|Year : 2021 | Volume
| Issue : 1 | Page : 18-21
Comparative analysis of expression of lupus erythematosus in geriatrics versus adults: A retrospective study from tertiary care centre, Rajasthan, India
Neha Gupta, Vijay Paliwal, Puneet Bhargava, Deepak Kumar Mathur
Department of Dermatology, SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||16-Apr-2021|
|Date of Acceptance||08-Jul-2021|
|Date of Web Publication||17-Aug-2021|
Dr. Vijay Paliwal
No. 92/208, Mansarovar, Jaipur - 302 020, Rajasthan
Source of Support: None, Conflict of Interest: None
Objective: Comparative analysis of expression of lupus erythematosus (LE) in geriatrics versus adults. Materials and Methods: We analyzed and compare the patient's records attending our department between June 2017 and June 2019, diagnosed clinically and immunologically as LE between the two groups. Results: Sixty patients, 30 in each group, met ACRA criteria, were enrolled with mean age of presentation for early-onset was 28 ± 9.8 years and late-onset, 59 ± 4.8 years. Most of the patients were females with decrease in sex ratio with age. The most common presentations were malar rash, photosensitivity, and oral ulcers. Joint complaints, lung and cardiac involvement, and nonscarring alopecia were more common in the elderly. Direct Coombs test positive hemolytic anemia, renal involvement in forms of proteinuria and lupus nephritis, and neurological involvement were seen more commonly in adults. In immunological parameters, antinuclear antibody, anti-double standard DNA antibody (AntiDsDNA), and anti-smith antibody testing were done. AntiDsDNA positivity was more in adults correlate with disease severity. We calculate the systemic LE disease activity index 2000 score was higher in the adult population. Conclusion: Our study illustrated that disease activity and damage are more in adults in comparison to geriatrics. However, geriatrics had more organ damage that may be attributable to associated comorbidities. Although the connective tissue diseases in the elderly needs less aggressive management, it requires more attention for possible organ damage due to associated comorbidities.
Keywords: Connective tissue disease, geriatrics population, systemic lupus erythematosus
|How to cite this article:|
Gupta N, Paliwal V, Bhargava P, Mathur DK. Comparative analysis of expression of lupus erythematosus in geriatrics versus adults: A retrospective study from tertiary care centre, Rajasthan, India. J Indian Acad Geriatr 2021;17:18-21
|How to cite this URL:|
Gupta N, Paliwal V, Bhargava P, Mathur DK. Comparative analysis of expression of lupus erythematosus in geriatrics versus adults: A retrospective study from tertiary care centre, Rajasthan, India. J Indian Acad Geriatr [serial online] 2021 [cited 2021 Oct 24];17:18-21. Available from: http://www.jiag.com/text.asp?2021/17/1/18/323939
| Introduction|| |
Connective tissue diseases (CTD) are chronic autoimmune inflammatory conditions; include Lupus erythematosus (LE), systemic sclerosis, dermatomyositis/polymyositis, rheumatoid arthritis, Sjogren syndrome, etc. All are immune complex-mediated autoimmune conditions.
Systemic LE (SLE) is a multisystem disease that primarily affects women in their reproductive years. It was not thought of as a disease of the elderly. However, with advanced diagnostic tests and increased awareness, more cases of late-onset lupus have been reported. Late-onset lupus represents a distinct lupus phenotype usually defined in the literature as onset at age 50 years and is reported to occur in 3%–18%.
Several authors suggest that age at onset influence disease expression, so that patients with late-onset SLE may constitute a separate subgroup, with distinct clinical features, disease course, and outcome.,,,,,,, Studies have reported that these patients present commonly with an insidious onset and have less neurologic and renal involvement 7–8.
The present study was planned to compare the clinical features, evolution, and pattern of expression of CTD in the geriatric population versus the adult population.
Retrospective hospital-based comparative study.
| Materials and Methods|| |
We analyzed the records of patients attending our department between June 2017 and June 2019 who diagnosed clinically and immunologically as SLE (on the basis of the American Academy of Rheumatology Criteria for SLE-ACR).
This is a retroprospective epidemiological study, in which data were collected from the medical records of SLE patients being followed up, either as in- or out-patients, at the hospitals in the region of northern Rajasthan. A total of 60 lupus patients were identified from 2017 to 2019. Thirty patients were included in each group. All were fulfilling at least 4 of the 1997 ACR classification criteria for SLE.
Patients with diagnosis of SLE at the age of 60 or later were classified as the late-onset lupus group, while those in whom the diagnosis took place before 60 years served as the early-onset control group.
The variables included in this protocol are (1) demographic profile; gender of the patient, age at the onset of the disease, defined as the age at which the patient presented the initial manifestations clearly attributable to SLE, age at diagnosis, defined as the age at which the patient fulfilled 4 or more of the revised ACR criteria for the classification of SLE, (2) dermatological manifestations at the time of diagnosis, (3) systemic involvement on the basis of symptoms/signs and laboratory investigations at the time of diagnosis, (4) severity and damage due to disease activity using the SLE disease activity index 2000 (SLEDAI-2K) (6) immunological profile of the patients.
Data were compared by the Chi-square test and unpaired Student's t-test according to the variables. A P < 0.05 considered significant.
Sixty patients, 30 in each group, who met ACRA criteria, were enrolled in this study.
