Abstract Background Data on post-acute COVID-19 in autoimmune rheumatic diseases (ARD) are scarce, focusing on a single disease, with variable definitions of this condition and time of vaccination. The aim of this study was to evaluate the frequency and pattern of post-acute COVID-19 in vaccinated patients with ARD using established diagnosis criteria. Methods Retrospective evaluation of a prospective cohort of 108 ARD patients and 32 non-ARD controls, diagnosed with SARS-CoV-2 infection (RT-PCR/antigen test) after the third dose of the CoronaVac vaccine. Post-acute COVID-19 (≥ 4 weeks and > 12 weeks of SARS-CoV-2 symptoms) were registered according to the established international criteria. Results ARD patients and non-ARD controls, balanced for age and sex, had high and comparable frequencies of ≥ 4 weeks post-acute COVID-19 (58.3% vs. 53.1%, p = 0.6854) and > 12 weeks post-acute COVID-19 (39.8% vs. 46.9%, p = 0.5419). Regarding ≥ 4 weeks post-acute COVID-19, frequencies of ≥ 3 symptoms were similar in ARD and non-ARD controls (54% vs. 41.2%, p = 0.7886), and this was also similar in > 12 weeks post-acute COVID-19 (68.3% vs. 88.2%, p = 0.1322). Further analysis of the risk factors for ≥ 4 weeks post-acute COVID-19 in ARD patients revealed that age, sex, clinical severity of COVID-19, reinfection, and autoimmune diseases were not associated with this condition (p > 0.05). The clinical manifestations of post-acute COVID-19 were similar in both groups (p > 0.05), with fatigue and memory loss being the most frequent manifestations. Conclusion We provide novel data demonstrating that immune/inflammatory ARD disturbances after third dose vaccination do not seem to be a major determinant of post-acute COVID-19 since its pattern is very similar to that of the general population. Clinical Trials platform (NCT04754698).

Os autores revisaram a influência dos fatores nutricionais sobre o lúpus eritematoso sistêmico (LES) e abordaram uma alternativa complementar em seu tratamento. A autoimunidade e o processo inflamatório do LES estão relacionados à presença de dislipidemias, obesidade, hipertensão arterial sistêmica e síndrome metabólica, que devem ser adequadamente consideradas para diminuir o risco cardiovascular. Uma alimentação com moderado teor energético e proteico, mas rica em vitaminas, minerais (principalmente os antioxidantes) e ácidos graxos mono/poli-insaturados, pode promover ação benéfica protetora contra danos tissulares e supressão da atividade inflamatória, além de auxiliar no tratamento dessas comorbidades. A dietoterapia é uma abordagem promissora, e algumas recomendações podem oferecer melhor qualidade de vida aos pacientes com LES.

The authors reviewed the influence of nutritional factors on systemic lupus erythematosus (SLE) and discussed an alternative treatment option. The autoimmunity and inflammatory process of SLE are related to the presence of dyslipidemia, obesity, systemic arterial hypertension, and metabolic syndrome, which should be properly considered to decrease cardiovascular risk. A diet with moderate protein and energy content, but rich in vitamins, minerals (especially antioxidants), and mono/polyunsaturated fatty acids can promote a beneficial protective effect against tissue damage and suppression of inflammatory activity, in addition to helping the treatment of those comorbidities. Diet therapy is a promising approach and some recommendations may offer a better quality of life to patients with SLE.

