Zúñiga, 2013).
Deficits in attention, learning, short-term memory, verbal function, visuospatial and motor skills have been reported in patients with SLE, with a prevalence between 14% and 79% (Zúñiga, 2013).
Diagnosis
A number of studies with patients suffering from lupus have derived a series of symptoms or alarm signs that may facilitate the early detection of the pathology, among which are found (FELUPUS, 2015):
- Facial or other types of erythema.
- Difficulty in flexing fingers, dry eyes and mouth.
- Growth aches.
- Acute reaction to insect bite.
- Family history of autoimmune diseases.
- Migraines / agoraphobia / claustrophobia in puberty.
- Problems of the menstrual cycle.
- Low in Lymphocytes .
- Glandular fever in puberty.
- Recurrent abortions.
There is no single, specific test for the diagnosis of lupus. The systemic involvement of the different organs makes it difficult to determine the diagnosis, taking months to years (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014).
Usually, the areas studied and analyzed are: skin, blood, joints, kidneys, pulp, nervous system, presence of fever, fatigue, weight loss or overweight, inflammation of glands, etc. (FELUPUS, 2015).
Therapeutic intervention
The different symptoms of lupus should be treated by a large number of specialists. (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014). The equipment can be composed of:
- GP
- Rheumatologists : They will treat the pathologies related to the joints and their inflammation.
- Immunologists : Will address deficiencies of the immune system.
- Nephrologists : Control the involvement of the kidneys.
- Hematologists : Examine the possible alterations present in the blood.
- Dermatologists : Will be in charge of the treatment of the pathologies of the skin.
- Neurologists : Examine possible alterations at the level of the central nervous system.
- Neuropsychologists : To address the possible cognitive consequences of nerve damage.
- Psychologists : Address the psychiatric consequences.
- Cardiologists : Will treat coronary and blood vessel problems.
The purpose of the intervention of the different specialists and the treatment plan is (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014):
- Prevent and treat the occurrence of outbreaks.
- Reduce organic damage.
- Reduce swelling and pain.
- Control the immune system.
- Prevent or reduce joint damage and balance hormones.
Thus, according to the Spanish Federation of Lupus , Shows that the treatments most used for the treatment of physical pathologies are:
- Nonsteroidal anti-inflammatory drugs (Eg, aspirin): it is used for the treatment of muscle or joint pain. Aspirin, heparin, or sintron are anticoagulant treatments.
- Anti-malaria drugs : They are used for the treatment of the cutaneous and articular affectation. The most common are hydroxychloroquine and mepacrine.
- Steroids : They are effective for the treatment of infamation and to control the active phases of the disease. The dose depends on the severity of the symptoms and is gradually decreased or withdrawn.
- Immunosuppressants They are only used in the most severe cases. The most common are: methotrexate, azathioprine, and cyclophosphamide.
In the case of the therapeutic approach of the neuropsychiatric aspects, the first step is the precise and concrete diagnosis of the different alterations presented by the individual.
In diagnosis the first tools used are: Anamnesis , Physical examination and neurological examination. This will guide the treatment or rehabilitation and rule out other types of alterations (Díaz-Cortés et al., 2015).
In the neurological examination, a variety of strategies may be used: serological studies, cerebrospinal fluid , Encephalography , Brain imaging studies (CT and MRI), and neuropsychological tests (Díaz-Cortés et al., 2015).
Within the neuropsychological tests, the assessment of the different cognitive functions must be included. In addition, a psychological assessment should be included to determine the associated emotional type factors (Zúñiga, 2013).
With regard to therapeutic intervention, there are currently no specific treatments or a standardized therapy in concrete for the treatment of these symptoms in lupus disease (Díaz-Cortés et al., 2015).
For the control of neurological lesions, several pharmacological approaches are usually employed through immunosuppressants or immunomodulators, steroids, anticoagulants, anticonvulsants, etc. (Díaz-Cortés et al., 2015).
However, to address the neuropsychological sequels, different neuropsychological rehabilitation resources are used (Díaz-Cortés et al., 2015). Intervention programs can deal comprehensively with all the deficits associated with cognitive function, or address them in a specific way.
The objective of these will be to maintain an adequate functional level of the person in his / her attentional resources, executive, memory, perceptive or linguistic skills among others. Interventions may also be initiated to try to recover or reach a pre-morbid level in some Concrete function.
On the other hand, the therapeutic approach through the psychological therapy will be essential for the treatment of depressive, anxiety or psychotic pathologies that can be derived as a consequence of the suffering of Lupus.
CONCLUSIONS
Lupus disease requires an early diagnosis and specialized and effective treatment, in order to reduce the possible functional consequences of the disease.
In many cases there is an important physical affectation that will have important repercussions, in terms of disability, mortality, social, labor, psychiatric, etc.
Patients diagnosed with Lupus require constant medical supervision and continued treatment. Therefore, these factors, together with the impact of the symptoms, may have a negative impact on the life of the patients as well as their families, and on interpersonal and professional relationships (FELUPUS, 2015).
References
- Díaz-Cortés, D., Correa-González, N., Díaz, M., Martín-Gutierrez, J., & Fernández-Ávila, D. (2015). Commitment of the central nervous system in lupus Systemic erythematosus. Rev Colomb Reumatol, 22 (1), 16-30.
- Diseases, N.I. (2014). What is Lupus? Retrieved from http://www.niams.nih.gov/.
- Lavalle Montalvo, C. (2012). Lupus: basic information for patients and relatives. Alfil, S.A.
- Lupus, F. E. (2015). Basic Guide to Lupus . Retrieved from http://www.felupus.org/.
- Soneira, S. (2005). Neuropsychiatric Manifestations of Systemic Lupus Erythematosus. Revista Argentina de Clínica Neuropsiquiátrica, 12 (2).
- Zúñiga, Y. (2013). Neuropsychological manifestations in pediatric patients with Systemic Lupus Erythematosus. Acta Neurológica Colombiana .