Sistemik lupus eritematozus hastalarındaki eklem tutulumu her zaman inflamatuar mı?

Year 2025, Volume: 8 Issue: 6, 953 - 958, 25.10.2025

Zehra Özsoy , Buğu Bulat , Güllü Sandal Uzun , Mustafa Ekici , Şerife Asya Germe Dağlıoğlu , Levent Kılıç , Ali İhsan Ertenli , Ali Akdoğan

Abstract

Giriş: Sistemik lupus eritematozus (SLE), kronik, otoimmün karakterli, birçok organ ve sistemi etkileyebilen bir bağ̆ dokusu hastalığıdır. Artralji ve myalji SLE hastalarında sık görülen semptomlardır ve sebebi inflamatuvar olabileceği gibi eklem hipermobilitesi veya fibromyaljiden de kaynaklanabilir. Çalışmamızda SLE hastalarındaki eklem ve kas şikayetlerinin inflamatuvar aktivite dışında hipermobilite veya fibromyalji ile ilişkisinin araştırılması amaçlanmıştır.
Materyal ve Metod: Çalışmamıza 2012 SLE sınıflama kriterlerini karşılayan hastalar dahil edildi. Son 6 ay içerisinde eklem mobilitesini etkileyecek cerrahi girişim geçirmiş olan, eşlik eden romatoid artrit, inflamatuar myozit gibi inflamatuar artritler ile seyredebilen hastalık tanıları bulunan hastalar çalışmadan dışlandı. Muayene esnasındaki hastalık aktivitesi SLE Hastalık Aktivite İndeksi-2000 değerlendirme formuna göre belirlendi. Hipermobilite Beighton Hipermobilite Skoru ile fibromyalji ise 2016 Fibromyalji Tanı Kriterleri ile baz alındı. Hastalar hipermobilitesi olan, fibromyaljisi olan ve her ikisi de olmayan olmak üzere 3 gruba ayrıldı. Demografik özellikler, eşlik eden komorbiditeler, tedavide kullanılan ilaçlar, aktivite ve ağrı skorları değerlendirildi.
Bulgular: Fibromyaljisi ve hipermobilitesi olan 6 hasta çalışmadan çıkartırdı. 120 hasta analize edildi. Hastaların 104’ü (%86.7) kadındı. Hastalık süresi median (min-max) değeri 12 (1-38) yıl idi. Hastaların 25’inde (%20.8) hipermobilite, 28’inde (%23.3) fibromyalji tespit edildi. Tüm grupta hipermobilite veya fibromiyaljisi olan hasta oranı %44.1’idi. Gruplar arasında komorbiditeler açısından istatiksel fark saptanmadı. Fibromiyaljisi olan hastalarda median hasta VAS değeri ve ağrı değerlendirmesi diğer iki gruba göre daha yüksek iken SLEDAI-2K aktivite skoru daha düşüktü. SLEDAI-2K Aktivite Skoru’na göre artrit her ikisi olmayan grupta daha sıktı. Pulse-steroid öyküsü hipermobilitesi olan ve fibromiyaljisi olan grup arasında (p:0.01), fibromiyaljisi olan ve her ikisi olmayan grup arasında (p:0.02) fark saptandı.
Sonuç: Hipermobilitenin neden olduğu, ciddi müsküloskeletal ağrı artralji, artrit ile karışabilmektedir ve klinisyence hastalığın progresyonu olarak algılanabilir. Bu durum gereksiz immünsüpresif tedavi verilmesine sebep olabilir. Bu nedenle SLE seyrinde eşlik edebilecek hipermobilite ve fibromyaljinin ayrıntılı şekilde değerlendirilmesi gerekmektedir.

Keywords

Sistemik lupus eritematozus , İnflamasyon , Hipermobilite , Fibromyalji , Artrit

Is joint involvement in patients with systemic lupus erythematosis always inflammatory?