INTRODUÇÃO: O Lúpus Eritematoso Sistêmico (LES) se caracteriza por períodos de exacerbação e remissão clínica que frequentemente são acompanhados por alterações nos níveis séricos de anticorpos específicos, como o anti-dsDNA, que está presente em 40% dos casos, associado principalmente à atividade renal. Recentemente houve a descrição de duas subpopulações de anticorpos antilipoproteína lipase (anti-LPL) no LES: uma com e a outra sem atividade anti-dsDNA. A possível relação desse último grupo de anticorpos com a atividade inflamatória de doença ainda não foi analisada no LES. OBJETIVOS: Avaliar longitudinalmente a associação dos níveis séricos dos anticorpos anti-LPL com atividade do LES em pacientes com anti-dsDNA persistentemente negativo. PACIENTES E MÉTODOS: Cinco pacientes com LES com anti-dsDNA persistentemente negativo mensurado por ELISA e por imunofluorescência indireta em crithidia luciliae e altos títulos de anti-LPL por ELISA (> 5 desvios-padrão (DP) da média de 20 controles normais) foram selecionados e acompanhados longitudinalmente durante um período mínimo de dois anos. RESULTADOS: Caso 1: Homem, 24 anos com LES desde 2001 apresentou hemorragia alveolar, proteinúria, hipertensão arterial sistêmica, eritema malar, aftas, artrite, FAN+, com SLEDAI (systemic lupus erythematosus disease activity index) = 16 e anti-LPL = 144UA. Tratado com pulso de metilprednisolona e prednisona com melhora clínica e SLEDAI = 0 e redução do anti-LPL (109UA). Nova atividade com acometimento renal em abril de 2002, SLEDAI = 10 e aumento de anti-LPL (150UA). Iniciada pulsoterapia de ciclofosfamida e metilprednisolona com boa resposta, SLEDAI = 0 e diminuição de anti-LPL (77UA) até a sua total negativação acompanhando a remissão do quadro no ano de 2003. Caso 2: Mulher, 32 anos, com LES desde 1997. Em setembro de 2001 iniciou vasculite cutânea, febre e rash, SLEDAI = 10, anti-LPL = 80UA. Em janeiro de 2002, teve atividade renal e HAS, SLEDAI = 8 e anti-LPL = 25UA, mas com a introdução de CE e ciclofosfamida evoluiu com melhora importante. Em 2003, assintomática, apresentava SLEDAI = 2 e anti-LPL = 12UA. Caso 3: Homem, 39 anos, com LES desde 1997. Estável em uso de cloroquina, sem atividade durante 3 anos, SLEDAI = 0 em todas as ocasiões e sem variação dos títulos de anti-LPL no período do estudo: 85UA (2001),100UA (2002) e 86UA (2003). Caso 4: Mulher, 58 anos com LES desde 1996. Remissão do LES desde agosto de 2001 e com SLEDAI = 0 no período do estudo. Títulos de anti-LPL sem flutuações significativas: 71UA (2001), 42UA (2002) e 61UA (2003). Caso 5: Mulher, 55 anos com LES desde 1989. Estável desde 2000 em uso de cloroquina, SLEDAI = 0, e títulos de anti-LPL também sem variações: 71UA (1999), 92UA (2001), 71UA (2002) e 90UA (2003). CONCLUSÃO: A avaliação longitudinal dos pacientes selecionados mostrou-se estar associada à flutuação dos títulos de anti-LPL com o SLEDAI, sugerindo ser essa variação um novo marcador de atividade do LES, na ausência de anticorpos anti-dsDNA.

