Letter to the Editor
Inflammation, systemic lupus erythematosus and the Kounis mast cell activation-associated syndrome
Inflamação, lúpus eritematoso sistémico e síndrome de Kounis associada à ativação dos mastócitos
Nicholas G. Kounis
Department of Medical Sciences, Southwestern Greece Highest Institute of Education and Technology, Patras, Greece
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Kounis" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Nicholas G." "apellidos" => "Kounis" "email" => array:1 [ 0 => "ngkounis@otenet.gr" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Medical Sciences, Southwestern Greece Highest Institute of Education and Technology, Patras, Greece" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Inflamação, lúpus eritematoso sistémico e síndrome de Kounis associada à ativação dos mastócitos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease of unknown origin that affects many organ systems. It is characterized by chronic inflammation that can induce abnormal vasomotion by reducing nitric oxide production and increasing endothelin-1 release, leading to endothelial injury and consequently to coronary artery spasm, which can progress to acute myocardial infarction (MI). This could be the result of either increased C-reactive protein, which induces significant expression of molecules associated with endothelial damage such as ICAM-1, VCAM-1 and E-selectin, or expansion of CD4 CD28 T cells, which induce cytolysis in endothelial cells and/or activation of macrophages and other related interacting cells such as mast cells.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Therefore an association with Kounis mast cell activation-associated syndrome, also known as coronary hypersensitivity disorder,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> cannot be excluded.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the very interesting paper by de Matos Soeiro et al. published in the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> concerning 11 patients with acute coronary syndromes, it was concluded that coronary artery disease in young people with SLE due to premature atherosclerosis should be always be borne in mind because of its high mortality rate.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Indeed, the following inflammatory substances and conditions that are associated with Kounis syndrome should be always considered in patients with lupus erythematosus, including:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Interleukin-9, a T-cell derived factor preferentially expressed by CD4+ T cells that has been characterized in human and murine systems.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0025" class="elsevierStylePara elsevierViewall">Mast cell tryptase, which can be an indicator of type I hypersensitivity reaction and may serve as a surrogate marker of anaphylaxis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Macrophages and their polarization have been found to contribute to the initiation and perpetuation of SLE.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Hypereosinophilic syndrome, which is associated with SLE.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Mast cells, macrophages and (very few) eosinophils are present in inflamed rheumatoid synovial tissue and sites of cartilage erosion in SLE and other autoimmune conditions, including rheumatoid arthritis.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with SLE have higher risk of acute MI compared with non-SLE controls, and this risk is more significant in females. In addition, SLE is an independent risk factor for post-acute MI mortality.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0050" class="elsevierStylePara elsevierViewall">Platelets bearing complement protein C4d (P-C4d) were initially determined to be specific for diagnosis of SLE and were later found to be associated with acute ischemic stroke in non-SLE patients. P-C4d may identify a subset of SLE patients with a worse clinical prognosis and is associated with all-cause mortality and stroke in these patients. P-C4d may be a prognostic biomarker as well as a pathogenic clue that links platelets, complement activation, and thrombosis.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0055" class="elsevierStylePara elsevierViewall">The R131 allele of the Fc gamma receptor IIa (FcγRIIa) is associated with SLE incidence and disease severity but also with coronary artery disease. This finding implies that risk stratification of SLE patients and other high-risk patients with troponin-negative angina could be significantly improved by FcγRIIa genotyping.