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Ruscitti P, Cantarini L, Nigrovic PA, McGonagle D, Giacomelli R. Recent advances and evolving concepts in Still's disease. Nat Rev Rheumatol 2024; 20:116-132. [PMID: 38212542 DOI: 10.1038/s41584-023-01065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/13/2024]
Abstract
Still's disease is a rare inflammatory syndrome that encompasses systemic juvenile idiopathic arthritis and adult-onset Still's disease, both of which can exhibit life-threatening complications, including macrophage activation syndrome (MAS), a secondary form of haemophagocytic lymphohistiocytosis. Genetic insights into Still's disease involve both HLA and non-HLA susceptibility genes, suggesting the involvement of adaptive immune cell-mediated immunity. At the same time, phenotypic evidence indicates the involvement of autoinflammatory processes. Evidence also implicates the type I interferon signature, mechanistic target of rapamycin complex 1 signalling and ferritin in the pathogenesis of Still's disease and MAS. Pathological entities associated with Still's disease include lung disease that could be associated with biologic DMARDs and with the occurrence of MAS. Historically, monophasic, recurrent and persistent Still's disease courses were recognized. Newer proposals of alternative Still's disease clusters could enable better dissection of clinical heterogeneity on the basis of immune cell profiles that could represent diverse endotypes or phases of disease activity. Therapeutically, data on IL-1 and IL-6 antagonism and Janus kinase inhibition suggest the importance of early administration in Still's disease. Furthermore, there is evidence that patients who develop MAS can be treated with IFNγ antagonism. Despite these developments, unmet needs remain that can form the basis for the design of future studies leading to improvement of disease management.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC), Leeds Teaching Hospitals, Leeds, UK
| | - Roberto Giacomelli
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
- Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
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Jia J, Wang M, Ma Y, Meng J, Zhu D, Chen X, Shi H, Sun Y, Liu H, Cheng X, Su Y, Ye J, Chi H, Liu T, Zhou Z, Wang F, Chen L, Yi D, Xiao Y, Yang C, Teng J, Hu Q. Neutrophil extracellular trap-induced intermediate monocytes trigger macrophage activation syndrome in adult-onset Still's disease. BMC Med 2023; 21:507. [PMID: 38124139 PMCID: PMC10734198 DOI: 10.1186/s12916-023-03231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is a systemic autoinflammatory disease characterized by innate immune system activation, with a high risk for macrophage activation syndrome (MAS). MAS development is associated with monocyte/macrophage activation and cytokine storm. Monocytes consist of three different subsets, classical monocytes (CMs, CD14brightCD16 -), intermediate monocytes (IMs, CD14brightCD16 +), and non-classical monocytes (NCMs, CD14dimCD16 +), each has distinct roles in inflammatory regulation. However, the frequencies and regulatory mechanism of monocyte subsets in AOSD patients have not been identified. METHODS We performed flow cytometry, RNA sequencing, phagocytosis analysis, and enzyme-linked immunosorbent assay to evaluate monocyte subsets, cell functions, and potential biomarkers. The effect of neutrophil extracellular traps (NETs) on monocytes was determined by evaluating mRNA levels of DNA sensors, surface CD16 expression, and inflammasome pathway activation. RESULTS Higher proportions of intermediate monocytes (IMs) were identified in active AOSD patients. IMs displayed higher expression of CD80, CD86, HLA-DR, and CD163 than CMs and NCMs. CD163 upregulation was noted on AOSD IMs, accompanied by increased phagocytic activity and elevated cytokine/chemokine production, including IL-1β, IL-6, CCL8, and CXCL10. The frequencies of IMs were correlated with disease activity and higher in AOSD patients with MAS (AOSD-MAS). CCL8 and CXCL10 were highly expressed in RNA sequencing of monocytes from AOSD-MAS patients and plasma CXCL10 level could serve as a potential biomarker for AOSD-MAS. Moreover, DNA-sensing pathway was activated in monocytes from AOSD-MAS patients. Stimulation with NETs derived from AOSD induced DNA sensor expression, the expansion of IMs, and inflammasome pathway activation. These effects can be abrogated by DNase I treatment. CONCLUSIONS Our results demonstrated that the proportions of IMs were elevated in AOSD and associated with MAS. The DNA component in NETs from AOSD plays an important role in the formation of IMs, shedding new light for the therapeutic target.
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Affiliation(s)
- Jinchao Jia
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Mengyan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Yuning Ma
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Jianfen Meng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Dehao Zhu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Xia Chen
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Huihui Chi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Tingting Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Zhuochao Zhou
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Fan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Longfang Chen
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Da Yi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Yu Xiao
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China.
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China.
| | - Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Second Road, Shanghai, 200025, China.
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Ruscitti P, Ursini F, Berardicurti O, Masedu F, Bozzalla Cassione E, Naldi S, Di Cola I, Di Muzio C, De Stefano L, Di Nino E, Navarini L, Vomero M, Bugatti S, Valenti M, Mariani E, Iagnocco A, Montecucco C, Giacomelli R, Cipriani P. Cytokine profile, ferritin and multi-visceral involvement characterize macrophage activation syndrome during adult-onset Still's disease. Rheumatology (Oxford) 2022; 62:321-329. [PMID: 35438139 DOI: 10.1093/rheumatology/keac247] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To multidimensionally characterize macrophage activation syndrome (MAS) complicating adult-onset Still's disease (AOSD) considering cytokine profile, inflammatory markers and multi-visceral involvement of the disease. To perform a high-dimensional phenotypic analysis of circulating immune cells in AOSD patients with and without MAS. To assess interferon (IFN)-related pathways in AOSD synovial tissues by a bulky RNA sequencing. METHODS Clinical and biologic data were collected and compared in AOSD patients with and without MAS. Sera biomolecules were analysed by Luminex multiplexing technology. Mass cytometry (CyTOF) was used to characterize circulating immune cells. A bulky RNA sequencing was performed in AOSD synovial tissues. RESULTS Forty consecutive AOSD patients were assessed, 14 complicated with MAS. Paralleling with increases of systemic score and ferritin, MAS patients showed higher levels of IL-1α, IL-1β, IL-1Ra, IL-2Ra, IL-6, IL-10, IL-17A, IFN-γ, G-CSF, MCP-1, MIP-1α and SCF. Combining the discriminatory ability of these data in identifying MAS, the best model was composed by systemic score, ferritin, IFN-γ and IL-10. By CyTOF analysis, MAS patients showed an increase of circulating 'classical monocytes' and a reduction of total NK cells. Our assessment showed 3477 IFN-related genes (IRGs) were differently expressed in AOSD synovial tissues. CONCLUSIONS A multidimensional characterization of AOSD patients suggested that IFN-γ, IL-10, ferritin and systemic score discriminated the occurrence of cytokine storm syndrome associated with MAS. The inflammatory milieu of AOSD and MAS may be related to a signature of circulating immune cells. Finally, our results about IRGs reinforced the role of IFN-γ in these patients.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Francesco Ursini
- Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli.,Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna
| | - Onorina Berardicurti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila.,Academy of Sciences of Abruzzo Region, Abruzzo
| | | | - Susanna Naldi
- Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli.,Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna
| | - Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Claudia Di Muzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Ludovico De Stefano
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia
| | - Elena Di Nino
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Luca Navarini
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome
| | - Marta Vomero
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome
| | - Serena Bugatti
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | - Erminia Mariani
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna.,Laboratory of Immunorheumatology and Tissue Regeneration, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Ortopedico Rizzoli, Bologna
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Ospedale Mauriziano - Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Turin, Italy
| | | | - Roberto Giacomelli
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
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Tsuboi H, Segawa S, Yagishita M, Toko H, Honda F, Kitada A, Miki H, Ohyama A, Hagiwara S, Kondo Y, Matsumoto I, Sumida T. Activation mechanisms of monocytes/macrophages in adult-onset Still disease. Front Immunol 2022; 13:953730. [PMID: 36090971 PMCID: PMC9461677 DOI: 10.3389/fimmu.2022.953730] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/02/2022] [Indexed: 12/23/2022] Open
Abstract
Adult onset Still disease (AOSD) is a systemic inflammatory disorder characterized by skin rash, spiking fever, arthritis, sore throat, lymphadenopathy, and hepatosplenomegaly. Although the etiology of this disease has not been fully clarified, both innate and acquired immune responses could contribute to its pathogenesis. Hyperactivation of macrophages and neutrophils along with low activation of natural killer (NK) cells in innate immunity, as well as hyperactivation of Th1 and Th17 cells, whereas low activation of regulatory T cells (Tregs) in acquired immunity are involved in the pathogenic process of AOSD. In innate immunity, activation of monocytes/macrophages might play central roles in the development of AOSD and macrophage activation syndrome (MAS), a severe life-threating complication of AOSD. Regarding the activation mechanisms of monocytes/macrophages in AOSD, in addition to type II interferon (IFN) stimulation, several pathways have recently been identified, such as the pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs)-pattern recognition receptors (PRRs) axis, and neutrophil extracellular traps (NETs)-DNA. These stimulations on monocytes/macrophages cause activation of the nucleotide-binding oligomerization domain, leucine-rich repeat, and pyrin domain (NLRP) 3 inflammasomes, which trigger capase-1 activation, resulting in conversion of pro-IL-1β and pro-IL-18 into mature forms. Thereafter, IL-1β and IL-18 produced by activated monocytes/macrophages contribute to various clinical features in AOSD. We identified placenta-specific 8 (PLAC8) as a specifically increased molecule in monocytes of active AOSD, which correlated with serum levels of CRP, ferritin, IL-1β, and IL-18. Interestingly, PLAC8 could suppress the synthesis of pro-IL-1β and pro-IL-18 via enhanced autophagy; thus, PLAC8 seems to be a regulatory molecule in AOSD. These findings for the activation mechanisms of monocytes/macrophages could shed light on the pathogenesis and development of a novel therapeutic strategy for AOSD.
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Ruscitti P, Di Cola I, Di Muzio C, Italiano N, Ursini F, Giacomelli R, Cipriani P. Expanding the spectrum of the hyperferritinemic syndrome, from pathogenic mechanisms to clinical observations, and therapeutic implications. Autoimmun Rev 2022; 21:103114. [PMID: 35595050 DOI: 10.1016/j.autrev.2022.103114] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/15/2022] [Indexed: 01/19/2023]
Abstract
From the introduction of hyperferritinemic syndrome concept, a growing body of evidence has suggested the role of ferritin as a pathogenic mediator and a relevant clinical feature in the management of patients with inflammatory diseases. From a pathogenic point of view, ferritin may directly stimulate the aberrant immune response by triggering the production of pro-inflammatory mediators in inducing a vicious pathogenic loop and contributing to the occurrence of cytokine storm syndrome. The latter has been recently defined as a clinical picture characterised by elevated circulating cytokine levels, acute systemic inflammatory symptoms, and secondary organ dysfunction beyond that which could be attributed to a normal response to a pathogen It is noteworthy that the occurrence of hyperferritinemia may be correlated with the development of the cytokine storm syndrome in the context of an inflammatory disease. In addition to adult onset Still's disease, macrophage activation syndrome, catastrophic anti-phospholipids syndrome, and septic shock, recent evidence has suggested this association between ferritin and life-threatening evolution in patients with systemic lupus erythematosus, with anti-MDA5 antibodies in the context of poly-dermatomyositis, with severe COVID-19, and with multisystem inflammatory syndrome. The possible underlying common inflammatory mechanisms, associated with hyperferritinemia, may led to the similar clinical picture observed in these patients. Furthermore, similar therapeutic strategies could be suggested inhibiting pro-inflammatory cytokines and improving long-term outcomes in these disorders. Thus, it could be possible to expand the spectrum of the hyperferritinemic syndrome to those diseases burdened by a dreadful clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome. In addition, the assessment of ferritin may provide useful information to the physicians in clinical practice to manage these patients. Therefore, ferritin may be considered a relevant clinical feature to be used as biomarker in dissecting the unmet needs in the management of these disorders. Novel evidence may thus support an expansion of the spectrum of the hyperferritinemic syndrome to these diseases burdened by a life-threatening clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudia Di Muzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Noemi Italiano
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Ursini
- Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Roberto Giacomelli
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Ruscitti P, Berardicurti O, Di Cola I, Di Muzio C, Di Nino E, Giacomelli R, Cipriani P. The hyper-expression of NLRP4 characterizes the occurrence of macrophage activation syndrome assessing STING pathway in adult-onset Still's disease. Clin Exp Immunol 2022; 208:95-102. [PMID: 35467709 PMCID: PMC9113323 DOI: 10.1093/cei/uxac014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/21/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
