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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the literature there have been few case reports of systemic lupus erythematosus &#40;SLE&#41; and gout occurring concomitantly in the same patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Hyperuricaemia is relatively frequent in SLE&#44; with a reported prevalence of 25&#8211;41&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> for which there are several predisposing factors&#58; many patients have nephritis and renal insufficiency&#44; receive diuretics and some are on low-dose aspirin&#44; all contributing to decreased uric acid excretion&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Nevertheless&#44; they rarely develop gout clinically&#46; Besides age and gender distribution of both diseases&#44; many other factors may play a role in this association&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">First&#44; it is known that the inflammatory response in acute gouty arthritis largely arises from the interaction between polymorphonuclear leukocytes and monosodium urate &#40;MSU&#41; crystals&#46; In SLE&#44; it has been demonstrated that these cells have impaired chemotactic activity and phagocytosis&#44; which may hamper the reaction to MSU crystals&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Secondly&#44; it is thought that complement plays an important role in the pathogenesis of gouty arthritis&#44; as MSU crystals activate both classical and alternative pathways of complement in synovial fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> As active SLE is characterized by decreased serum and synovial complement levels&#44; in these situations it is expected that inflammatory response to MSU crystals will be impaired&#46; This view is further supported by the fact that most cases of gout occur when SLE is quiescent&#44; with complement levels in the normal range&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Alterations in the structure of MSU crystals may provide another explanation&#46; It has been demonstrated that Apo B lipoprotein binds to the crystal surface&#44; thereby physically inhibiting particle&#8211;cell interaction and subsequent phagocytosis of MSU and membrane activation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Apo B lipoprotein levels may be elevated in SLE&#44; by a process that can be related to the disease itself and&#47;or induced by corticosteroids&#44; one of the cornerstone treatments in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Additionally&#44; it is well known that corticosteroids are powerful suppressors of the inflammatory response&#44; blocking vasodilatation and increased vascular permeability and reducing neutrophils chemotaxis and phagocytosis&#44; and likely impede clinical typical gout attacks&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Furthermore&#44; in clinical practice routine microscopy evaluation of synovial fluid is unfortunately underused&#44; so gout attacks may be misdiagnosed as lupus arthritis flares&#46; Consequently&#44; gout diagnosis is late&#44; with high rates of tophaceous forms&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">More recently&#44; the knowledge about inflammasome contribution to the pathogenesis of certain diseases has progressed&#46; Inflammasome is a term used to describe multimeric cytoplasmic protein complexes that detect pathogen-associated and danger-associated molecular patterns &#40;PAMPS and DAMPs respectively&#41; and mediate the activation of caspase-1&#44; the primary enzyme responsible for activation of the pro-inflammatory cytokines IL-1&#946; and IL-18&#46; Several types of inflammasomes exist&#44; but the best studied is the Nod-like receptor protein 3 &#40;NLRP3&#41; inflammasome&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> The importance of inflammasome and IL-1 &#946; activation in gout is clearly established&#44; however in SLE it is an emerging concept&#46; It is noteworthy that both uric acid and DNA are DAMPs&#44; and both induce NLRP3 inflammasome&#44; although the exact molecular details of this pathway in both conditions are not entirely known&#46; It has been demonstrated that NLRP3 plays an important role in lupus nephritis animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Moreover&#44; it has been shown that anti-dsDNA antibodies activate NLRP3 inflammasome in monocytes&#47;macrophages by binding to toll-like receptor 4 and inducing the production of mitochondrial reactive oxygen species&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> As gout and SLE share this pathway in their pathogenesis&#44; that appears to be related with SLE activity and nephritis&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> it seems reasonable to think that it could play a role in the interplay between both diseases&#46; As previously stated&#44; gout attacks are less common in active lupus&#46; The authors hypothesize there could be a counterregulatory mechanism in inflammasome pathway&#46; However&#44; further research is needed to clarify this subject&#46;</p></span>"
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Letter to the Editor
Revisiting the association between systemic lupus erythematosus and gout
Revisitando la asociación entre lupus eritematoso sistémico y gota
Francisca Aguiara,b,
Autor para correspondencia
francisca.ra@hotmail.com

Corresponding author.