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0060" class="elsevierStylePara elsevierViewall">SLE nearly doubles mortality and event hazards in cardiovascular disease (MI, stroke, or congestive heart failure) compared to age- and sex-matched comparisons. This raises research questions regarding delayed SLE diagnosis versus accelerated cardiovascular disease prior to SLE, particularly in older-onset SLE.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Cardiovascular events including acute MI and stroke in SLE patients are caused by multifactorial mechanisms, including both traditional and disease-specific risk factors. An overall evaluation with individual risk stratification based on both these features is important to correctly manage these patients in order to reduce negative outcomes.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Consequently, in order to elucidate the pathophysiology of the association of SLE and acute coronary syndromes and to discover potential therapeutic and preventive measures for acute coronary events, a search for inflammatory cells and measurement of inflammatory cell mediators released from these cells should always be performed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary artery spasm as a cause for myocardial infarction in patients with systemic inflammatory disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 4 | 19 |
| 2024 October | 93 | 35 | 128 |
| 2024 September | 99 | 28 | 127 |
| 2024 August | 97 | 28 | 125 |
| 2024 July | 102 | 30 | 132 |
| 2024 June | 97 | 26 | 123 |
| 2024 May | 64 | 22 | 86 |
| 2024 April | 66 | 19 | 85 |
| 2024 March | 80 | 15 | 95 |
| 2024 February | 87 | 22 | 109 |
| 2024 January | 48 | 25 | 73 |
| 2023 December | 58 | 29 | 87 |
| 2023 November | 52 | 25 | 77 |
| 2023 October | 57 | 16 | 73 |
| 2023 September | 44 | 25 | 69 |
| 2023 August | 50 | 15 | 65 |
| 2023 July | 53 | 8 | 61 |
| 2023 June | 58 | 8 | 66 |
| 2023 May | 63 | 22 | 85 |
| 2023 April | 31 | 4 | 35 |
| 2023 March | 52 | 20 | 72 |
| 2023 February | 42 | 19 | 61 |
| 2023 January | 61 | 14 | 75 |
| 2022 December | 36 | 17 | 53 |
| 2022 November | 40 | 24 | 64 |
| 2022 October | 42 | 18 | 60 |
| 2022 September | 43 | 29 | 72 |
| 2022 August | 55 | 36 | 91 |
| 2022 July | 61 | 42 | 103 |
| 2022 June | 31 | 18 | 49 |
| 2022 May | 40 | 28 | 68 |
| 2022 April | 45 | 20 | 65 |
| 2022 March | 48 | 27 | 75 |
| 2022 February | 67 | 21 | 88 |
| 2022 January | 63 | 22 | 85 |
| 2021 December | 42 | 29 | 71 |
| 2021 November | 58 | 31 | 89 |
| 2021 October | 60 | 31 | 91 |
| 2021 September | 37 | 23 | 60 |
| 2021 August | 43 | 24 | 67 |
| 2021 July | 31 | 21 | 52 |
| 2021 June | 38 | 12 | 50 |
| 2021 May | 66 | 34 | 100 |
| 2021 April | 99 | 64 | 163 |
| 2021 March | 83 | 14 | 97 |
| 2021 February | 77 | 17 | 94 |
| 2021 January | 57 | 14 | 71 |
| 2020 December | 54 | 6 | 60 |
| 2020 November | 46 | 13 | 59 |
| 2020 October | 77 | 8 | 85 |
| 2020 September | 86 | 10 | 96 |
| 2020 August | 30 | 8 | 38 |
| 2020 July | 69 | 4 | 73 |
| 2020 June | 62 | 4 | 66 |
| 2020 May | 64 | 1 | 65 |
| 2020 April | 53 | 18 | 71 |
| 2020 March | 33 | 10 | 43 |
| 2020 February | 147 | 35 | 182 |
| 2020 January | 44 | 5 | 49 |
| 2019 December | 64 | 5 | 69 |
| 2019 November | 61 | 9 | 70 |
| 2019 October | 70 | 23 | 93 |
| 2019 September | 98 | 7 | 105 |
| 2019 August | 41 | 7 | 48 |
| 2019 July | 45 | 14 | 59 |
| 2019 June | 43 | 6 | 49 |
| 2019 May | 28 | 9 | 37 |
| 2019 April | 22 | 13 | 35 |
| 2019 March | 42 | 7 | 49 |
| 2019 February | 39 | 11 | 50 |
| 2019 January | 65 | 8 | 73 |
| 2018 December | 56 | 9 | 65 |
| 2018 November | 55 | 8 | 63 |
| 2018 October | 161 | 13 | 174 |
| 2018 September | 58 | 9 | 67 |
| 2018 August | 33 | 11 | 44 |
| 2018 July | 16 | 4 | 20 |
| 2018 June | 26 | 9 | 35 |
| 2018 May | 34 | 3 | 37 |
| 2018 April | 30 | 11 | 41 |
| 2018 March | 26 | 3 | 29 |
| 2018 February | 19 | 5 | 24 |
| 2018 January | 14 | 6 | 20 |
| 2017 December | 43 | 13 | 56 |
| 2017 November | 26 | 11 | 37 |
| 2017 October | 30 | 10 | 40 |
| 2017 September | 29 | 10 | 39 |
| 2017 August | 30 | 13 | 43 |
| 2017 July | 34 | 11 | 45 |
| 2017 June | 34 | 6 | 40 |
| 2017 May | 23 | 6 | 29 |
| 2017 April | 27 | 3 | 30 |
| 2017 March | 26 | 22 | 48 |
| 2017 February | 25 | 5 | 30 |
| 2017 January | 28 | 6 | 34 |
| 2016 December | 21 | 9 | 30 |
| 2016 November | 30 | 5 | 35 |
| 2016 October | 26 | 6 | 32 |
| 2016 September | 35 | 14 | 49 |
| 2016 August | 3 | 3 | 6 |
| 2016 July | 13 | 4 | 17 |
| 2016 June | 14 | 6 | 20 |
| 2016 May | 12 | 1 | 13 |
| 2016 April | 24 | 9 | 33 |
| 2016 March | 29 | 11 | 40 |
| 2016 February | 30 | 14 | 44 |
| 2016 January | 28 | 20 | 48 |
| 2015 December | 31 | 12 | 43 |
| 2015 November | 27 | 3 | 30 |
| 2015 October | 27 | 15 | 42 |
| 2015 September | 39 | 11 | 50 |
| 2015 August | 30 | 11 | 41 |
| 2015 July | 17 | 7 | 24 |
| 2015 June | 33 | 9 | 42 |
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