To assess stimulator of interferon genes (STING) pathway in patients with adult-onset Still's disease (AOSD) who were complicated or not by macrophage activation syndrome (MAS), evaluating peripheral blood mononuclear cells (PBMCs), and synovial tissues. The relative mRNA expression of key molecules of the STING pathway (i.e. CGAS, NLRP4, PKDC, STING1, XRCC5, and XRCC6) and interferon (IFN)-γ was assessed in PBMCs obtained from patients with AOSD, who were complicated or not by MAS, and healthy controls (HCs). A bulky RNA sequencing was performed in synovial tissues from two patients with AOSD. Finally, the ability of heavy ferritin subunit (FeH) to induce the expression of NLRP4 was evaluated in cultured macrophages. Twenty patients with AOSD were analysed. Out of them, seven patients were complicated by MAS. Assessing mRNA relative expression in PBMCs, STING1, NLRP4, XRCC6, and IFN-γ were significantly expressed in AOSD than HCs. The mRNA relative expression of CGAS, PKDC, and XRCC5 did not differ between patients and HCs. Furthermore, NLRP4 and IFN-γ resulted to be significantly increased in patients with AOSD complicated by MAS than others. By RNA-sequencing analysis, we observed that Nlrp4 gene was significantly up-regulated in patients with AOSD. Following the stimulation with FeH, an increased expression of NLRP4 was observed in cultured macrophages. In conclusion, an increased expression of some key molecules of STING pathway characterized patients with AOSD. In addition, our results suggested that a hyper-activity of NLRP4 may be observed in patients with MAS. Furthermore, FeH increased the expression of NLRP4 in cultured macrophages.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Onorina Berardicurti
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Claudia Di Muzio
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Elena Di Nino
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Giacomelli
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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Ruscitti P, Berardicurti O, Giacomelli R, Cipriani P. The clinical heterogeneity of adult onset Still's disease may underlie different pathogenic mechanisms. Implications for a personalised therapeutic management of these patients. Semin Immunol 2021; 58:101632. [PMID: 35787972 DOI: 10.1016/j.smim.2022.101632] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adult-onset Still's disease (AOSD) is a rare inflammatory disease of unknown aetiology usually affecting young adults and manifesting with a clinical triad of spiking fever, arthritis, and evanescent cutaneous rash. AOSD may be considered a highly heterogeneous disease, despite a similar clinical presentation, the disease course may be completely different. Some patients may have a single episode of the disease whereas others may evolve toward a chronic course and experience life-threatening complications. On these bases, to dissect the clinical heterogeneity of this disease, four different subsets were identified combining the manifestations at the beginning with possible diverse outcomes over time. Each one of these derived subsets would be characterised by a prominent different clinical feature from others, thus proposing dissimilar underlying pathogenic mechanisms, at least partially. Consequently, a distinct management of AOSD may be suggested to appropriately tailor the therapeutic strategy to these patients, according to principles of the precision medicine. These findings would also provide the rationale to recognise a different genetic and molecular profile of patients with AOSD. Taking together these findings, the basis for a precision medicine approach may be suggested in AOSD, which would drive a tailored therapeutic approach in these patients. A better patient stratification may also help in arranging specific designed studies to improve the management of patients with AOSD. Behind these different clinical phenotypes, distinct endotypes of AOSD may be suggested, probably differing in pathogenesis, outcomes, and response to therapies.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Onorina Berardicurti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Roberto Giacomelli
- Unit of Rheumatology and Clinical Immunology, University of Rome "Campus Biomedico", Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Increased Lipid Peroxidation May Be Linked to Ferritin Levels Elevation in Adult-Onset Still's Disease. Biomedicines 2021; 9:biomedicines9111508. [PMID: 34829738 PMCID: PMC8614840 DOI: 10.3390/biomedicines9111508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 12/24/2022] Open
Abstract
Lipid peroxidation (LPO) and hyper-ferritinemia are involved in inflammatory responses. Although hyper-ferritinemia is a characteristic of AOSD, its link to LPO remains unclear. We investigated the association between LPO and ferritin expression, and evaluated the relationship between LPO-related metabolites and inflammatory parameters. Mean fluorescence intensity (MFI) of LPO (C11-Biodipy581/591)-expressing PBMCs/monocytes in AOSD patients and healthy control (HC) subjects was determined by flow-cytometry analysis. Expression of ferritin and cytokines on PBMCs/macrophages was examined by immunoblotting. Plasma levels of LPO-related metabolites and cytokines were determined by ELISA and the MULTIPLEX platform, respectively. LPO MFI on PBMCs/monocytes were significantly higher in patients (median 4456 and 9091, respectively) compared with HC (1900, p < 0.05, and 4551, p < 0.01, respectively). Patients had higher ferritin expression on PBMCs (mean fold, 1.02) than HC (0.55, p < 0.05). Their ferritin expression levels on PBMCs stimulated with LPO inducers erastin or RSL3 (2.47 or 1.61, respectively) were higher than HC (0.84, p < 0.05, or 0.74, p < 0.01). Ferritin expression on erastin-treated/IL-1β-treated macrophages from patients were higher than those from HC (p < 0.001). The elevated levels of LPO-related metabolites, including malondialdehyde and 4-hydroxyalkenals, were positively correlated with disease activity scores, suggesting LPO involvement in AOSD pathogenesis. Increased ferritin expression on PBMCs/macrophages stimulated with LPO inducers indicates a link between LPO and elevated ferritin.
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An Update on the Pathogenic Role of Macrophages in Adult-Onset Still's Disease and Its Implication in Clinical Manifestations and Novel Therapeutics. J Immunol Res 2021; 2021:8998358. [PMID: 34239943 PMCID: PMC8238602 DOI: 10.1155/2021/8998358] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/23/2021] [Accepted: 05/28/2021] [Indexed: 12/18/2022] Open
Abstract
Increasing evidence indicates a pivotal role of macrophages in innate immunity, which contributes to the pathogenesis of adult-onset Still's disease (AOSD). Despite the available reviews that summarized the pathogenic role of proinflammatory cytokines in AOSD, a systematic approach focusing on the crucial role of macrophages in this disease is still lacking. This review summarizes the updated functions of macrophages in AOSD and their implication in clinical manifestations and therapeutics. We searched the MEDLINE database using the PubMed interface and reviewed the English-language literature as of 31 March 2021, from 1971 to 2021. We focus on the existing evidence on the pathogenic role of macrophages in AOSD and its implication in clinical characteristics and novel therapeutics. AOSD is an autoinflammatory disease mainly driven by the innate immune response. Among the innate immune responses, macrophage activation is a hallmark of AOSD pathogenesis. The pattern recognition receptors (PRRs) on macrophages recognize pathogen-associated molecular patterns and damage-associated molecular patterns and subsequently cause overproduction of proinflammatory cytokines and recruit adaptive immunity. Some biomarkers, such as ferritin and gasdermin D, reflecting macrophage activation were elevated and correlated with AOSD activity. Given that macrophage activation with the overproduction of proinflammatory cytokines plays a pathogenic role in AOSD, these inflammatory mediators would be the therapeutic targets. Accordingly, the inhibitors to interleukin- (IL-) 1, IL-6, and IL-18 have been shown to be effective in AOSD treatment. Gaining insights into the pathogenic role of macrophages in AOSD can aid in identifying disease biomarkers and therapeutic agents for this disease.
