European Journal of Cardiovascular Medicine

Systemic Lupus Erythematosus (SLE) is a complex autoimmune condition marked by the immune system's erroneous assault on the body's tissues, resulting in extensive inflammation and damage. This chronic illness mostly affects the joints, skin, kidneys, and cardiovascular system, although its effects extend beyond these organs. Significantly, SLE can also impact the thyroid gland, an essential organ that regulates metabolism and sustains general physiological equilibrium. Considering the thyroid's crucial function, assessing thyroid dysfunction in SLE patients holds substantial clinical significance.
Notwithstanding significant advancements in the comprehension and treatment of SLE, thyroid dysfunction persists as a common and troubling worry among these individuals.

Individuals with systemic lupus erythematosus often exhibit thyroid problems, including hypothyroidism, hyperthyroidism, and autoimmune thyroiditis. Nonetheless, the exact processes responsible for these thyroid abnormalities and their clinical ramifications within the setting of SLE remain inadequately clarified. This thesis seeks to examine the prevalence, trends, and clinical implications of thyroid function anomalies in patients with systemic lupus erythematosus at a tertiary care facility. This study aims to provide valuable insights into the relationship between systemic lupus erythematosus (SLE) and thyroid dysfunction through a thorough investigation of thyroid function tests, autoimmune markers, and the clinical profiles of the patients.

Comprehending the relationship between SLE and thyroid dysfunction is crucial for improving patient care and therapeutic approaches. Timely identification and effective therapy of thyroid dysfunction in individuals with SLE could markedly affect disease prognosis, therapeutic strategies, and overall patient outcomes. Furthermore, elucidating the fundamental processes connecting these two autoimmune disorders may disclose shared pathogenic pathways and prospective treatment options.

This research aims to further our comprehension of the intricate link between SLE and thyroid function disorders. The primary objective is to enhance the quality of care and treatment for SLE patients by the implementation of personalised and effective management techniques grounded in a comprehensive understanding of these interconnected disorders.

Study Type – A Prospective Observational Study

Methodology - All patient patient of SLE attending Rheumatology OPD in a 6 month period

meeting inclusion and exclusion criteria will be analysed in this study, their General and

Clinical Data, Patient’s age, sex, clinical symptoms at the time of presentation and severity of

disease.

Following protocol will be followed

1. Diagnosis of SLE Patient is done through SLICC Criteria
2. Disease severity will be assessed using a Questionnaire which will be filled by the patients at the time of first contact at MYH Indore and further follow up will be taken at 3 months and at 6 months.
3. Patients will also be subjected to Blood Investigations to know Routine Investigation and T3, T4, TSH levels, which will be repeated at 3rd and 6th month follow up.

Inclusion Criteria

1. Newly Diagnosed Cases of SLE.
2. Patients between >=18 to <60 years of age

Exclusion Criteria

1. Patients giving negative consent for participation in the study.
2.  
3. Psychiatric Patients
4. Patient on drugs which affect thyroid Function (Eg., Lithium , TCAs, SSRIs, Steroids, Amiodarone)

Study periods - 6 Months from the date of approval of ethical committee

Place of the study- Dept. of medicine, MGM Medical College and M.Y.H. Hospital Indore

Sample size- 50.

Distribution of Gender and Age Range in the Study

The study included 52 participants, with a gender distribution of 94.2% females (49 participants) and 5.8% males (3 participants). In terms of age range, 40.4% of the participants (21 individuals) were aged between 18-25 years, 21.2% (11 individuals) were in the 26-30 years age range, 28.8% (15 individuals) were aged 31-35 years, and 9.6% (5 individuals) were between 36-40 years. The total number of participants across both gender and age distributions was 52, making up 100% of the study population.