Abstract

Aims: Systemic lupus erythematosus (SLE) is a chronic autoimmune connective tissue disease that can affect multiple organs and systems. Arthralgia and myalgia are common symptoms in patients with SLE, and their etiology may be inflammatory or may result from joint hypermobility or fibromyalgia. This study aimed to investigate whether musculoskeletal complaints in SLE patients are attributable solely to inflammatory activity or whether they may also be associated with hypermobility or fibromyalgia.
Methods: Patients who fulfilled the 2012 SLE classification criteria were included. Patients who had undergone surgical procedures affecting joint mobility within the last 6 months, or those with concomitant diseases such as rheumatoid arthritis or inflammatory myositis that may present with inflammatory arthritis, were excluded from the study. Disease activity at the time of examination was assessed using the SLE Disease Activity Index-2000 (SLEDAI-2K). Hypermobility was evaluated using the Beighton Hypermobility Score, and fibromyalgia was assessed according to the 2016 Fibromyalgia Diagnostic Criteria. Patients were divided into three groups: those with hypermobility, those with fibromyalgia, and those with neither condition. Demographic characteristics, comorbidities, medications, disease activity, and pain scores were analyzed.
Results: Six patients with both fibromyalgia and hypermobility were excluded. A total of 120 patients were analyzed, of whom 104 (86.7%) were female. The median (min-max) disease duration was 12 (1-38) years. Hypermobility was detected in 25 patients (20.8%) and fibromyalgia in 28 patients (23.3%). Overall, 44.1% of the cohort had either hypermobility or fibromyalgia. No significant differences were found between groups in terms of comorbidities. Patients with fibromyalgia had higher median patient VAS and pain scores compared with the other two groups, while their SLEDAI-2K activity scores were lower. Arthritis, according to SLEDAI-2K, was more frequent in the group without hypermobility or fibromyalgia. A significant difference in pulse-steroid use was found between the hypermobility and fibromyalgia groups (p=0.01) and between the fibromyalgia and neither group (p=0.02).
Conclusion: Severe musculoskeletal pain due to hypermobility may mimic arthralgia or arthritis and may be misinterpreted by clinicians as disease progression. This could lead to unnecessary immunosuppressive therapy (risk of overtreatment), which could lead to increased risk of infection and liver and kidney dysfunction. Therefore, hypermobility and fibromyalgia, which may coexist in the course of SLE, should be thoroughly evaluated. In our study, a significant frequency (almost half of the patients) of pain was due to non-inflammatory causes.

Keywords

Systemic lupus erythematosus , inflammation , hypermobility , fibromyalgia , arthritis

Ethical Statement

This study was conducted in accordance with the 2013 revision of the Declaration of Helsinki and was approved by the Hacettepe University Health Sciences Research Ethics Committee (SBA 24/837, 03/09/2024).

