Coexistence of RA and SLE - is it rare?

[Guest guest]

Hi !!

Thank you so much for the detailed reading. It is very interesting

to check out documentation and presentations from the medical field.

I appreciate your taking the time to investigate this and publish the

results on the board.

Hope today is a good day.

Stacey

> Coexistence of RA and SLE - is it rare?

>

>

> ****************************************

>

>

> An excerpt from a March 14, 2004 HealthTalk " Ask the Doctor "

> with Gardner, M.D.:

>

>

> Cheryl:

>

> I have lupus and rheumatoid arthritis. What are the best drugs for

> relief with the least side effects? My lupus is not causing any

problems

> or pain, but my arthritis causes me pain and inflammation.

>

>

> Dr. Gardner:

>

> It is a rare person that has both RA and SLE. Sometimes people are

> mislabeled with one or the other because people with RA can have a

> positive test for lupus and visa versa. There is a condition called

> Sjogren's syndrome that I frequently see mislabeled as both

diseases due

> to the presence of a positive ANA, the test for lupus and positive

> rheumatoid factor, the test for RA. I would check with your

> rheumatologist to make sure you have both. There are rare people

who in

> fact have both and we call it " rhupus. " Many medications treat both

> including methotrexate, hydroxychloroquine, azathioprine,

leflunomide

> and prednisone. Currently one should avoid the TNF inhibitors due

to the

> concern about making lupus worse although this remains to be proven.

>

>

http://www.healthtalk.com/rheumatoidarthritis/askthedoctor/031504.cfm

>

>

> ****************************************

>

>

> Lupus. 2002;11(5):287-92.

>

>

> Clinical and immunogenetic characterization of Mexican patients with

> 'rhupus'.

>

> Simon JA, Granados J, Cabiedes J, Morales JR, Varela JA.

>

> Department of Immunology and Rheumatology, Instituto Nacional de

> Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, CP, Mexico

DF.

> abrahamsimon@m...

>

> The coexistence of systemic lupus erythematosus and rheumatoid

arthritis

> (rhupus) is a rare clinical condition. To date, 50 cases of rhupus

have

> been described worldwide; however, the lack of clinical criteria for

> this rheumatic condition has created confusion in the

characterization

> of this disorder. Nevertheless, in this paper we describe a

> comprehensive clinical and serological characterization of a cohort

of

> 22 Mexican patients with rhupus, supported by generic HLA-DR

> phenotyping. We found that rhupus patients have a special clinical

> behavior. In this setting, the signs and symptoms of rheumatoid

> arthritis prevail, little organic damage associated with systemic

lupus

> erythematosus (SLE) exists and none of the cases present thrombosis

or

> morbidity during pregnancy in spite of presenting a high frequency

of

> anticardiolipin antibodies. We also found an increased frequency of

> HLA-DR1 and HLA-DR2 alleles compared to healthy ethnically matched

> controls, systemic lupus erythematosus and rheumatoid arthritis

> patients.

>

> PMID: 12090562

>

> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?

cmd=Retrieve & db=PubMed & list_uids=12090562 & dopt=Abstract

>

>

> ****************************************

>

>

> From lupus expert Dr. Wallace's medical reference

text " Dubois'

> Lupus Erythematosus " (2002):

>

> Chapter 46

> Differential Diagnosis and Disease Associations

>

>

> " Coexistence of Systemic Lupus Erythematosus and Rheumatoid

Arthritis

>

>

> Do SLE and RA coexist? It has long been known that patients may

start

> with a diagnosis of RA or SLE that becomes SLE or RA over a period

of

> years. Assuming that MCTD is not present, however, the true

coexistence

> of these conditions is rare. Despite the frequent clinical overlap

> between RA and SLE features, the combination of advanced, deforming,

> erosive RA and a significant degree of biopsy-proven SLE is an

extremely

> unusual finding.

>

> Occasional case reports have appeared documenting a true

coexistence. Of

> my own group's 464 patients with idiopathic SLE, one had classic

> seropositive, erosive, nodular RA with biopsy-documented

proliferative

> SLE nephritis and nephrotic syndrome. The concurrence of SCLE in

> patients with RA who are Ro/SSA-positive is more common. Cohen and

Webb

> reported the development of SLE in 11 Australian patients with

typical

> RA who were observed over a 17-year period, but the total number of

> patients with RA followed was not stated. Brand et al. presented 11

> coexisting cases; most had class II genetic determinations of both

> disorders. Panush et al. have identified a true coexistence in six

of

> 7,000 patients with RA who were evaluated over an 11-year period.