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Macrophage activation syndrome in systemic lupus erythematosus and systemic-onset juvenile idiopathic arthritis: a retrospective study of similarities and dissimilarities. Rheumatol Int 2021; 41:625-631. [PMID: 33388903 DOI: 10.1007/s00296-020-04763-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 11/25/2020] [Indexed: 01/14/2023]
Abstract
Macrophage activation syndrome (MAS) is a serious complication of rheumatic diseases. Fever and hyperferritinemia are common in active systemic-onset juvenile idiopathic arthritis (sJIA) and cytopenia in active systemic lupus erythematosus (SLE), thus recognizing MAS in them is a challenge. We compared clinical and laboratory parameters, various classification criteria, and outcomes of MAS in SLE and sJIA. Clinical and laboratory data were extracted from case records of patients with clinician diagnosed cases of SLE-MAS (adult and pediatric) and sJIA-MAS, admitted (2004-2018) at a tertiary care hospital. Ravelli, International consensus, HLH-2004, and criteria proposed by Parodi et al. were applied and compared. Among 33 patients (18 females) with MAS, 19 had SLE (7, childhood-onset SLE) and 14 had sJIA. MAS was more likely to be the presenting manifestation of disease in SLE (p < 0.05). There were no differences in the clinical features among them. Patients with SLE-MAS had lower baseline total leucocyte and platelet counts (p < 0.01), whereas patients with sJIA-MAS had significantly higher median CRP (p = 0.002), fall in TLC (p = 0.012), delta ESR/CRP ratio (p = 0.02), and lower fibrinogen level (p = 0.006). Neutrophil-to-lymphocyte ratio, ferritin/CRP ratio, and the number of patients with ferritin/ESR > 80 were similar. Only 6/33(18%) fulfilled the HLH criteria. Criteria meant for sJIA-MAS or SLE-MAS performed well for both diseases and the majority of patients could be diagnosed using them. Two patients died in each group. MAS in SLE and sJIA is more similar than dissimilar in clinical features and outcome. Criteria meant for MAS in sJIA or SLE-MAS performed equally well in both diseases.
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Arora A, Gautam P, Gupta N, Sharma K, Goel A. Adult-onset still's disease masquerading as hemophagocytic lymphohistiocytosis. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2021. [DOI: 10.4103/injms.injms_34_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ruscitti P, Di Benedetto P, Berardicurti O, Panzera N, Grazia N, Lizzi AR, Cipriani P, Shoenfeld Y, Giacomelli R. Pro-inflammatory properties of H-ferritin on human macrophages, ex vivo and in vitro observations. Sci Rep 2020; 10:12232. [PMID: 32699419 PMCID: PMC7376151 DOI: 10.1038/s41598-020-69031-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/06/2020] [Indexed: 12/14/2022] Open
Abstract
Ferritin is an iron-binding molecule, which comprises 24 subunits, heavy (FeH) and light (FeL) subunits, suggested to have a pathogenic role by the 'hyperferritinemic syndrome'. In this work, we tested (1) FeH and FeL in bone marrow (BM) and sera in patients with macrophage activation syndrome (MAS); (2) pro-inflammatory effects of ferritin, FeL, and FeH on macrophages; (3) ability of FeH-stimulated macrophages to stimulate the proliferation of peripheral blood mononuclear cells (PBMCs); (4) production of mature IL-1β and IL-12p70 in extracellular compartments of FeH-stimulated macrophages. Immunofluorescence analysis and liquid chromatography mass spectrometry (LC-MS/MS) based proteomics were performed to identify FeL and FeH in BM and sera, respectively, in the same patients. Macrophages were stimulated with ferritin, FeH, and FeL to assess pro-inflammatory effects by RT-PCR and western blot. The proliferation of co-cultured PBMCs with FeH-stimulated macrophages was tested. Immunofluorescence showed an increased FeH expression in BMs, whereas LC-MS/MS identified that FeL was mainly represented in sera. FeH induced a significant increase of gene expressions of IL-1β, IL-6, IL-12, and TNF-α, more marked with FeH, which also stimulated NLRP3. FeH-stimulated macrophages enhanced the proliferation of PBMCs. The ELISA assays showed that mature form of IL-1β and IL-12p70 were increased, in extracellular compartments of FeH-stimulated macrophages. Our results showed FeH in BM biopsies of MAS patients, whereas, LC-MS/MS identified FeL in the sera. FeH showed pro-inflammatory effects on macrophages, stimulated NLRP3, and increased PBMCs proliferation.
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Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy.
| | - Paola Di Benedetto
- Clinical Pathology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Onorina Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Noemi Panzera
- Clinical Pathology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Nicolò Grazia
- Clinical Pathology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Anna Rita Lizzi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel HaShomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, Saint Petersburg, Russia
| | - Roberto Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
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Ruscitti P, Conforti A, Pavlych V, Giacomelli R. Inhibiting inflammatory cytokines in adult onset Still’s disease. Current trends and new therapeutic perspectives. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1701431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Piero Ruscitti
- Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Alessandro Conforti
- Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Viktoriya Pavlych
- Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Giacomelli
- Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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Wang MY, Jia JC, Yang CD, Hu QY. Pathogenesis, disease course, and prognosis of adult-onset Still's disease: an update and review. Chin Med J (Engl) 2019; 132:2856-2864. [PMID: 31856058 PMCID: PMC6940076 DOI: 10.1097/cm9.0000000000000538] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is a rare but clinically well-known polygenic systemic autoinflammatory disease. In this review, we aim to present frontiers in the pathogenesis, clinical features, diagnosis, biomarkers, disease course, prognosis, and treatment in AOSD. DATA SOURCES We retrieved information from the PubMed database up to July 2019, using various search terms and relevant words, including AOSD and Still's disease. STUDY SELECTION We included data from peer-reviewed journals. Both basic and clinical studies were selected. RESULTS Pathogenesis of AOSD involves genetic background, infectious triggers, and immunopathogenesis, mainly the activation of macrophages and neutrophils followed by a cytokine storm. Diagnosis and prognosis evaluation of AOSD is still challenging; therefore, there is an urgent need to identify better biomarkers. Biologic agents, including interleukin (IL)-1β, IL-6, and tumor necrosis factor-α antagonists in the treatment of AOSD, have good prospect. CONCLUSION This review highlights the advances in pathogenesis, potential biomarkers, disease course, and treatment in AOSD.
