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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 41  |  Issue : 4  |  Page : 148-151

Clinical and immunological profile of systemic lupus erythematosus in a pediatric population in North India


Department of Pediatrics, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Submission12-May-2014
Date of Acceptance09-Sep-2014
Date of Web Publication19-Dec-2014

Correspondence Address:
Bhardwaj Parveen
Department of Pediatrics, Indira Gandhi Medical College, Shimla, Himachal Pradesh - 171 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-161X.147354

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  Abstract 

Context
Systemic lupus erythematosus is usually missed in the pediatric population because of lower awareness among pediatricians.
Aims
The aim of this work was to study the clinical and immunological profile of lupus in children.
Settings and design
This study was carried out at a tertiary teaching institute of North India; this was a retrospective hospital-based study.
Participants and methods
Case records of 16 children of systemic lupus erythematosus in the age group 5-15 years were reviewed from hospital records.
Statistical analysis used
Means, proportions, and percentages were calculated using Epi Info 7.
Results
The mean age of children at the time of diagnosis was 12.1 years, with a female to male ratio of 5: 1. Fever (81.2%), rash (68.7%), arthritis (56.2%), and photosensitivity (56.2%) were the common clinical manifestations. Anemia was observed in 56.2%, whereas thrombocytopenia was noted in 31.2%. The kidney was the second most common system to be involved, with involvement in 43.7% of cases. Central nervous system involvement was observed in 31.2% of cases. Cardiac involvement was noted in 18% of cases. Antinuclear antibody was positive in all children. Three children died; two died of severe sepsis and one because of cardiogenic shock.
Conclusion
Systemic lupus should be considered a possible cause in adolescents presenting with multisystem involvement.

Keywords: autoantibodies, children, malar rash, systemic lupus erythematosus, vasculities


How to cite this article:
Vijay Y, Parveen B. Clinical and immunological profile of systemic lupus erythematosus in a pediatric population in North India. Egypt Rheumatol Rehabil 2014;41:148-51

How to cite this URL:
Vijay Y, Parveen B. Clinical and immunological profile of systemic lupus erythematosus in a pediatric population in North India. Egypt Rheumatol Rehabil [serial online] 2014 [cited 2018 Aug 14];41:148-51. Available from: http://www.err.eg.net/text.asp?2014/41/4/148/147354


  Introduction Top


Systemic lupus erythematosus (SLE), a rheumatic disease of unknown cause, is characterized by autoantibodies directed against self-antigens, leading to inflammatory damage of many target organs including the joints, kidneys, blood-forming cells, and the central nervous system (CNS). The incidence of lupus is not known, but varies by location and ethnicity. Disease onset before 8 years of age is unusual, although lupus has been diagnosed even in the first year of life. Female predominance varies from 4: 1 before puberty to 8: 1 afterwards [1] . Juvenile SLE is a more aggressive disease than adult SLE, having a markedly higher prevalence and severity of nephritis and CNS disease, requiring higher doses of corticosteroids and other immunosuppressive drugs [2],[3],[4],[5],[6] .


  Participants and methods Top


We reviewed the hospital records of children younger than 15 years of age who were diagnosed to have SLE at this center between January 2010 and December 2013. The diagnosis of SLE was made on the basis of the American College of Rheumatology criteria [7] . We recorded the details of clinical signs, symptoms, drug intake, and the various investigations performed such as complete hemogram, reticulocytes count, direct Coombs test, liver and kidney function tests, 24-h urinary proteins, and urinary microscopy; relevant radiological investigations were performed where indicated. ECG and echocardiography were also performed when indicated. In the immunological tests, antinuclear antibodies (ANAs) and antibodies titers to double-stranded DNA (dsDNA) were measured using an indirect immunofluorescence test; ANA titer of more than 1: 40 and an anti-dsDNA antibody level of more than 55 IU/ml were considered positive. Estimation of anti-Smith antibodies (anti-SM) was carried out by an enzyme immunoassay and a level more than 80 IU/ml was considered positive. C3 estimation was performed in patients with lupus nephritis. Lupus nephritis was diagnosed by renal biopsy and the biopsy specimen was examined by light and immunofluorescence microscopy and classified according to the revised WHO criteria [8] .