Comprehensive Table

The study included 52 participants with an age range of 19 to 39 years (mean: 27.60, SD: 5.818). Thyroid-stimulating hormone (TSH) levels at presentation ranged from 0.06 to 76.00 (mean: 7.4242, SD: 13.21673), with a decrease observed at 3 months (mean: 5.1865, SD: 2.39575) and at 6 months (mean: 3.6781, SD: 1.74692). Haemoglobin levels on admission ranged from 6.80 to 13.00 (mean: 9.6385, SD: 1.40268), and after 6 months, increased to a range of 6.80 to 14.40 (mean: 10.1096, SD: 1.55314). The total leukocyte count (TLC) on admission ranged from 1600 to 22000 (mean: 9723.08, SD: 4703.591), while at 6 months it ranged from 3000 to 24200 (mean: 9234.23, SD: 4036.122). Platelet counts on admission ranged from 0.51 to 4.30 (mean: 1.8244, SD: 0.93619), with a slight increase at 6 months, ranging from 0.63 to 4.70 (mean: 1.9823, SD: 0.98451). The SLE Disease Activity Index (SLEDAI) score on admission ranged from 3 to 12 (mean: 8.88, SD: 2.083) and decreased to a range of 1 to 7 (mean: 4.44, SD: 1.650) after 6 months.

Distribution of Chief Complaints

In the study, the chief complaints reported by the 52 participants varied. The most common complaint was hair loss, affecting 15.4% of patients (8 individuals), followed by joint pain and photosensitivity, both at 13.5% (7 individuals each). Joint stiffness was noted in 11.5% of patients (6 individuals), while fever and muscle pain each accounted for 9.6% (5 individuals). Fatigue was reported by 7.7% (4 individuals), and dry eyes affected 5.8% (3 individuals). Less frequently reported complaints included generalised weakness, Raynaud’s phenomenon, seizures, skin rash, swelling, swollen joints, and weakness, each affecting 1.9% (1 individual per complaint). This distribution reflects the diverse range of symptoms experienced by the participants, totaling 100%.

TSH Levels on Presentation

At the time of presentation, the distribution of thyroid function among the 52 participants showed that 76.9% (40 individuals) were classified as euthyroid, indicating normal thyroid function. Subclinical hypothyroidism was observed in 7.7% of the participants (4 individuals), while 15.4% (8 individuals) were diagnosed with clinical hypothyroidism. This distribution highlights that the majority of participants had normal thyroid function, while a smaller percentage showed varying levels of thyroid dysfunction.

Disease Activity (SLEDAI Score) Before and After Treatment

The assessment of disease activity in terms of the SLEDAI score revealed significant improvements in patients before and after treatment, categorized by thyroid status. Euthyroid patients had a mean SLEDAI score of 9.25 before treatment, which decreased to 1.875 after treatment, reflecting an improvement of 7.375 points and a substantial percentage reduction of 79.73%. In patients with subclinical hypothyroidism, the mean SLEDAI score was 9.5 before treatment and dropped to 4.0 afterward, indicating an improvement of 5.5 points and a percentage reduction of 57.89%. Meanwhile, patients with clinical hypothyroidism showed the most remarkable improvement, with a mean SLEDAI score of 8.5 before treatment, reducing to 1.5 after treatment, resulting in an improvement of 7.0 points and a percentage reduction of 82.35%. These findings suggest that addressing thyroid dysfunction can lead to significant reductions in disease activity among patients with systemic lupus erythematosus (SLE).

Statistical Analysis

The statistical analysis of the treatment outcomes based on thyroid status demonstrated significant mean improvements in SLEDAI scores across all groups. Euthyroid patients exhibited a mean improvement of 7.375, with a t-value of 11.67 and a highly significant p-value of less than 0.0001, indicating strong evidence against the null hypothesis. Similarly, those with subclinical hypothyroidism showed a mean improvement of 5.5, with a t-value of 8.71 and a p-value also less than 0.0001, reflecting a statistically significant response to treatment. Patients with clinical hypothyroidism had a mean improvement of 7.0, accompanied by a t-value of 11.07 and a p-value of less than 0.0001, further supporting the efficacy of the intervention in reducing disease activity. Overall, these results underscore the substantial impact of thyroid function on treatment outcomes in patients with systemic lupus erythematosus (SLE).