INTRODUCTION: Systemic lupus erythematosus (SLE) is characterized by periods of clinical flares and remission that are followed by alterations of sera specific autoantibodies such as anti-dsDNA, present in 40% of the cases and strongly associated with renal involvement. Recently, there was a description of two subpopulations of anti-lipoprotein lipase antibodies (anti-LPL) in SLE: with and without anti-dsDNA activity. A possible relationship between these antibodies with inflammatory activity of SLE was not analyzed. OBJECTIVES: To evaluate longitudinally the association between anti-LPL with lupus activity in patients persistently negatives for anti-dsDNA antibodies. PATIENTS AND METHODS: Five SLE patients with persistently negative anti-dsDNA measured by ELISA and indirect immunofluorescence using crithidia luciliae and high titers of anti-LPL by ELISA (> 5 SD) were selected and followed for at least 2 years. RESULTS: Case 1: A 24-year-old male with SLE since 2001, presented with alveolar hemorrhage, proteinuria, systemic hypertension, malar rash, oral ulcers, polyarthritis, positive ANA, SLEDAI=16 and anti-LPL=144U. He was treated with intravenous (IV) methylprednisolone followed by prednisone and had an excellent response. SLEDAI=0, anti-LPL decreased to 109U. New renal flare in April 2002, SLEDAI=10 and a new increment of anti-LPL (150U). IV Cyclophosphamide and methylprednisolone were started and he achieved remission, SLEDAI=0 and a decrease of anti-LPL (77U) until become negative in 2003. Case 2: A 32-year-old female had SLE since 1997. In September 2001 began cutaneous vasculitis, fever and rash, SLEDAI=10, anti-LPL=80U. In January 2002, she had renal involvement and systemic hypertension, SLEDAI=8 and anti-LPL= 25U. She received corticosteroid and cyclophosphamide and improved. In 2003, she was asymptomatic, SLEDAI=2 and anti-LPL=12U. Case 3: A 39-year-old male has SLE since 1997. He was stable, under chloroquine use, without disease activity for 3 years, SLEDAI=0 in all period studied and no fluctuation of anti-LPL titers: 85U (2001),100U (2002) e 86U (2003). Case 4: A 58-year-old female had SLE since 1996. She was in remission since August 2001 with a SLEDAI=0 during all this study. Anti-LPL titers did not significantly change: 71U (2001), 42U (2002) e 61U (2003). Case 5: A 55-year-old female had SLE since 1989. She was stable since 2000 using chloroquine, SLEDAI=0, and anti-LPL titers without variations: 71U (1999), 92U (2001), 71U (2002) e 90U (2003). CONCLUSION: The longitudinal evaluation of the selected patients showed a positive correlation between the fluctuations of the titers of anti-LPL with the SLEDAI score. These findings suggest that this variation may be a new marker for lupus activity in patients without anti-dsDNA antibodies.

A maioria das informações relativas ao curso da doença de pacientes com lúpus eritematoso sistêmico (LES) é restrita aos primeiros cinco anos após o diagnóstico. Entretanto, dados sobre a precocidade de instalação dos danos são pouco descritos. OBJETIVO: identificar os danos precoces de pacientes com LES de diagnóstico recente e verificar a influência da própria doença ou de sua terapêutica como principal causa para a instalação destes danos. MÉTODOS: foram estudados retrospectivamente 82 pacientes com LES, cujo diagnóstico foi realizado de 1998 até 1999 em nosso serviço. Em todos os pacientes o escore do índice de dano do Systemic Lupus Internacional Collaborating Clinics/American College of Rheumatology-Damage Index (SLICC/ACR-DI) foi avaliado no momento do diagnóstico e anualmente três vezes consecutivas. As manifestações clínicas e o esquema terapêutico foram avaliados nas consultas médicas. O escore do SLICC/ACR para cada órgão/sistema e a prevalência dos danos foi identificado, assim como a sua possível causa (doença ou terapia). RESULTADOS: A idade (média) inicial foi de 31,6 anos com predomínio do sexo feminino (94%). A maioria dos pacientes (94%) apresentou manifestações cutâneas e articulares, seguidas pelas renais (40%), pulmonares (28%) e neurológicas (18%). Ao final do estudo, 52 pacientes (63,4%) não apresentaram seqüelas (sem pontuação no SLICC). Dos 30 pacientes restantes, 16 tiveram escore = 1 e 14 pacientes apresentaram escore = 2. No total observamos 36 danos, sendo 23 atribuídos à doença e 13 à terapia (64% vs 36%, p < 0,05). Os sistemas mais freqüentemente acometidos foram o articular e o neurológico (27,7%), seguidos pelo renal (13,8%). Todos os pacientes com comprometimento neurológico tiveram danos precoces decorrentes da própria doença (apesar da terapêutica agressiva) enquanto a terapêutica com corticóide foi responsável pelos danos em 7/10 pacientes com dano articular (osteonecrose). O dano renal foi observado em 13,8% dos pacientes (nefrite grave não responsiva ao tratamento). Outros efeitos adversos da terapia foram angina, catarata, diabetes e menopausa precoce. CONCLUSÕES: este estudo sugere que o dano precoce é ainda um importante problema no LES. São necessárias estratégias eficazes no sentido de minimizar as seqüelas, com destaque para as neurológicas. Redução da morbidade associada à terapia com corticóide também deve ser considerada utilizando-se agentes poupadores de esteróides.