It was

> concluded that rhupus did not occur more frequently than expected

from

> the chance concurrence of SLE and RA (1.2%). Van Vollenhoven's

group at

> Stanford found " rhupus " in 13 patients among 1,507 with RA and 893

with

> SLE. Seven appeared to have transformed from SLE to RA. "

>

>

>

> ****************************************

>

>

> Archives of Internal Medicine

> Vol. 148 No. 7, July 1, 1988

>

> 'Rhupus' syndrome

>

> R. S. Panush, N. L. , S. Longley and E. Webster

> Department of Medicine, College of Medicine, University of

> Florida.

>

> Occasionally patients with overlapping features of rheumatoid

> arthritis (RA) and systemic lupus erythematosus (SLE),

termed " rhupus, "

> have been encountered. We wanted to ascertain the frequency of such

> patients and determine whether they represent a unique overlap

syndrome.

> Of approximately 7000 new patients evaluated over 11 years, we

> identified six patients who had, on the average, 6.7 American

Rheumatism

> Association criteria for RA and 4.2 criteria for SLE. Criteria for

RA

> included chronic symmetric arthritis with morning stiffness (six

> patients); subcutaneous nodules (two patients); positive rheumatoid

> factors test (four patients); and radiologic erosions (four

patients).

> The criteria for SLE included malar rash (three patients); discoid

lupus

> erythematosus (two patients); biopsy-proved nephritis (one patient);

> photosensitivity (one patient); leukopenia/thrombocytopenia (four

> patients); positive antinuclear antibodies or lupus erythematosus

cell

> test (six patients); hypocomplementemia (two patients); and abnormal

> results from skin biopsy (two patients). During observations of up

to

> ten years, the conditions of three patients were stable or

improved, one

> died, and two were unavailable for follow-up. Patients usually did

not

> have conditions that evolved to classic rheumatic disease patterns.

> Rhupus was not common and did not occur more frequently (0.09%

> prevalence among our patients) than expected from chance

concurrence of

> SLE and RA (calculated at 1.2%). These observations confirm that

rhupus

> indeed exists as a syndrome manifested by patients sharing features

of

> probable coincidental concurrence of RA and SLE, but not as a unique

> clinical pathologic or immunologic syndrome. Appreciation of these

> patients with rhupus is important since their therapy and outcome

differ

> from those having RA or SLE alone.

>

> http://archinte.ama-assn.org/cgi/content/abstract/148/7/1633?

ijkey=3bdbcb16f360c02be00b65e7f1bd960252dee62c & keytype2=tf_ipsecsha

>

>

> ****************************************

>

>

>

>

>

> I'll tell you where to go!

>

> Mayo Clinic in Rochester

> http://www.mayoclinic.org/rochester

>

> s Hopkins Medicine

> http://www.hopkinsmedicine.org

[Guest guest]

Coexistence of RA and SLE - is it rare?

****************************************

From lupus expert Dr. Wallace's medical reference text " Dubois'

Lupus Erythematosus " (2007):

Chapter 49

Differential Diagnosis and Disease Associations

Page 961

Coexistence of Systemic Lupus Erythematosus and Rheumatoid Arthritis

Do SLE and RA coexist? It has long been known that patients may start

with a diagnosis of RA or SLE that becomes SLE or RA over a period of

years. Assuming that MCTD is not present, however, the true coexistence

of these conditions is rare. Despite the frequent clinical overlap

between RA and SLE features, the combination of advanced, deforming,

erosive RA and a significant degree of biopsy-proven SLE is an extremely

unusual finding.