  Results Top


Of 16 children with SLE, three were boys and the rest were females, and the female to male ratio was 5: 1. The mean age at the time of diagnosis was 12.1 years (range 7-15 years). Three of the 16 (19%) children were younger than 10 years of age. Most of the children were diagnosed within 6 months of the initial symptoms. Important clinical features and laboratory parameters are summarized in [Table 1] and [Table 2].
Table 1 Clinical features

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Table 2 Laboratory parameters

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Fever was the most common clinical features observed in 81% of the cases, followed by malar rash ([Figure 1]), and arthritis was present in 68 and 56.2% of the cases, respectively. Other features were oral ulcer (43.7%), photosensitivity (56.2%), breathlessness (43.7%), vasculities (37.5%) ([Figure 2]), edema (43.5%), and hypertension (31.2%) as shown in [Table 1]. Neurological manifestations were observed in five (31.2%) patients, seizures were observed in three children, and hemiparesis with upper motor neuron-type seventh cranial nerve palsy was observed in one child. Psychosis was noted in one patient. In the cardiovascular system, pericardial effusion was noted in two children and one child had cardiogenic shock. Malar rash was noted in 68.7% of the patients and was the most common mucocutaneous manifestation, followed by oral ulcer in 43.7%, vasculitic lesions in 37.5% of the cases, and one patient with oral candidiasis. Renal involvement was present in 50% (8/16) of patients. Nephrotic range proteinuria (>40 mg/m 2 /h) was found in five patients and microscopic hematuria (>5 RBC/HPF) was observed in seven patients. Azotemia was observed in four patients and two patients required dialysis. Seven patients had lupus nephritis, of whom two had class 2 nephritis, two had class 3 nephritis, and three had class 4 nephritis according to the WHO classification of lupus nephritis. Hepatosplenomegaly and ascites were observed in 37.5 and 25%, respectively, hepatitis was observed in two patients, and other causes of hepatitis were ruled out. In hematological system, anemia was noted in 56.2%, followed by thrombocytopenia (31.2%) and leukopenia (12.5%). High erythrocyte sedimentation rate was noted in 68.7%. ANA was positive in all cases, antibodies to dsDNA were positive in nine patients, and anti-SM was positive in two cases. Low C3 levels were noted in seven patients. There were three deaths in our series. Two children died of severe septicemia with multisystem involvement and one died because of cardiogenic shock. The rest of the patients are under regular follow-up. We treated our patients with oral prednisolone at a dose of 1-2 mg/kg/day and hydroxychloroquine 3-5 mg/kg/day; these drugs were slowly tapered down after assessing the disease activity and serological remission. Children with lupus nephritis were treated with intravenous methylprednisolone (10-30 mg/kg/dose) for 3 days, followed by oral prednisolone and oral/intravenous cyclophosphamide (0.5-2.5 mg/kg/day). Intravenous cyclophosphamide was administered to the patients who had more severe renal involvement.
Figure 1 Malar rash.

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Figure 2 Vasculitic lesion in the foot.

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  Discussion Top


We diagnosed 16 cases of SLE over the past 4 years. Most of our patients were diagnosed within 6 months of their initial symptoms and the mean age at the time of diagnosis was 12.1 years. In our case series, the female to male ratio was 5 : 1, which is similar to other studies [9],[10] . Fever, rash, arthritis, and oral ulcer were the most predominant clinical features, which are also mentioned in other studies [11],[12] . In our case series, 43% had breathlessness, which is not mentioned in other studies [10],[11],12] ; four out of seven patients with breathlessness had restrictive lung disease on spirometry, and the reasons for breathlessness in the other two cases were anemia and pleural effusion, respectively. Other clinical features reported were alopecia (25%), hepatitis (12.5%), pedal edema (43%), and hypertension (31.2%), identical to that reported by Hari et al. [12] . CNS involvement was noted in 31.2% of the patients, which is the same as reported by others [10] , and in our series, one patient had complete hemiparesis of the left side of the body because of vasculitis. MRI brain and magnetic resonance angiography showed infarct in striate branches of the right middle cerebral artery. Cardiovascular manifestations are known to occur in up to 30% of children with SLE [13],[14] . In our case series, cardiac involvement was noted in 18%; we noted pericardial effusion and cardiogenic shock that was secondary to myocarditis, but we did not find any vegetations or pulmonary hypertension on echocardiography. One child had cardiogenic shock, which was managed with ionotropes, ionodilators, and ventilatory support, but the child succumbed to the illness. Hematological involvement may be noted in up to 50% of children with SLE [13],[14] . We recorded hematological involvement in 56% of the patients, which is similar to other studies [12] . Anemia was noted in 56%; three children had severe anemia and required packed red blood cell transfusions, whereas the rest were managed on steroids and showed improvement. Thrombocytopenia was noted in 31% and leukopenia in 12%.

Renal involvement occurs in 30-70% of children with SLE [1] . The most common initial manifestations of nephritis are microscopic hematuria (79%), followed by proteinuria, including nephritic syndrome (55%), and acute renal failure as a presenting manifestation of nephritis is rare (1.4%) [15] . We had two patients with acute renal failure who required dialysis. Renal involvement was noted in 43.7%, which is similar to other studies [9] . Microscopic hematuria and proteinuria were noted in 43 and 50%, respectively. Three of our patients had class 4 nephritis and were managed by monthly intravenous infusions of cyclophosphamide (500-1000 mg/m 2 ), followed by dosing every 3 months for 18 months. One patient died of severe sepsis with multiorgan dysfunction.