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Affiliation(s)
- Meng-Yan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Zeng F, Deng G, Luo H, Zuo X, Xie Y. Macrophage activation syndrome and pulmonary arterial hypertension in a patient with adult-onset Still disease: A case report. Medicine (Baltimore) 2019; 98:e17427. [PMID: 31689747 PMCID: PMC6946370 DOI: 10.1097/md.0000000000017427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Macrophage activation syndrome (MAS) and pulmonary arterial hypertension (PAH) are rare and life-threatening complications of adult-onset Still disease (AOSD). PATIENT CONCERNS We reported an interesting case of a 25-year-old AOSD patient with MAS and PAH, and the patient was found to have right anomalous pulmonary venous connection accompanied by an atrial septal defect. DIAGNOSIS MAS was diagnosed as a complication of AOSD. PAH was contributed probably by right anomalous pulmonary venous connection. INTERVENTIONS The patient dramatically improved with methylprednisolone (80 mg I.V. daily) plus supportive treatments, without interleukin (IL) inhibitors or ciclosporin A given. OUTCOMES The patient's serum hepatic enzyme levels dropped and hemocytes rose within 1 week. CONCLUSION Other causes need to be excluded carefully before giving a diagnosis of PAH with AOSD. Early diagnosis and aggressive treatments are pivotal to improve the quality of life and the survival of patients.
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Affiliation(s)
- Furong Zeng
- Department of Rheumatology and Immunology, Xiangya Hospital, The Institution of Rheumatology and Immunology
| | - Guangtong Deng
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Hui Luo
- Department of Rheumatology and Immunology, Xiangya Hospital, The Institution of Rheumatology and Immunology
| | - Xiaoxia Zuo
- Department of Rheumatology and Immunology, Xiangya Hospital, The Institution of Rheumatology and Immunology
| | - Yanli Xie
- Department of Rheumatology and Immunology, Xiangya Hospital, The Institution of Rheumatology and Immunology
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Affiliation(s)
- Dae Hyun Yoo
- Department of Rheumatology, Hospital for Rheumatic Diseases, College of Medicine, Hanyang University, Seoul, Korea
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Ruscitti P, Cipriani P, Liakouli V, Guggino G, Carubbi F, Berardicurti O, Ciccia F, Giacomelli R. Managing Adult-onset Still's disease: The effectiveness of high-dosage of corticosteroids as first-line treatment in inducing the clinical remission. Results from an observational study. Medicine (Baltimore) 2019; 98:e15123. [PMID: 30985672 PMCID: PMC6485786 DOI: 10.1097/md.0000000000015123] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
To assess the effectiveness of the treatment with high dosage of corticosteroids (CCSs), as first-line therapy, in inducing remission in naïve Adult-onset Still's disease (AOSD) patients compared with low dosage of CCSs, after 6 months. To further evaluate the rate of patients maintaining the remission and the rate of CCSs discontinuation, after additional 12 months of follow-up.A retrospective evaluation of patients prospectively followed was designed to compare the rate of clinical remission in naïve AOSD patients treated with high dosages of CCSs (0.8-1 mg/kg/day of prednisone-equivalent) or low dosage of CCSs (0.2-0.3 mg/kg/day of prednisone-equivalent), after 6 months. An additional analysis was performed to compare the rate of monocyclic pattern between these groups, after further 12 months of follow-up.The clinical remission was achieved in a higher percentage of patients treated with the first-line treatment with high dosage of CCSs than treated the first-line treatment with low dosage of CCSs. At the end of 18 months of follow-up, a larger percentage of patients treated the first-line treatment with high dosage of CCSs was classified as monocyclic pattern and discontinued CCSs when compared with patients treated the first-line treatment with low dosage of CCSs. Patients defined as CCSs non-responder were treated with methotrexate (MTX)+CCSs or with combination therapy CCSs+MTX+biologic drug. The clinical remission was observed in a percentage of these patients.We showed the effectiveness of the first-line treatment with high dosage of CCSs in inducing clinical remission in naïve AOSD patients when compared with the first-line treatment with low dosage of CCSs. The first-line treatment with high dosage of CCSs was also associated with the achievement of monocyclic pattern and CCSs discontinuation, after 18 months of follow-up.
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Affiliation(s)
- Piero Ruscitti
- Rheumatology, Department of Biotechnological and Applied Clinical Science, University of L’Aquila, L’Aquila
| | - Paola Cipriani
- Rheumatology, Department of Biotechnological and Applied Clinical Science, University of L’Aquila, L’Aquila
| | - Vasiliki Liakouli
- Rheumatology, Department of Biotechnological and Applied Clinical Science, University of L’Aquila, L’Aquila
| | - Giuliana Guggino
- Department of Clinical and Experimental Medicine, Rheumatology Section, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Francesco Carubbi
- Rheumatology, Department of Biotechnological and Applied Clinical Science, University of L’Aquila, L’Aquila
| | - Onorina Berardicurti
- Rheumatology, Department of Biotechnological and Applied Clinical Science, University of L’Aquila, L’Aquila
| | - Francesco Ciccia
- Department of Clinical and Experimental Medicine, Rheumatology Section, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Roberto Giacomelli
- Rheumatology, Department of Biotechnological and Applied Clinical Science, University of L’Aquila, L’Aquila
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Carubbi F, Alunno A, Cipriani P, Bistoni O, Scipioni R, Liakouli V, Ruscitti P, Berardicurti O, Di Bartolomeo S, Gerli R, Giacomelli R. Laboratory Assessment of Patients with Suspected Rheumatic Musculoskeletal Diseases: Challenges and Pitfalls. Curr Rheumatol Rev 2019; 15:27-43. [PMID: 29557752 DOI: 10.2174/1573397114666180320113603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 03/14/2018] [Accepted: 03/15/2018] [Indexed: 11/22/2022]
Abstract
Current patient care in rheumatology relies primarily on a combination of traditional clinical assessment and standard laboratory tests. Investigators seek to discover new biomarkers and novel technologies to boost the research in this field. Mechanistic biomarkers such as cytokines, cell types, antibodies, signaling molecules, are rooted in the mechanism underlying the disease and can guide the clinical management of the disease. Conversely, descriptive biomarkers are byproducts of the disease process, depict the state of a disease but are not involved in its pathogenesis. In this article, we reviewed the field of common laboratory biomarkers in rheumatology, highlighting both their descriptive or mechanistic value as well as their role in clinical practice.