Occasional case reports have appeared documenting a true coexistence. Of

my own group's 464 patients with idiopathic SLE, one had classic

seropositive, erosive, nodular RA with biopsy-documented proliferative

SLE nephritis and nephrotic syndrome. The concurrence of SCLE in

patients with RA who are Ro/SSA-positive is more common. Cohen and Webb

reported the development of SLE in 11 Australian patients with typical

RA who were observed over a 17-year period, but the total number of

patients with RA followed was not stated. Brand et al. presented 11

coexisting cases; most had class II genetic determinations of both

disorders. Panush et al. have identified a true coexistence in six of

7,000 patients with RA who were evaluated over an 11-year period. It was

concluded that rhupus did not occur more frequently than expected from

the chance concurrence of SLE and RA (1.2%). Van Vollenhoven's group at

Stanford found " rhupus " in 13 patients among 1,507 with RA and 893 with

SLE. Seven appeared to have transformed from SLE to RA.

****************************************

New England Journal of Medicine

Correspondence

Volume 357:2517-2518 December 13, 2007 Number 24

Rheumatoid Arthritis, Systemic Lupus Erythematosus, and STAT4

" To the Editor: Remmers and colleagues (Sept. 6 issue)1 show that a

variant allele of STAT4 confers an increased risk of both rheumatoid

arthritis and systemic lupus erythematosus and thus suggest a shared

pathway for these diseases. If two diseases share a common pathogenic

pathway, the expected prevalence of their concurrence should exceed

the chance probability of having both diseases. The clinical

coexistence of rheumatoid arthritis and systemic lupus erythematosus

is rare.2,3,4,5 In the largest reported cohort of patients with this

condition, the observed prevalence of concurrent rheumatoid arthritis

and systemic lupus erythematosus was 0.09% among patients with

inflammatory arthritis ... "

http://content.nejm.org/cgi/content/extract/357/24/2517

****************************************

Med Hypotheses. 2007;68(4):906-9.

Rembrandt's Bockenolle has a butterfly rash and digital

deformities: overlapping syndrome of rheumatoid arthritis and systemic

lupus erythematosus.

Hayakawa S, Komine-Aizawa S, Osaka S, Iida T, Hayakawa J, Nishinarita

S, Nemoto N.

Division of Infectious Disease Control and Clinical Immunology, Nihon

University Medical Research Institute, 30-1 Ohyaguchi-kamimachi,

Itabashiku, Tokyo 173-8610, Japan.

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are

the most common autoimmune disorders, although they each have very

different pathophysiology. In general, RA is considered to be a

Th1-mediated disease, while SLE is a Th2-mediated disease. Thus, their

overlapping, in so called " rhupus " , is a rare condition. In Rembrandt

van Rijn's (1606-1669) portrait of the middle-aged Bockenolle,

we have what may be the earliest depiction of a case of rhupus

syndrome: the coexistence of a butterfly rash and digital deformities.

This suggests the possible historical importance of an RA epidemic

which took place in the early 17th century.

PMID: 17113236

http://www.ncbi.nlm.nih.gov/pubmed/17113236

****************************************

Clin Rheumatol. 2006 Mar;25(2):164-7. Epub 2005 Jun 25.

Lupus arthropathy: a case series of patients with rhupus.

Fernández A, Quintana G, Rondón F, Restrepo JF, Sánchez A, Matteson

EL, Iglesias A.

Department of Internal Medicine, Rheumatology Unit, Universidad

Nacional de Colombia, Bogota, Colombia.

Among the clinical manifestations of systemic lupus erythematosus

(SLE) is an arthropathy, which is usually nonerosive. In many cases

the joint involvement is mild. A subset of patients have deforming,

nonerosive Jaccoud's arthropathy, and a minority have an arthropathy

with clinical findings similar to rheumatoid arthritis (RA) that has

been called " rhupus. " We report our series of eight patients (seven

female, one male) with rhupus arthropathy. Patients were between the

ages of 17 and 38 years (average: 30.3 years) at disease onset. All

had deforming or Jaccoud's arthropathy, and three had erosive disease.

The arthritis was typically the first disease manifestation. Other

symptoms of lupus including vasculitis and glomerulonephritis appeared

after an average of 2.8 years. All had positive antinuclear antibody

and rheumatoid factor. Rhupus arthritis is not a combination of RA and

SLE, but should be regarded as a variant of the arthropathy of lupus.

PMID: 15980935

http://www.ncbi.nlm.nih.gov/pubmed/15980935

****************************************

An excerpt from a March 14, 2004 HealthTalk " Ask the Doctor "

with Gardner, M.D.:

Cheryl:

I have lupus and rheumatoid arthritis. What are the best drugs for

relief with the least side effects? My lupus is not causing any problems

or pain, but my arthritis causes me pain and inflammation.