The majority of the information available about the disease course of patients with systemic lupus erythematosus (SLE) is restricted to the first five years after disease onset. However, data about early damage were rarely reported. OBJECTIVE: to describe the early damage outcome of SLE patients in early disease and to discriminate the influence of disease itself or its therapy as the main cause of their damage. METHODS: we retrospectively studied 82 patients with SLE, diagnosed during the period from 1998 to 1999 in our institution. In all patients the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI) was scored at the diagnosis and annually for the next three years. Clinical manifestations were evaluated at each visit as well as the therapy. The SLICC/ACR-DI scores for each organ system and the prevalence of damage within organ systems were assessed, as well as its possible main cause (disease or therapy). RESULTS: the mean age at entry was 31.6 years with female predominance of 94%. The majority of the patients (94%) presented cutaneous and articular involvement, 40% renal, 28% pulmonary, and 18% neurological manifestations. At the end of the study, 52 (63.4%) patients had no damage to score with SLICC. From the remaining 30 patients, 16 had a score of 1 and 14 had a score = 2. In total, 36 damages occurred, 23 of them attributed to the disease and 13 to the therapy (64% vs. 36%; p < 0.05). The most frequently injured systems were the articular and the neurological (27.7%) ones, followed by the renal (13.8%) system. All patients with neurological involvement have early damage due to the disease itself in spite of the aggressive therapeutic whereas from 10 patients with articular damage, 70% (7) were associated with steroid therapy (osteonecrosis). In contrast, premature renal injury was observed in 13.8%, all of them with unresponsive severe nephritis. Other adverse effect of therapy included 1 angina, 2 cataracts, 1 diabetes and 2 premature menopauses. CONCLUSIONS: this study suggests that early damage is still a major problem in SLE that reinforces the need for new strategies in order to minimize injury, particularly for neurological manifestations. Moreover, it also seems important to reduce morbidity induced by corticosteroid therapy with the use of steroid-sparing agents.

Descrevemos o caso de uma paciente com retocolite ulcerativa que apresentou gangrena cutânea secundária à trombose microvascular. Esta rara complicação da doença inflamatória intestinal é decorrente do estado de hipercoagulabilidade observado na sua fase de atividade inflamatória. Foi necessário estabelecer diagnóstico diferencial com poliarterite nodosa pelo acometimento abdominal e cutâneo. As alterações intestinais foram demonstradas pela colonoscopia com biópsia e as vasculares por ultrasonografia com Doppler de membros inferiores e biópsia da lesão cutânea. A paciente foi tratada com prednisona (1 mg/kg), sulfassalazina e anticoagulação plena e evoluiu com remissão da doença cutânea e intestinal.

We reported a patient with ulcerative colitis who developed microvascular thrombosis with secondary cutaneous gangrene. This is an uncommon complication of bowel inflammatory disease due to the hypercoagulability state that occurs in the active inflammatory phase. Differential diagnosis with polyarteritis nodosa had to be performed due to the presence of abdominal and cutaneous manifestations. The diagnosis was confirmed by colonoscopy and biopsies of various segments of the bowel, Doppler ultrasonography of the legs and biopsy of the cutaneous lesion. The patient was treated with prednisone (1 mg/kg), sulfasalazine and anticoagulation, with remission of cutaneous and bowel manifestations.