On immunological investigations, ANA positivity was noted in all our patients. Anti-dsDNA antibody titers were positive in 56% of the cases, which is similar to other studies [12] . Anti-SM were tested in only three patients, of whom, two had a positive result. Anti-SM are highly specific for SLE, but these are detected in only about 50% of patients with SLE [6] . Serum complement levels can be a useful measure of disease activity and low levels are observed in about 90% children with active nephritis, and the level increases with treatment [16] . Low complement levels were noted in 43.7%, which were less than that reported in other studies [10],[11],[17] . As complement is an acute-phase reactant, hypocomplementemia may not be always observed in the acute phase of the disease [13] .


  Conclusion Top


We would like to emphasize the fact that the SLE is a multisystem disease that has a varied presentation. In the early phase of the illness, clinical features are often subtle and the diagnosis can be missed if a high index of suspicion is not kept. The disease has an overall poor prognosis; thus, early identification is imperative to a good outcome.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ardoin SP, Schanberg LE. In: Kliegman RM, Stanton BF, Schor NF, Geme JWS, Behrman RE,editors. Systemic lupus erythematosus. Nelson textbook of pediatrics. 19th ed. Philadelphia: Elsevier 2012; 841-845.  Back to cited text no. 1
    
2.
Font J, Cervera R, Espinosa G, Pallarés L, Ramos-Casals M, Jiménez S, et al. Systemic lupus erythematosus (SLE) in childhood: analysis of clinical and immunological findings in 34 patients and comparison adults. Ann Rheum Dis 1998; 57 :456-459.  Back to cited text no. 2
    
3.
Rood MJ, ten Cate R, van Suijlekom-Smit LW, den Ouden EJ, Ouwerkerk FE, Breedveld FC, et al. Childhood-onset systemic lupus erythematosus: clinical presentation and prognosis in 31 patients. Scand J Rheumatol 1999; 28 :222-226.  Back to cited text no. 3
    
4.
Tucker LB, Menon S, Schaller JG, Isenberg DA. Adult and childhood-onset systemic lupus erythematosus: a comparison of onset, clinical features, serology, and outcome. Br J Rheumatol 1995; 34 :866-872.  Back to cited text no. 4
[PUBMED]    
5.
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6.
Mina R, Brunner HI. Paediatric lupus - are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus. Rheum Dis Clin N Am 2010; 36 :53-80.  Back to cited text no. 6
    
7.
Hochberg MC. Updating the American College of Rheumatology criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1997; 40 :1725.  Back to cited text no. 7
    
8.
Churg J, Bernstein J, Glassock RJ. Lupus Nephritis, In: Churg J, Berstein J, Glassock RJ, eds. Renal diseases. Classification and atlas of glomerular disease. 2nd ed. New York: Igaku-Shoin; 1995:151.  Back to cited text no. 8
    
9.
Chandrashekran AN, Rajendran CP, Ramakrishan S, Madhavan R, Pratibhan M. Childhood systemic lupus erythematosus in South India. Indian J Pediatr 1994; 61 :223-229.  Back to cited text no. 9
    
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Singh S, Kumar L, Khetarpal R, Aggarwal P, Marwaha RK, Minz RW, et al. Clinical and immunological profile of SLE: some unusual features. Indian Pediatr 1997; 34 :979-986.  Back to cited text no. 11
    
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Hari P, Bagga A, Mahajan P, Dinda A. Outcome of lupus nephritis in Indian children. Lupus 2009; 18 :348-354.  Back to cited text no. 12
    
13.
Cassidy JT, Petty RE. Systemic lupus erythematosus. In: Cassidy JT, Petty RE, Eds. Textbook of pediatric rheumatology. 3rd ed. Philadelphia, PA, USA: W.B. Saunders Company 1995; 260-322.  Back to cited text no. 13
    
14.
Schur PH. In: Kelly WN, Harris ED, Ruddy S, Sledge CB, editors. Clinical features of systemic lupus erythematosus. Textbook of rheumatology. 4th ed. Philadelphia: W.B. Saunders Company 1993; 1017-1042.  Back to cited text no. 14
    
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Cameron JS. Lupus nephritis in childhood and adolescence. Paediatr Nephrol 1994; 8 :230-249.  Back to cited text no. 15
    
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Petty RE, Laxer RM. In: Cassidy JT, Petty RE, Laxer RM, Lindsley CB, editors. Systemic lupus erythematosus. Textbook of pediatric rheumatology. Philadelphia, PA: Elsiever Saunders 2005; 342-391.  Back to cited text no. 16
    
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Ali US, Dalvi AS, Merchant RH, Mehta KP, Chablani AT, Badakere SS, et al. Systemic lupus erythematosus in Indian children. Indian Pediatr 1989; 26:868-873.  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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