Supporting Institution

none

Thanks

none

References

• Mills JA. Systemic lupus erythematosus. N Engl J Med. 1994;330(26):1871-1879. doi:10.1056/NEJM199406303302608
• Ceccarelli F, Perricone C, Cipriano E, et al. Joint involvement in systemic lupus erythematosus: from pathogenesis to clinical assessment. Semin Arthritis Rheum. 2017;47(1):53-64. doi:10.1016/j.semarthrit.2017.03.022
• Boudreau PA, Steiman I, Mior S. Clinical management of benign joint hypermobility syndrome: a case series. J Can Chiropr Assoc. 2020;64(1):43-54.
• Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413-418. doi:10.1136/ard.32.5.413
• Johnsson P, Kohlin C, Rasmusson G, Bengtsson A, Sturfelt G, Nived O. Differences in body structure and function between patients with systemic lupus erythematosus and healthy individuals, with particular reference to joint hypermobility. Scand J Rheumatol. 2016;46(1):40-43. doi:10.3109/03009742.2016.1158313
• Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46(3):319-329. doi:10.1016/j.semarthrit.2016.08.012
• Buskila D, Press J, Abu-Shakra M. Fibromyalgia in systemic lupus erythematosus: prevalence and clinical implications. Clin Rev Allergy Immunol. 2003;25(1):25-28. doi:10.1385/CRIAI:25:1:25
• Petri M, Orbai AM, Alarcon GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012;64(8):2677-2686. doi:10.1002/art.34473
• Bertoli AM, Fernandez M, Alarcon GS, Vila LM, Reveille JD. Systemic lupus erythematosus in a multiethnic US cohort LUMINA (XLI): factors predictive of self-reported work disability. Ann Rheum Dis. 2007;66(1):12-17. doi:10.1136/ard.2006.055343
• Al Dhanhani AM, Gignac MA, Su J, Fortin PR. Work disability in systemic lupus erythematosus. Arthritis Rheum. 2009;61(3):378-385. doi:10.1002/art.24347
• Ball EM, Bell AL. Lupus arthritis-do we have a clinically useful classification? Rheumatology (Oxford). 2012;51(5):771-779. doi:10.1093/rheumatology/ker381
• Gormezano NW, Silva CA, Aikawa NE, et al. Chronic arthritis in systemic lupus erythematosus: distinct features in 336 paediatric and 1830 adult patients. Clin Rheumatol. 2016;35(1):227-231. doi:10.1007/s10067-015-3127-3
• Cervera R, Khamashta MA, Font J, et al. Systemic lupus erythematosus: clinical and immunologic patterns of disease expression in a cohort of 1,000 patients. The European Working Party on Systemic Lupus Erythematosus. Medicine (Baltimore). 1993;72(2):113-124.
• Conti F, Ceccarelli F, Perricone C, et al. The chronic damage in systemic lupus erythematosus is driven by flares, glucocorticoids and antiphospholipid antibodies: results from a monocentric cohort. Lupus. 2016;25(7):719-726. doi:10.1177/0961203315627199
• Chattopadhyay A, Ghosh A. Jaccoud’s arthropathy. Rheumatology (Oxford). 2020;59(10):p3117. doi:10.1093/rheumatology/keaa128
• Mediwake R, Isenberg DA, Schellekens GA, van Venrooij WJ. Use of anti-citrullinated peptide and anti-RA33 antibodies in distinguishing erosive arthritis in patients with systemic lupus erythematosus and rheumatoid arthritis. Ann Rheum Dis. 2001;60(1):67-68. doi:10.1136/ard.60.1.67
• Van Vugt RM, Derksen RH, Kater L, Bijlsma JW. Deforming arthropathy or lupus and rhupus hands in systemic lupus erythematosus. Ann Rheum Dis. 1998;57(9):540-544. doi:10.1136/ard.57.9.540
• Gladman DD, Ibanez D, Urowitz MB. Systemic lupus erythematosus disease Activity Index 2000. J Rheumatol. 2002;29(2):288-291.
• Gladman DD, Goldsmith CH, Urowitz MB, et al. Crosscultural validation and reliability of 3 disease activity indices in systemic lupus erythematosus. J Rheumatol. 1992;19(4):608-611.
• Wolfe F, Petri M, Alarcón GS, et al. Fibromyalgia, systemic lupus erythematosus, and evaluation of SLE activity. J Rheumatol. 2009;36(1):82-88. doi:10.3899/jrheum.080212
• Morlino S, Castori M. Placing joint hypermobility in context: traits, disorders and syndromes. Br Med Bull. 2023;147(1):90-107. doi:10.1093/bmb/ldad013
• Rodgers KR, Gui J, Dinulos MB, Chou RC. Ehlers-Danlos syndrome hypermobility type is associated with rheumatic diseases. Sci Rep. 2017;7:39636. doi:10.1038/srep39636
• Hudson N, Starr MR, Esdaile JM, Fitzcharles MA. Diagnostic associations with hypermobility in rheumatology patients. Br J Rheumatol. 1995;34(12):1157-1161. doi:10.1093/rheumatology/34.12.1157
• Bridges AJ, Smith E, Reid J. Joint hypermobility in adults referred to rheumatology clinics. Ann Rheum Dis. 1992;51(6):793-796. doi:10.1136/ard.51.6.793
• Babini SM, Cocco JAM, Babini JC, de la Sota M, Arturi A, Marcos JC. Atlantoaxial subluxation in systemic lupus erythematosus: further evidence of tendinous alterations. J Rheumatol. 1990;17(2):173-177.
• Mercan R, Bulut Gokten D, Yümün Kavak F. Frequency of hypermobility in patients diagnosed with systemic lupus erythematosus and demographic, clinical characteristics of these patients. Eskisehir Med J. 2024;5(1):19-22. doi:10.48176/esmj.2024.154
• Al-Osami MH, Mohammed S, Ali WI, Fawzi HA. The relationship between hypermobility syndrome and systemic lupus erythematosus. Ind J Public Health Res Develop. 2018;9(12):526-532.
• Gumà M, Olivé A, Roca J, et al. Association of systemic lupus erythematosus and hypermobility. Ann Rheum Dis. 2002;61(11):1024-1026. doi:10.1136/ard.61.11.1024
• Bleifeld CJ, Inglis AE. The hand in systemic lupus erythematosus. J Bone Joint Surg Am. 1974;56(6):1207-1215.
• Klemp P, Majoos FL, Charlton D. Articular mobility in systemic lupus erythematosus (SLE). Clin Rheumatol. 1987;6(2):202-207. doi:10.1007/BF02201025
• Castori M. Ehlers-Danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations. ISRN Dermatol. 2012;2012:751768. doi:10.5402/2012/751768
• Castori M, Camerota F, Celletti C, Grammatico P, Padua L. Ehlers-Danlos syndrome hypermobility type and the excess of affected females: possible mechanisms and perspectives. Am J Med Genet A. 2010;152A(9):2406-2408. doi:10.1002/ajmg.a.33585
• Wallace DJ, Schwartz E, Chi-Lin H, Peter JB. The ‘rule out lupus’ rheumatology consultation: clinical outcomes and perspectives. J Clin Rheumatol. 1995;1(3):158-164.
• Morand EF, Miller MH, Whittingham S, Littlejohn GO. Fibromyalgia syndrome and disease activity in systemic lupus erythematosus. Lupus. 1994;3(3):187-191. doi:10.1177/096120339400300310
• Romano TJ. Management of pain in arthritis. Am J Pain Manag. 1992;2(3):211-214.