Rheumatology Criteria Ignore Neurological Presenting Symptoms

September 22, 2014

Neurological symptoms may be the presenting feature in lupus, sarcoidosis, vasculitis, and other rheumatic diseases, notes this review. Treatment may also cause neurological side effects including demyelination, tremor, and psychosis.

Nouh, A, Carbunar O, Ruland S. Neurology of Rheumatologic Disorders. Curr Neurol Neurosci Rep. (2014) 14:456. doi: 10.1007/s11910-014-0456-6

Disease criteria seldom recognize or include neurologic disorders associated with rheumatic complaints, observes this review from Loyola University. The result can be delays in diagnosis and appropriate treatment.

Among the neurological problems it considers are:

Neuropsychiatric and central nervous system manifestations which are the presenting symptoms in up to 25% of patients with systemic lupus erythematosus (SLE), including demyelination (sometimes called "lupus sclerosis");

Peripheral neuropathies that affect nearly half of Sjögren’s Syndrome patients, sometimes predating more typical symptoms for months or years;

Neurological manifestations, often dubbed 'neurosarcoidosis,' are the presenting feature in up to 74% of patients with sarcoidosis;

Antibody-associated neurological problems in systemic sclerosis;

Central and peripheral nervous system injury due to inflammation-mediated vascular injury in vasculitis.

The mechanisms differ. In SLE brain ischemia, thromboses (often associated with antiphospholipid antibodies), and premature atherosclerosis are implicated. Antibody-related damage is also responsible in systemic sclerosis, and vascular inflammation is the "common denominator" in vasculitis.

Treatments may also cause nerve damage, the review notes. For example, central nervous system demyelination and optic neuritis are reported in patients receiving some tumor necrosis alpha (TNFα) blockers. Psychosis is associated with corticosteroids and antimalarials, and tremor and incoordination may arise in patients taking cyclosporine, mycophenolate mofetil, or tacrolimus.

Better classification criteria and newfound autoantibodies should improve the speed and accuracy of diagnosis, the authors conclude.