The mean age of presentation for early-onset of SLE was 28 ± 9.8 years and for late-onset, it was 59 ± 4.8 years. Most of the patients in both early-and late-onset groups were females with sex ratio 14:1 and 3:2, respectively (P < 0.05). The time between onset and diagnosis is 7.7 ± 4.5 and 9.2 ± 4.2 in early-and late-onset age groups [Table 1]. As we can conclude by the results of [Table 2]. The most common presentations were malar rash, photosensitivity, and oral ulcers which were found in around 91.66% of cases, (93.33% early vs. 90% late-onset age groups, P > 0.05). Discoid rash is seen in 38.33% more in late-onset age group (53.33% vs. 23.33%, P < 0.05). Joint complaints were seen in 66.66% cases more common in elderly (80% vs. 53.33%, P < 0.05). Lung involvement is seen in about 30% patients, more common in elderly (46.66% vs. 13.33%, P < 0.05). Neurological involvement is seen in 13.33% of cases. Direct Coombs test positive hemolytic anemia is seen in 35% cases, more common in adults (53.33% vs. 16.66%, P < 0.05). Renal involvement in form of proteinuria and lupus nephritis is seen in around 48.33% of cases, more common in adults (63.33 vs. 33.33%, P < 0.05). Biopsy proven cases of lupus nephritis develop in 2, one of them is 13 year old and one is 28 year old. Cardiac involvement is seen in 25% cases more common in elderly (36.66% vs. 13.33%, P < 0.05). Nonscarring alopecia is seen in around 46.66% of cases in which 60% occur in the elderly and 33.33% seen in adults (P < 0.05). In immunological parameters, antinuclear antibody (ANA), anti-double standard DNA antibody (AntiDsDNA), and anti-smith antibody testing were done in which 86.66% cases were positive for ANA 90% in adults versus 83.33% in elderly. AntiDsDNA positive in 78.33% of cases, more in adults (90%) than elderly (66.66%) (P < 0.05). Anti-smith antibody testing was not commonly done because of financial issues it was positive in 5% of the patients, one was adult and two were elderly among who get the done. When we calculate the SLEDAI score of both the population the score for the adult population (13.82 ± 7.54) was higher than the geriatric (12.86 ± 4.53) age group but the difference was not statistically significant.
|Table 1: Demographic characteristics of study population for lupus erythematosus|
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|Table 2: Clinical and laboratory characteristics of study population for lupus erythematosus|
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| Discussion|| |
Several studies have emphasized that the age of onset of SLE influences the expression and course of the disease, although the different clinical features of SLE in elderly patients have been inconsistent.,,, We report data on the impact of age at disease onset and on disease evolution in SLE patients. We compared the clinical features, disease evolution, and pattern of disease expression of CTD in the geriatric and adult population; both groups were exposed to the same investigations and modalities of treatment. Previous studies reported that female-to-male ratio declines in late-onset lupus which is consistent with our study., Our study shows a similar, predominantly female patient population (76.66%), which is in agreement with other studies., The most common presentations were malar rash, photosensitivity, and oral ulcers which are almost equal in both the groups (P < 0.05). Discoid rash was most common finding observed in the elderly than in adults (53.33 vs. 23.33, P < 0.05) and with a female: male ratio of 1.2:1. We showed that the late-onset group had less major organ involvement, with less neurological manifestations, hematological, nonscarring alopecia and renal disease, but more common joint involvement, lung involvement, and cardiac involvement, according to ACR criteria, all of these findings were statistically significant. Moreover, we observed a lower disease activity in late-onset SLE at the first visit. Furthermore, we found that the overall frequency of AntiDsDNA positivity is 78.33% more in adult (90%) than in the elderly (66.66%), which is statistically significant. We hypothesized that level of AntiDsDNA will correlate with severe disease and kidney, neurological, and hematological system involvement in the adult age group. When we calculate the SLEDAI scores of both the population the score for the adult population (13.82 ± 7.54) was higher than the geriatric (12.86 ± 4.53) age group but the difference was not statistically significant. We hypothesized that this may be due to comorbidities associated with advancing age. Five of the patient belong to the age group <50 years died due to disease activity at a very young age between 25 and 30 years none of the geriatric patients die due to SLE disease activity, which shows a higher mortality in the young population due to SLE. Formiga et al. assessed the presentation of 12 late-onset SLE patients compared with 88 with early-onset disease, and also showed that late-onset patients had lower SLEDAI scores. Conversely, some studies reported high disease activity in late-onset SLE. Lalani et al. included 161 patients with late-onset disease and 1367 with early-onset disease from a multicenter Canadian cohort study. This study used the systemic lupus activity measure (SLAM) to assess disease activity, and noted that there was significantly higher SLAM in the late-onset group while there were no differences in SLEDAI. As the SLAM includes noninflammatory features, this may explain the difference between this study and ours.
Although in our report, the disease activity and clinical features were milder in late-onset patients. In addition, they had a higher prevalence of hypertension, osteoarthritis in the elderly and hypercholesterolemia which may have contributed to the damage accumulation in the cardiovascular, articular, and renal systems. Although the activity of disease was less in the late-onset group, yet the late-onset group developed more damage. This can most probably be attributed to the impact of aging and comorbidities.
Limitations of our study are the relatively small number of patients in both the groups and the validity of the study is also limited by the retroprospective nature of it, as the collection of the data may not be most accurate.
| Conclusion|| |
Our study illustrated the disease activity and damage in early-and late-onset SLE. The adult population has more severe disease morbidity and mortality in comparison to the elderly. We observed that late-onset SLE patients had milder disease activity in comparison to adults; however, they had more organ damage that may be attributable to associated comorbidities. Although the CTD in the elderly population requires less aggressive management due to associated comorbidities these patients require more attention for possible organ damage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]