Dr. Gardner:

It is a rare person that has both RA and SLE. Sometimes people are

mislabeled with one or the other because people with RA can have a

positive test for lupus and visa versa. There is a condition called

Sjogren's syndrome that I frequently see mislabeled as both diseases due

to the presence of a positive ANA, the test for lupus and positive

rheumatoid factor, the test for RA. I would check with your

rheumatologist to make sure you have both. There are rare people who in

fact have both and we call it " rhupus. " Many medications treat both

including methotrexate, hydroxychloroquine, azathioprine, leflunomide

and prednisone. Currently one should avoid the TNF inhibitors due to the

concern about making lupus worse although this remains to be proven.

http://www.healthtalk.com/rheumatoidarthritis/askthedoctor/031504.cfm

****************************************

Lupus. 2002;11(5):287-92.

Clinical and immunogenetic characterization of Mexican patients with

'rhupus'.

Simon JA, Granados J, Cabiedes J, Morales JR, Varela JA.

Department of Immunology and Rheumatology, Instituto Nacional de

Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, CP, Mexico DF.

abrahamsimon@...

The coexistence of systemic lupus erythematosus and rheumatoid arthritis

(rhupus) is a rare clinical condition. To date, 50 cases of rhupus have

been described worldwide; however, the lack of clinical criteria for

this rheumatic condition has created confusion in the characterization

of this disorder. Nevertheless, in this paper we describe a

comprehensive clinical and serological characterization of a cohort of

22 Mexican patients with rhupus, supported by generic HLA-DR

phenotyping. We found that rhupus patients have a special clinical

behavior. In this setting, the signs and symptoms of rheumatoid

arthritis prevail, little organic damage associated with systemic lupus

erythematosus (SLE) exists and none of the cases present thrombosis or

morbidity during pregnancy in spite of presenting a high frequency of

anticardiolipin antibodies. We also found an increased frequency of

HLA-DR1 and HLA-DR2 alleles compared to healthy ethnically matched

controls, systemic lupus erythematosus and rheumatoid arthritis

patients.

PMID: 12090562

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

\

2090562

****************************************

Archives of Internal Medicine

Vol. 148 No. 7, July 1, 1988

'Rhupus' syndrome

R. S. Panush, N. L. , S. Longley and E. Webster

Department of Medicine, College of Medicine, University of

Florida.

Occasionally patients with overlapping features of rheumatoid

arthritis (RA) and systemic lupus erythematosus (SLE), termed " rhupus, "

have been encountered. We wanted to ascertain the frequency of such

patients and determine whether they represent a unique overlap syndrome.

Of approximately 7000 new patients evaluated over 11 years, we

identified six patients who had, on the average, 6.7 American Rheumatism

Association criteria for RA and 4.2 criteria for SLE. Criteria for RA

included chronic symmetric arthritis with morning stiffness (six

patients); subcutaneous nodules (two patients); positive rheumatoid

factors test (four patients); and radiologic erosions (four patients).

The criteria for SLE included malar rash (three patients); discoid lupus

erythematosus (two patients); biopsy-proved nephritis (one patient);

photosensitivity (one patient); leukopenia/thrombocytopenia (four

patients); positive antinuclear antibodies or lupus erythematosus cell

test (six patients); hypocomplementemia (two patients); and abnormal

results from skin biopsy (two patients). During observations of up to

ten years, the conditions of three patients were stable or improved, one

died, and two were unavailable for follow-up. Patients usually did not

have conditions that evolved to classic rheumatic disease patterns.

Rhupus was not common and did not occur more frequently (0.09%

prevalence among our patients) than expected from chance concurrence of

SLE and RA (calculated at 1.2%). These observations confirm that rhupus

indeed exists as a syndrome manifested by patients sharing features of

probable coincidental concurrence of RA and SLE, but not as a unique

clinical pathologic or immunologic syndrome. Appreciation of these

patients with rhupus is important since their therapy and outcome differ

from those having RA or SLE alone.

http://archinte.ama-assn.org/cgi/content/abstract/148/7/1633?ijkey=3bdbcb16f360c\

\

02be00b65e7f1bd960252dee62c & keytype2=tf_ipsecsha

*********************************************************************

Not an MD