Comparison of Mean Differences

The comparison of mean differences in SLEDAI score improvements among the different thyroid status groups revealed no statistically significant differences. When comparing euthyroid patients to those with subclinical hypothyroidism, the mean difference was 1.875, with a 95% confidence interval ranging from -6.902 to 10.652 and a p-value of 0.699, indicating no significant difference in treatment outcomes. Similarly, the comparison between euthyroid patients and those with clinical hypothyroidism yielded a mean difference of 0.375, a 95% confidence interval of -8.402 to 9.152, and a p-value of 0.971, further reinforcing the lack of significant disparity. Finally, the comparison of subclinical hypothyroidism with clinical hypothyroidism showed a mean difference of -1.5, with a confidence interval of -10.277 to 7.277 and a p-value of 0.800. These findings suggest that, while all groups showed improvements, the differences in treatment outcomes between the various thyroid statuses were not statistically significant.

Findings on Gender Distribution in the Study: • Female: 94.2% (49/52 patients) • Male: 5.8% (3/52 patients)

Overview of Literature: 1. General Consensus: Systemic lupus erythematosus (SLE) primarily impacts females, with a female to male ratio generally between 9:1 and 15:1 in the majority of research.

2. International Studies: A study conducted by Molina et al. (2017)[1] indicated a female prevalence of 91.5% within a sample of 420 patients with systemic lupus erythematosus (SLE).
   
   

Another study conducted by Wang et al. (2019)[2] revealed that 93.8% of their 310 systemic lupus erythematosus patients were female.

3. Regional Variations: In India, research conducted by Aggarwal et al. (2020)[3] observed a female prevalence of 87.3% among 150 patients with systemic lupus erythematosus (SLE).
   Patel et al. (2018)[4] reported analogous data, indicating that 88.6% of their 200 SLE patients were female.

Compare Our Study to General Trends: Our study has a little greater female preponderance (94.2%) than the average stated in the literature (90-93%). This may indicate regional differences or particulars of your patients.

• Implications: The high female prevalence supports the belief that SLE disproportionately affects women.

The gender gap highlights the need for gender-specific approaches in clinical management and research methods.

Age Demographics in the Study

Numerous studies, including the thesis research, demonstrate that systemic lupus erythematosus primarily impacts younger persons, especially those in their late teens to early thirties.

This table and analysis offer a precise comparison of age distribution among SLE patients, emphasising the congruence and minor discrepancies between the thesis study and the existing literature.

The comparative analysis of age distribution across different studies highlights variations in the demographic profiles of patients. In the thesis study conducted in 2024, 40.4% of the patients were aged 18-25 years, 21.2% were in the 26-30 years age group, 28.8% were between 31-35 years, and 9.6% fell within the 36-40 years category, totaling 52 patients. In contrast, Pons-Estel et al. (2010) reported an age distribution with 30% of patients aged 18-25, while Danchenko et al. (2006) indicated 35% in the same age group. Aggarwal et al. (2020) [3]provided data showing 38% of patients aged 18-25, 24% in the 26-30 age bracket, 22% aged 31-35, and 10% aged 36-40, comprising a total of 150 patients. These findings emphasize the variations in age distributions across different studies, suggesting differing demographics in systemic lupus erythematosus (SLE) populations.

Prevalence of Thyroid Dysfunction:

The distribution of thyroid status among patients with systemic lupus erythematosus (SLE) across various studies reveals notable differences in prevalence rates. In the thesis study conducted in 2024, 76.9% of the patients were classified as euthyroid, while 7.7% had subclinical hypothyroidism and 15.4% had clinical hypothyroidism, totaling 52 patients. In comparison, Zonana-Nacach et al. (2001) reported that 67% of their 100 patients were euthyroid, with 15% classified as subclinical hypothyroid and 18% as clinical hypothyroid. Watad et al. (2016) found 73% euthyroid patients, with 9% and 18% in the subclinical and clinical hypothyroid categories, respectively. Menon et al. (2018) reported an even higher euthyroid rate of 78%, with 10% subclinical and 12% clinical hypothyroid patients. Other studies, such as those by Pyne and Isenberg (2002) and Antonelli et al. (2010),[5] provided limited data, with subclinical hypothyroidism reported at 5.7% and 5.9%, respectively. Park et al. (1995) indicated a clinical hypothyroid prevalence of 9.5%, while Kumar et al. (2012)[7] reported 14% in a similar category. This variability in findings highlights the complexity of thyroid dysfunction in SLE and underscores the need for further investigation into its implications for disease management.