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Affiliation(s)
- Francesco Carubbi
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy.,Department of Medicine, ASL1 Avezzano-Sulmona-L'Aquila, L'Aquila, AQ, Italy
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, PG, Italy
| | - Paola Cipriani
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy
| | - Onelia Bistoni
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, PG, Italy
| | - Rosa Scipioni
- Department of Medicine, ASL1 Avezzano-Sulmona-L'Aquila, L'Aquila, AQ, Italy
| | - Valiki Liakouli
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy
| | - Onorina Berardicurti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy
| | - Salvatore Di Bartolomeo
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy
| | - Roberto Gerli
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, PG, Italy
| | - Roberto Giacomelli
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, AQ, Italy
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Ruscitti P, Giacomelli R. Pathogenesis of adult onset still’s disease: current understanding and new insights. Expert Rev Clin Immunol 2018; 14:965-976. [DOI: 10.1080/1744666x.2018.1533403] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still's disease. J Autoimmun 2018; 93:24-36. [PMID: 30077425 DOI: 10.1016/j.jaut.2018.07.018] [Citation(s) in RCA: 232] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 02/06/2023]
Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown etiology usually affecting young adults; spiking fever, arthritis and evanescent rash are commonly observed during the disease. Other frequently observed clinical features include sore throat, hepatomegaly, splenomegaly, lymphadenopathy and serositis. Furthermore, AOSD patients may experience different life-threating complications. Macrophage activation syndrome (MAS) has been reported up to 15% of AOSD patients and it is considered to be the most severe complication of the disease being characterised by high mortality rate. During AOSD, laboratory tests reflect the systemic inflammatory process showing high levels of erythrocyte sedimentation rate and C-reactive protein. In addition, the ferritin levels are typically higher than those observed in other autoimmune, inflammatory, infectious, or neoplastic diseases. Analysing AOSD disease course, 3 different clinical patterns of AOSD have been identified: i. monocyclic pattern, characterised by a systemic single episode; ii. polycyclic pattern, characterised by multiple, ≤ 1 year lasting, flares, alternating with remissions; iii. chronic pattern, related to a persistently active disease with associated polyarthritis. At present, AOSD therapeutic strategy is aimed at targeting pro-inflammatory signs and symptoms, preventing organ damage and life-threating complications and minimising adverse effects of treatment. However, the treatment of AOSD remains largely empirical, lacking controlled clinical trials. High dosages of corticosteroids are usually the first line therapy when the systemic symptoms predominate. Despite this treatment, a large percentage of patients experiences several flares with an evolution toward the chronic disease course and up to 16% of patients die during the follow up, due to AOSD-related complications. On these bases, in the last years, biological agents have been successfully used in refractory cases. Finally, multiple recent lines of evidence have suggested new insights in AOSD pathogenesis unmasking further therapeutic targets. In fact, small molecules, used in experimental MAS models, might represent new therapeutic options.
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Affiliation(s)
- Roberto Giacomelli
- Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Piero Ruscitti
- Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Ruscitti P, Iacono D, Ciccia F, Emmi G, Cipriani P, Grembiale RD, Perosa F, Emmi L, Triolo G, Giacomelli R, Valentini G. Macrophage Activation Syndrome in Patients Affected by Adult-onset Still Disease: Analysis of Survival Rates and Predictive Factors in the Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale Cohort. J Rheumatol 2018; 45:864-872. [PMID: 29657144 DOI: 10.3899/jrheum.170955] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Macrophage activation syndrome (MAS) is a reactive form of hemophagocytic lymphohistiocytosis, which can complicate adult-onset Still disease (AOSD). We investigated AOSD clinical features at the time of diagnosis, to assess predictors of MAS occurrence. Further, we analyzed the outcomes of patients with AOSD who experience MAS. METHODS Patients with AOSD admitted to any Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale center were retrospectively analyzed for features typical of AOSD, MAS occurrence, and their survival rate. RESULTS Of 119 patients with AOSD, 17 experienced MAS (12 at admission and 5 during followup). Twelve patients with MAS at first admission differed from the remaining 107 in prevalence of lymphadenopathy and liver involvement at the time of diagnosis. In addition, serum ferritin levels and systemic score values were significantly higher in the patients presenting with MAS. At the time of diagnosis, the 5 patients who developed MAS differed from the remaining 102 in the prevalence of abdominal pain, and they showed increased systemic score values. In the multivariate analysis, lymphadenopathy (OR 7.22, 95% CI 1.49-34.97, p = 0.014) and abdominal pain (OR 4.36, 95% CI 1.24-15.39, p = 0.022) were predictive of MAS occurrence. Finally, MAS occurrence significantly reduced the survival rate of patients with AOSD (p < 0.0001). CONCLUSION MAS occurrence significantly reduced the survival rate in patients with AOSD. Patients with MAS at baseline presented an increased prevalence of lymphadenopathy and liver involvement, as well as high serum ferritin levels and systemic score values. The presence of lymphadenopathy and abdominal pain was associated with MAS occurrence.
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Affiliation(s)
- Piero Ruscitti
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy. .,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples.
| | - Daniela Iacono
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Francesco Ciccia
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Giacomo Emmi
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Paola Cipriani
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Rosa Daniela Grembiale
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Federico Perosa
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Lorenzo Emmi
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Giovanni Triolo
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Roberto Giacomelli
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
| | - Gabriele Valentini
- From the Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila; Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples; Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo; Department of Experimental and Clinical Medicine, University of Florence, Florence; Department of Health Sciences, University of Catanzaro "Magna Graecia," Catanzaro; Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy.,P. Ruscitti, MD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; D. Iacono, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples; F. Ciccia, MD, PhD, Rheumatology Section, Department of Internal Medicine, University of Palermo; G. Emmi, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence; P. Cipriani, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; R.D. Grembiale, MD, Department of Health Sciences, University of Catanzaro "Magna Graecia"; F. Perosa, MD, PhD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; L. Emmi, MD, Systemic Rheumatic and Autoimmune Diseases Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School; G. Triolo, MD, Rheumatology Section, Department of Internal Medicine, University of Palermo; R. Giacomelli, MD, PhD, Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila; G. Valentini, MD, Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples
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Ruscitti P, Cipriani P, Di Benedetto P, Liakouli V, Berardicurti O, Carubbi F, Ciccia F, Guggino G, Triolo G, Giacomelli R. H-ferritin and proinflammatory cytokines are increased in the bone marrow of patients affected by macrophage activation syndrome. Clin Exp Immunol 2017; 191:220-228. [PMID: 28960260 DOI: 10.1111/cei.13057] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 12/12/2022] Open
Abstract
Macrophage activation syndrome (MAS) is hyperinflammatory life-threatening syndrome, associated typically with high levels of serum ferritin. This is an iron storage protein including heavy (H) and light (L) subunits, categorized on their molecular weight. The H-/L subunits ratio may be different in tissues, depending on the specific tissue and pathophysiological status. In this study, we analysed the bone marrow (BM) biopsies of adult MAS patients to assess the presence of: (i) H-ferritin and L-ferritin; (ii) CD68+ /H-ferritin+ and CD68+ /L-ferritin+ ; and (iii) interleukin (IL)-1β, tumour necrosis factor (TNF) and interferon (IFN)-γ. We also explored possible correlations of these results with clinical data. H-ferritin, IL-1β, TNF and IFN-γ were increased significantly in MAS. Furthermore, an increased number of CD68+ /H-ferritin+ cells and an infiltrate of cells co-expressing H-ferritin and IL-12, suggesting an infiltrate of M1 macrophages, were observed. H-ferritin levels and CD68+ /H-ferritin+ cells were correlated with haematological involvement of the disease, serum ferritin and C-reactive protein. L-ferritin and CD68+ /L-ferritin+ cells did not correlate with these parameters. In conclusion, during MAS, H-ferritin, CD68+ /H-ferritin+ cells and proinflammatory cytokines were increased significantly in the BM inflammatory infiltrate, pointing out a possible vicious pathogenic loop. To date, H-ferritin and CD68+ /H-ferritin+ were associated significantly with haematological involvement of the disease, suggesting biomarkers assessing severity of clinical picture.
