Dr David Gillis MB BS FRACP FRCPA - Staff Specialist, Division of Human Immunology
Reprinted from The Bulletin, number 132, September 2004
Inflammation is an important process which plays a central role in patients with Lupus, Scleroderma and Sjogren's syndrome. The process of inflammation is a common process, if one has a physical injury, you get swelling and pain and redness in the area of the injury. A similar process happens in systemic rheumatic disease but due to another cause of abnormal antibody production and immune response. The swelling is caused by leakage of fluid from blood vessels. The redness is caused by swelling of the blood vessels. The pain is caused by activation of nerves at the site of inflammation. Later on if the inflammation continues, cells leave the blood vessels to go onto tissues. In systemic rheumatic disease this process happens in the joints and internal organs. If you get swelling, pain and redness in the joints then you would get an arthritis type picture, as happens in lupus. In Sjogren's syndrome, inflammation occurs in the salivary glands. Early on in Scleroderma you get swelling of the skin and tendons.
Inflammation has to be contrasted with pain due to other causes, typically fibromyalgia pain which is not associated with swelling or redness. This pain is caused by dysfunction of nerves without inflammation. Sometimes pain can occur because of structural problems such as misalignment of bones or joints as occurs in degenerative joint disease affecting the spinal cord.
Inflammation has either to be local or generalised in which case it affects many organs or many parts of the body at the same time. In this situation people can feel generally unwell with flu-like symptoms, loss of weight and problems with eating with loss of muscle bulk. These effects are due to substances given off by the inflammatory focus. These substances are called cytokines and have many effects on the body. They can affect your sleep; you may have difficulty sleeping or sleep too much and still feel very tired. The muscles can ache and there can be a breakdown of muscle tissue. Blood sugar and fatty acids can rise in the blood stream.
The liver makes certain proteins, such as C reactive protein, which are secreted into the blood stream to dampen down the inflammatory response and help to protect against infection.
Another protein given off by the liver is the clotting factor fibrinogen.
We measure these proteins in the blood to see whether or not there is an inflammatory process present. The C reactive protein is normally barely detectable in the blood but in acute inflammation it can go up to approximately 1000 times from baseline. We also have a measurement technique called ESR, which looks at the rate of fall of red blood cells in blood - they fall quicker in the presence of fibrinogen. We use ESR also to diagnose inflammatory conditions.
So how are these inflammatory markers in people with Lupus ? ESR is used to follow the disease. If the ESR is high and the clinical picture is correct then it is a fair chance that the lupus is active. However, for reasons we don't understand, the other inflammatory marker C reactive protein does not go up with acute lupus. However, C reactive protein only goes up if there is infection in addition to lupus. A similar picture is seen with Sjogren's syndrome.
CRP and ESR can be very high during the acute stages of scleroderma. However, a normal CRP in ESR does not exclude active disease.
Many of the treatments used in Lupus, Scleroderma and Sjogren's syndrome are directed towards decreasing inflammation. Non-steroidal anti-inflammatory drugs suppress but do not switch off underlying inflammation. They can suppress the pain and swelling but the underlying process continues. Prednisolone decreases cytokine production in inflammation. However, Prednisolone has many side effects and we frequently use other drugs that suppress the immune system. These drugs include Azaphioprine and Cyclophosphamide. There is a range of newer anti-inflammatory drugs on the horizon, one of which is called anti-TNF antibody, this decreases the production and actions of one of the major cytokines involved in all these diseases.
Disclaimer :
The Lupus Group of W.A. (Inc.) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.