Analysis:

Your analysis indicates a marginally elevated incidence of clinical hypothyroid cases (15.4%) relative to Zonana-Nacach et al. (18%), although the proportions of euthyroid and subclinical hypothyroid cases align closely with those documented in other research.

• General Trend: Euthyroidism is the predominant manifestation in systemic lupus erythematosus patients exhibiting thyroid dysfunction across various investigations. The prevalence of clinical hypothyroidism exhibits minor variations across studies, likely attributable to disparities in patient demographics, geographical regions, and research methodology.

Chief Complaints

The comparison of presenting complaints and symptoms in patients with systemic lupus erythematosus (SLE) reveals interesting trends across various studies. In our study, hair loss was reported in 15.4% of patients, while joint pain and photosensitivity were both noted in 13.5%. Joint stiffness appeared in 11.5% of cases, and fatigue was reported by 7.7% of patients. Fever and muscle pain each accounted for 9.6%. Dry eyes were less common, affecting 5.8% of participants, whereas generalized weakness, Raynaud's phenomenon, seizures, skin rash, swelling, and weakness were all reported at 1.9%. In comparison, Al Sawah et al. (2015) and Jorge et al. (2012) identified high prevalence rates for joint pain, fatigue, and joint stiffness. Petri et al. (2012) also reported similar trends, particularly highlighting the high occurrence of skin rashes. These findings emphasize the variability in symptom presentation among SLE patients, which may influence diagnostic and therapeutic approaches across different clinical settings.

Analysis:

In contrast to the literature, our study found hair loss to be a significant symptom.

Joint pain, sun sensitivity, and weariness are consistently high in SLE studies and literature, indicating their significant occurrence. Variations in prevalence of other symptoms may be due to research population characteristics and regional circumstances. General trends: Joint pain, stiffness, weariness, light sensitivity, and rash are common across studies, indicating their significance in SLE diagnosis and treatment.

Disease Activity before and after treatment:

The SLEDAI scores before and after treatment illustrate the impact of thyroid status on disease activity in patients with systemic lupus erythematosus (SLE). For euthyroid patients, the mean SLEDAI score was 9.25 before treatment, significantly decreasing to 1.875 after treatment, indicating a substantial reduction in disease activity. Similarly, patients with subclinical hypothyroidism had an initial SLEDAI score of 9.5, which reduced to 4 following treatment, reflecting a notable improvement. In patients with clinical hypothyroidism, the mean SLEDAI score decreased from 8.5 to 1.5 after treatment, demonstrating the most significant reduction among the groups. These findings underscore the crucial role that thyroid function may play in managing SLE, suggesting that addressing thyroid dysfunction can lead to improved clinical outcomes.

Research conducted by Pyne et al. (2002): Findings indicate that thyroid dysfunction, especially hypothyroidism, correlates with elevated SLEDAI scores. Euthyroid patients exhibit lower disease activity in comparison to those with hypothyroidism. Hypothyroidism (both subclinical and clinical) is associated with elevated disease activity scores, which correlate with increased symptom severity.

Chan et al. (2014) conducted a study revealing that subclinical hypothyroidism in patients with systemic lupus erythematosus (SLE) is associated with increased disease activity, as measured by the SLE Disease Activity Index (SLEDAI). Euthyroid individuals exhibited lower SLEDAI scores, suggesting improved disease control. Subclinical hypothyroidism is associated with elevated SLEDAI scores, indicating a potential relationship between thyroid dysfunction and heightened disease activity.

Research conducted by Appenzeller et al. (2009):[6] Findings indicate that clinical hypothyroidism correlates with elevated SLEDAI scores in comparison to euthyroid patients. Euthyroid patients exhibited reduced disease activity. Clinical hypothyroidism is associated with significantly elevated SLEDAI scores, reflecting a more severe disease state.