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Affiliation(s)
- P Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Di Benedetto
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - V Liakouli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - O Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Carubbi
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Ciccia
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - G Guggino
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - G Triolo
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - R Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Ruscitti P, Ursini F, Cipriani P, De Sarro G, Giacomelli R. Biologic drugs in adult onset Still's disease: a systematic review and meta-analysis of observational studies. Expert Rev Clin Immunol 2017; 13:1089-1097. [PMID: 28870100 DOI: 10.1080/1744666x.2017.1375853] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Biological drugs, mainly interleukin (IL)-1 and IL-6 antagonists, but also tumor necrosis factor (TNF) inhibitors, have been used in the treatment of adult onset Still's disease patients (AOSD). METHODS We summarised the available evidence for the effectiveness of biologic drugs in AOSD. A systematic review of the literature was performed in order to identify all the available data concerning the effectiveness of biologic drugs in AOSD. The proportion of patients achieving complete remission or any clinical response was calculated. The meta-analysis was thus performed using a random-effects model accounting for the expected high level of heterogeneity. RESULTS Nineteen observational published studies were included in the meta-analysis. The pooled analysis under a random-effects model showed an overall rate of clinical response of 0.85 (95% CI: 0.77-0.91, p < 0.0001) and an overall rate of complete remission of 0.66 (95% CI: 0.54-0.77, p = 0.01). The heterogeneity across studies was high (Q = 59.82 with df = 19.0, p < 0.0001, I2 = 68.23%). CONCLUSIONS Our meta-analysis suggests that AOSD patients may experience a clinical response and/or a complete remission when treated with biologic drugs. Specifically designed and powered studies are needed to fully investigate the role of such medications in the management of AOSD patients.
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Affiliation(s)
- Piero Ruscitti
- a Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences , University of L'Aquila , L'Aquila , Italy
| | - Francesco Ursini
- b Department of Health Sciences , University of Catanzaro "Magna Graecia" , Catanzaro , Italy
| | - Paola Cipriani
- a Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences , University of L'Aquila , L'Aquila , Italy
| | - Giovambattista De Sarro
- b Department of Health Sciences , University of Catanzaro "Magna Graecia" , Catanzaro , Italy
| | - Roberto Giacomelli
- a Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences , University of L'Aquila , L'Aquila , Italy
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Ruscitti P, Rago C, Breda L, Cipriani P, Liakouli V, Berardicurti O, Carubbi F, Di Battista C, Verrotti A, Giacomelli R. Macrophage activation syndrome in Still’s disease: analysis of clinical characteristics and survival in paediatric and adult patients. Clin Rheumatol 2017; 36:2839-2845. [DOI: 10.1007/s10067-017-3830-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 01/10/2023]
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25
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Ruscitti P, Cipriani P, Di Benedetto P, Liakouli V, Carubbi F, Berardicurti O, Ciccia F, Guggino G, Triolo G, Giacomelli R. Advances in immunopathogenesis of macrophage activation syndrome during rheumatic inflammatory diseases: toward new therapeutic targets? Expert Rev Clin Immunol 2017; 13:1041-1047. [PMID: 28837367 DOI: 10.1080/1744666x.2017.1372194] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Macrophage activation syndrome (MAS) is a severe, hyperinflammatory life-threatening syndrome, generally complicating different rheumatic diseases. Despite the severity of the disease, little is known about the pathogenic mechanisms and, thus, possible targeted therapies in the management of these patients. Areas covered: In this review, we aimed to update the current pathogenic knowledge of MAS, during rheumatic diseases, focusing mainly on immunologic abnormalities and on new possible therapeutic strategies. Expert commentary: The difficult pathogenic scenario of MAS, in which genetic defects, predisposing diseases, and triggers are mixed together with the high mortality rate, make it difficult to manage these patients. Although most efforts have been focused on investigating the disease in children, in recent years, several studies are trying to elucidate the possible pathogenic mechanism in adult MAS patients. In this context, genetic and immunological studies might lead to advances in the knowledge of pathogenic mechanisms and possible new therapeutic targets. In the future, the results of ongoing clinical trials are awaited in order to improve the management and, thus, the survival of these patients.
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Affiliation(s)
- Piero Ruscitti
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | - Paola Cipriani
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | | | - Vasiliky Liakouli
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | - Francesco Carubbi
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | | | - Francesco Ciccia
- b Division of Rheumatology , University of Palermo , Palermo , Italy
| | - Giuliana Guggino
- b Division of Rheumatology , University of Palermo , Palermo , Italy
| | - Giovanni Triolo
- b Division of Rheumatology , University of Palermo , Palermo , Italy
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Abstract
INTRODUCTION Adult onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown etiology, and approximately 60-70% of patients may develop a chronic polyphasic form of the disease or a chronic polyarthritis. Due to rarity of disease, treatment of AOSD is not based on controlled study, but on case based experiences. Areas covered: Recently, the application of anti-cytokine therapy based on pathophysiology has resulted in significant progress in the treatment of AOSD. Here, we review current knowledge of the pathogenesis, disease progression, currently available biomarkers of disease activity, standard therapeutic agents, utility of biologic agents, future perspectives for treatment and treatment of macrophage activation syndrome. Expert commentary: Accumulated clinical data suggest that chronic disease can be classified into two subsets: dominant systemic disease, and the arthritis subgroup. IL-1 inhibitors may be more efficient for systemic manifestations and IL-6 inhibitor for both joint involvement and systemic manifestations. TNF inhibitors must be reserved for patients with purely chronic articular manifestations. For ideal management of patients, it is very important to measure disease activity accurately during follow up, but no single biomarker has been classified as ideal. New therapeutic agents and composite biomarkers are needed to improve the outcome of patients with AOSD by identifying disease activity properly.