, Iva Britoa,b, Jean Sibiliac,d
a Department, of Rheumatology, Centro Hospitalar São João, Porto, Portugal
b Faculty of Medicine of Porto University, Porto, Portugal
c Department of Rheumatology, University Hospital of Strasbourg, France
d Centre National de Référence “Maladies auto-immunes systémiques rares”, France
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the literature there have been few case reports of systemic lupus erythematosus &#40;SLE&#41; and gout occurring concomitantly in the same patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Hyperuricaemia is relatively frequent in SLE&#44; with a reported prevalence of 25&#8211;41&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> for which there are several predisposing factors&#58; many patients have nephritis and renal insufficiency&#44; receive diuretics and some are on low-dose aspirin&#44; all contributing to decreased uric acid excretion&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Nevertheless&#44; they rarely develop gout clinically&#46; Besides age and gender distribution of both diseases&#44; many other factors may play a role in this association&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">First&#44; it is known that the inflammatory response in acute gouty arthritis largely arises from the interaction between polymorphonuclear leukocytes and monosodium urate &#40;MSU&#41; crystals&#46; In SLE&#44; it has been demonstrated that these cells have impaired chemotactic activity and phagocytosis&#44; which may hamper the reaction to MSU crystals&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Secondly&#44; it is thought that complement plays an important role in the pathogenesis of gouty arthritis&#44; as MSU crystals activate both classical and alternative pathways of complement in synovial fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> As active SLE is characterized by decreased serum and synovial complement levels&#44; in these situations it is expected that inflammatory response to MSU crystals will be impaired&#46; This view is further supported by the fact that most cases of gout occur when SLE is quiescent&#44; with complement levels in the normal range&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Alterations in the structure of MSU crystals may provide another explanation&#46; It has been demonstrated that Apo B lipoprotein binds to the crystal surface&#44; thereby physically inhibiting particle&#8211;cell interaction and subsequent phagocytosis of MSU and membrane activation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Apo B lipoprotein levels may be elevated in SLE&#44; by a process that can be related to the disease itself and&#47;or induced by corticosteroids&#44; one of the cornerstone treatments in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Additionally&#44; it is well known that corticosteroids are powerful suppressors of the inflammatory response&#44; blocking vasodilatation and increased vascular permeability and reducing neutrophils chemotaxis and phagocytosis&#44; and likely impede clinical typical gout attacks&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Furthermore&#44; in clinical practice routine microscopy evaluation of synovial fluid is unfortunately underused&#44; so gout attacks may be misdiagnosed as lupus arthritis flares&#46; Consequently&#44; gout diagnosis is late&#44; with high rates of tophaceous forms&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">More recently&#44; the knowledge about inflammasome contribution to the pathogenesis of certain diseases has progressed&#46; Inflammasome is a term used to describe multimeric cytoplasmic protein complexes that detect pathogen-associated and danger-associated molecular patterns &#40;PAMPS and DAMPs respectively&#41; and mediate the activation of caspase-1&#44; the primary enzyme responsible for activation of the pro-inflammatory cytokines IL-1&#946; and IL-18&#46; Several types of inflammasomes exist&#44; but the best studied is the Nod-like receptor protein 3 &#40;NLRP3&#41; inflammasome&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> The importance of inflammasome and IL-1 &#946; activation in gout is clearly established&#44; however in SLE it is an emerging concept&#46; It is noteworthy that both uric acid and DNA are DAMPs&#44; and both induce NLRP3 inflammasome&#44; although the exact molecular details of this pathway in both conditions are not entirely known&#46; It has been demonstrated that NLRP3 plays an important role in lupus nephritis animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Moreover&#44; it has been shown that anti-dsDNA antibodies activate NLRP3 inflammasome in monocytes&#47;macrophages by binding to toll-like receptor 4 and inducing the production of mitochondrial reactive oxygen species&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> As gout and SLE share this pathway in their pathogenesis&#44; that appears to be related with SLE activity and nephritis&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> it seems reasonable to think that it could play a role in the interplay between both diseases&#46; As previously stated&#44; gout attacks are less common in active lupus&#46; The authors hypothesize there could be a counterregulatory mechanism in inflammasome pathway&#46; However&#44; further research is needed to clarify this subject&#46;</p></span>"
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