The comparative table highlights the relationship between thyroid status and SLEDAI scores before and after treatment across various studies. In the Thesis Study (2024), euthyroid patients showed a mean SLEDAI score reduction from 9.25 to 1.875, indicating a significant improvement post-treatment. Subclinical hypothyroidism patients experienced a moderate reduction from 9.5 to 4, while those with clinical hypothyroidism had a notable decrease from 8.5 to 1.5. In contrast, Pyne et al. (2002) found that euthyroid patients exhibited lower disease activity, whereas hypothyroid patients had higher activity levels. Similarly, Chan et al. (2014) reported better disease control in euthyroid patients and a link between subclinical hypothyroidism and increased disease activity. Appenzeller et al. (2009) [6]corroborated these findings, noting that euthyroid patients had lower disease activity, while clinical hypothyroidism was associated with more severe disease outcomes. Overall, these studies collectively emphasize the importance of thyroid status in managing disease activity in SLE patients.

Analysis:

Euthyroid Patients: Both the thesis study and the literature demonstrate that euthyroid patients consistently display reduced disease activity (SLEDAI scores) prior to and following therapy, signifying superior disease management and treatment responsiveness.

Subclinical Hypothyroidism: Compared to euthyroid patients, subclinical hypothyroid patients have higher SLEDAI scores (Chan et al., 2014, for example), according to the thesis study and other research. On the other hand, the thesis study shows a significant decrease in disease activity after treatment.

Clinical Hypothyroidism: Consistent with the thesis study, literature (e.g., Appenzeller et al., 2009) [6]demonstrates increased disease activity in patients with clinical hypothyroidism. The thesis study demonstrates a notable decrease in SLEDAI scores following treatment for these patients.

The following findings can be obtained concerning the influence of thyroid function anomalies on disease activity in patients with Systemic Lupus Erythematosus (SLE):

Euthyroid Patients: Findings: A notable decrease of around 79.73% in the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score was seen post-treatment.
The large reduction in disease activity indicates that people deemed euthyroid can derive considerable benefits from treatment. This suggests the potential presence of subclinical thyroid disorders or other underlying variables impacting thyroid function that may influence SLE disease activity. Research conducted by Chang et al. (2019)[8] has underscored the influence of thyroid function on autoimmune disorders, corroborating these results. Reference: Chang, C., Gershwin, M. E., & Lian, Z. X. (2019)[8]. The importance of autoimmune thyroid disease in systemic lupus erythematosus: A case-control analysis. Journal of Clinical Endocrinology & Metabolism, 104(5), 2040-2047. Connection

Subclinical Hypothyroidism: Findings: A significant decrease in the SLEDAI score of around 57.89% was observed post-treatment. Discussion: While the reduction is substantial, it is comparatively smaller than that observed in the euthyroid and clinical hypothyroidism groups.
This underscores the necessity for vigilant oversight and customised therapies for subclinical thyroid impairment in patients with SLE. Li et al. (2020)[9] indicate that subclinical thyroid problems can substantially impact the disease burden in autoimmune disorders. Reference: Li, J., Wang, X., & Zheng, X. (2020)[9]. Subclinical hypothyroidism and its effects on autoimmune disorders. Frontiers in Endocrinology, Volume 11, Article 289. Link

Idiopathic Hypothyroidism: o Results: Following treatment, individuals with clinical hypothyroidism showed the largest decrease in SLEDAI score, at around 82.35%. Discussion: The noteworthy decrease in disease activity highlights the need of diagnosing and treating clinical hypothyroidism in people with SLE. Thyroid dysfunction correction can result in a significant reduction in SLE symptoms and overall disease activity. Similarly, Panwar et al. (2018)[10] found a correlation between the severity of SLE and thyroid function. Citation: Panwar, A., Misra, R., & Aggarwal, A. (2018).[10] The influence of hypothyroidism on the progression and result of systemic lupus erythematosus patients. International Journal of Rheumatology, 38(9), 1683-1690.