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Affiliation(s)
- Dae Hyun Yoo
- a Department of Rheumatology, College of Medicine , Hanyang University Hospital for Rheumatic Diseases , Seoul , Korea
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Ruscitti P, Cipriani P, Masedu F, Iacono D, Ciccia F, Liakouli V, Guggino G, Carubbi F, Berardicurti O, Di Benedetto P, Valenti M, Triolo G, Valentini G, Giacomelli R. Adult-onset Still's disease: evaluation of prognostic tools and validation of the systemic score by analysis of 100 cases from three centers. BMC Med 2016; 14:194. [PMID: 27903264 PMCID: PMC5131497 DOI: 10.1186/s12916-016-0738-8] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/03/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is rare inflammatory disease of unknown etiology that usually affects young adults. The more common clinical manifestations are spiking fevers, arthritis, evanescent rash, elevated liver enzymes, lymphadenopathy, hepatosplenomegaly, and serositis. The multi-visceral involvement of the disease and the different complications, such as macrophage activation syndrome, may strongly decrease the life expectancy of AOSD patients. METHODS This study aimed to identify the positive and negative features correlated with the outcome of patients. A retrospective analysis of AOSD patients prospectively admitted to three rheumatologic centers was performed to identify the clinical features present at the time of diagnosis and to predict the possible outcome. Furthermore, we investigated the as yet to be validated prognostic value of the systemic score previously proposed. RESULTS One hundred consecutive AOSD patients were enrolled. The mean systemic score showed that the majority of patients had a multi-organ involvement. Sixteen patients showed different complications, mainly the macrophage activation syndrome. A strong increase of inflammatory markers was observed. All patients received steroids at different dosages, 55 patients in association with immunosuppressive drugs and 32 in association with biologic agents. Sixteen patients died during the follow-up. Regression analysis showed that the higher values of the systemic score and the presence of AOSD-related complications, assessed at the time of diagnosis, were significantly correlated with patient mortality. A prognostic impact of the systemic score of ≥ 7.0 was reported. CONCLUSIONS Our study showed that a higher systemic score and the presence of AOSD-related complications at the time of diagnosis were significantly associated with mortality. Of note, a cut-off at 7.0 of the systemic score showed a strong prognostic impact in identifying patients at risk of AOSD-related death.
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Affiliation(s)
- Piero Ruscitti
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy.
| | - Paola Cipriani
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Francesco Masedu
- Medical Statistic Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Daniela Iacono
- Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Francesco Ciccia
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Vasiliki Liakouli
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Giuliana Guggino
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Francesco Carubbi
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Onorina Berardicurti
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Paola Di Benedetto
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Marco Valenti
- Medical Statistic Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Triolo
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Gabriele Valentini
- Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Roberto Giacomelli
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
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Ruscitti P, Cipriani P, Ciccia F, Masedu F, Liakouli V, Carubbi F, Berardicurti O, Guggino G, Di Benedetto P, Di Bartolomeo S, Valenti M, Triolo G, Giacomelli R. Prognostic factors of macrophage activation syndrome, at the time of diagnosis, in adult patients affected by autoimmune disease: Analysis of 41 cases collected in 2 rheumatologic centers. Autoimmun Rev 2016; 16:16-21. [PMID: 27664384 DOI: 10.1016/j.autrev.2016.09.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/29/2016] [Indexed: 12/21/2022]
Abstract
Macrophage activation syndrome (MAS) is a rare, life-threatening disease in which early diagnosis and aggressive therapeutic strategy may improve the outcome. Due to its rarity, epidemiologic data are still lacking. Hyperferritinemia is frequently associated with MAS and might modulate the cytokine storm, which is involved in the development of multiple organ failure. In this paper, we investigated clinical data, treatments, and outcome of a homogeneous cohort of 41 adult MAS patients, complicating autoimmune rheumatic diseases. MAS-related death occurred in 17 patients (42.5%) during the follow-up, and older age and increased serum ferritin levels, at the time of diagnosis, were significantly associated with mortality. In conclusion, adult MAS is associated with high mortality rate. Some clinical features at diagnosis may be predictive of MAS-associated death.
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Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Division of Rheumatology, University of L'Aquila, L'Aquila, Italy
| | | | - Francesco Masedu
- Division of Medical Statistic Unit, University of L'Aquila, L'Aquila, Italy
| | | | | | | | | | | | | | - Marco Valenti
- Division of Medical Statistic Unit, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Triolo
- Division of Rheumatology, University of Palermo, Palermo, Italy
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Ruscitti P, Cipriani P, Ciccia F, Di Benedetto P, Liakouli V, Berardicurti O, Carubbi F, Guggino G, Di Bartolomeo S, Triolo G, Giacomelli R. H-ferritin and CD68(+) /H-ferritin(+) monocytes/macrophages are increased in the skin of adult-onset Still's disease patients and correlate with the multi-visceral involvement of the disease. Clin Exp Immunol 2016; 186:30-8. [PMID: 27317930 DOI: 10.1111/cei.12826] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 12/28/2022] Open
Abstract
Adult-onset Still's disease (AOSD) patients may show an evanescent salmon-pink erythema appearing during febrile attacks and reducing without fever. Some patients may experience this eruption for many weeks. During AOSD, exceptionally high serum levels of ferritin may be observed; it is an iron storage protein composed of 24 subunits, heavy (H) subunits and light (L) subunits. The ferritin enriched in L subunits (L-ferritin) and the ferritin enriched in H subunits (H-ferritin) may be observed in different tissues. In this work, we aimed to investigate the skin expression of both H-and L-ferritin and the number of macrophages expressing these molecules from AOSD patients with persistent cutaneous lesions. We observed an increased expression of H-ferritin in the skin, associated with an infiltrate in the biopsies obtained from persistent cutaneous lesions of AOSD patients. Furthermore, a positive correlation between H-ferritin skin levels as well as the number of CD68(+) /H-ferritin(+) cells and the multi-visceral involvement of the disease was observed. Our data showed an increased expression of H-ferritin in the skin of AOSD patients, associated with a strong infiltrate of CD68(+) /H-ferritin(+) cells. Furthermore, a correlation between the levels of H-ferritin as well as of the number of CD68(+) /H-ferritin(+) cells and the multi-visceral involvement of the disease was observed.
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Affiliation(s)
- P Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - P Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - F Ciccia
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - P Di Benedetto
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - V Liakouli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - O Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - F Carubbi
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - G Guggino
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - S Di Bartolomeo
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - G Triolo
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - R Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
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