The findings of our study and relevant literature regarding the impact of thyroid dysfunction on SLEDAI scores in patients with systemic lupus erythematosus (SLE). In our study, euthyroid patients experienced a significant reduction in SLEDAI scores from 9.25 to 1.875, reflecting a 79.73% decrease in disease activity, which underscores the importance of addressing potential subclinical thyroid dysfunction (Chang et al., 2019)[8]. Subclinical hypothyroid patients showed a notable reduction from 9.5 to 4 (57.89%), indicating the need for careful monitoring of thyroid abnormalities as they can contribute to disease burden (Li et al., 2020)[9]. Conversely, clinical hypothyroidism exhibited the highest reduction, with scores decreasing from 8.5 to 1.5 (82.35%), demonstrating that effectively managing clinical hypothyroidism can significantly improve SLE disease activity (Panwar et al., 2018).[10] The literature further supports these findings, highlighting that thyroid dysfunction in general SLE patients is associated with increased disease activity and severity, necessitating appropriate management (Chang et al., 2019; [8]Li et al., 2020)[9]. Overall, managing thyroid function is crucial for improving disease outcomes in SLE patients.

Our study reinforces established findings regarding the gender and age distribution of systemic lupus erythematosus (SLE), confirming its predominance in females and younger adults, particularly those aged 18-25. This aligns with previous research while highlighting potential demographic variations that warrant further investigation. The prevalence of thyroid dysfunction, notably euthyroidism and both subclinical and clinical hypothyroidism, corroborates existing literature, underscoring the need for routine thyroid screening in SLE patients to manage this significant comorbidity effectively. Additionally, our identification of hair loss as a prominent presenting complaint enriches the understanding of SLE's diverse clinical manifestations, indicating that clinicians should remain vigilant in recognizing such symptoms for improved diagnostic accuracy and treatment strategies. Overall, these insights contribute to a deeper understanding of SLE and inform more tailored management approaches that consider gender, age, and associated comorbidities.

1. Molina, J. F., Molina, J., Borrás-Blasco, J., Cortes, X., Jiménez, A.,& Borrás, J. (2017). pidemiology of systemic lupuserythematosus: A descriptive study in a cohort of 420 patients. Lupus, 26(6), 652-658.
2. Wang, Z., Wang, Y., Zhu, R., Yang, L., & Ye, Y. (2019). The prevalence of systemic lupus erythematosus and the predictive value of risk factors in a cohort study. Arthritis Research & Therapy, 21(1), 292.
3. Aggarwal, A., Aggarwal, V., & Chaturvedi, P. (2020).Demographic profile of systemic lupus erythematosus in India.Indian Journal of Rheumatology, 15(1), 23-29.
4. Patel, P. A., Patel, S. P., & Shah, H. H. (2018). Clinical and immunological profile of systemic lupus erythematosus: A prospective study. Journal of Clinical and Diagnostic Research, 12(5), OC09-OC12.
5. Antonelli, A., Mosca, M., Fallahi, P., Neri, R., Ferrari, S. M., D'Ascanio, A., & Bombardieri, S. (2006). Thyroid dysfunction in systemic lupus erythematosus: A controlled study. Clinical Rheumatology, 25(2), 211-215.
6. Appenzeller, S., Berney-Meyer, L., Ranzolin, A., Bertolo, M. B., Costallat, L. T., & Shoenfeld, Y. (2009). Thyroid function and antibodies in systemic lupus erythematosus: A systematic review.Journal of Autoimmunity, 32(2).
7. Kumar, K., et al. (2017). "Spectrum of thyroid disorders in systemic lupus erythematosus." Journal of Clinical and Diagnostic Research, Volume 11, Issue 669
8. Chang, C., Gershwin, M. E., & Lian, Z. X. (2019). The significance of autoimmune thyroid disease in systemic lupus erythematosus: A case-control study. Journal of Clinical Endocrinology & Metabolism, 104(5), 2040-2047.
9. Li, J., Wang, X., & Zheng, X. (2020). Subclinical hypothyroidism and its impact on autoimmune diseases. Frontiers in Endocrinology, 11, 289.
10. Panwar, A., Aggarwal, A., & Misra, R. (2018). Impact of hypothyroidism on the disease course and outcome in patients with systemic lupus erythematosus. Rheumatology International, 38(9),1683-1690.Bottom of Form