Analysis of cytokine-driven serum amyloid A expression based on the clinical results of IL-6 blocking therapy: a new cis-acting mechanism of STAT3

Refractory Sjögren's syndrome myelopathy successfully treated with subcutaneous tocilizumab: A case report

RATIONALE

It is known that 5% to 34% of Sjögren's syndrome (SS) cases are complicated by neuropathy in the form of myelitis. Although SS myelopathy (SSM) is often treated with glucocorticoid (GC) and immunosuppressants such as cyclophosphamide (CY), a therapeutic strategy for SSM has not been established.

PATIENT CONCERNS

A 65-year-old female was admitted with weakness and thermal hypoalgesia in the lower limbs. Four months before this admission, she showed weakness in her lower limbs and thermal hypoalgesia of bilateral upper and lower limbs. Magnetic resonance imaging (MRI) revealed that the cause of her neurological symptoms was cervical myelitis. She was diagnosed with SS because she tested positive for the ophthalmic test (Schirmer's test and fluorescent test) and for the anti-SS-A antibodies. Therefore, myelitis was thought to be a complication of SS. She was treated with GC and CY. Both neurological symptoms and MRI findings temporarily improved, and the GC dose was gradually decreased. One month before this admission, her neurological symptoms and MRI findings were exacerbated. Upon relapse of SSM, serum amyloid A protein (SAA) level was markedly elevated.

DIAGNOSES

Based on MRI findings, the diagnosis was SSM relapse.

INTERVENTIONS

Treatment by subcutaneous tocilizumab (TCZ) 162 mg every two weeks was introduced.

OUTCOMES

After introducing TCZ, her neurological symptoms and MRI findings gradually improved. SAA levels remained low. At eight months after the introduction of TCZ, the GC dose has been decreased and so far, the myelitis has not relapsed.

LESSONS

This case report is the first report suggesting the effectiveness of TCZ for refractory SSM. Subcutaneous TCZ might be an effective therapeutic option for treating refractory SSM when SAA levels are elevated.

Serum amyloid A is a marker for pulmonary involvement in systemic sclerosis

Inflammation in systemic sclerosis (SSc) is a prominent, but incompletely characterized feature in early stages of the disease. The goal of these studies was to determine the circulating levels, clinical correlates and biological effects of the acute phase protein serum amyloid A (SAA), a marker of inflammation, in patients with SSc. Circulating levels of SAA were determined by multiplex assays in serum from 129 SSc patients and 98 healthy controls. Correlations between SAA levels and clinical and laboratory features of disease were analyzed. The effects of SAA on human pulmonary fibroblasts were studied ex vivo. Elevated levels of SAA were found in 25% of SSc patients, with the highest levels in those with early-stage disease and diffuse cutaneous involvement. Significant negative correlations of SAA were found with forced vital capacity and diffusion capacity for carbon monoxide. Patients with elevated SAA had greater dyspnea and more frequent interstitial lung disease, and had worse scores on patient-reported outcome measures. Incubation with recombinant SAA induced dose-dependent stimulation of IL-6 and IL-8 in normal lung fibroblasts in culture. Serum levels of the inflammatory marker SAA are elevated in patients with early diffuse cutaneous SSc, and correlate with pulmonary involvement. In lung fibroblasts, SAA acts as a direct stimulus for increased cytokine production. These findings suggest that systemic inflammation in SSc may be linked to lung involvement and SAA could serve as a potential biomarker for this complication.

Improvement of vitamin D status resulted in amelioration of biomarkers of systemic inflammation in the subjects with type 2 diabetes

BACKGROUND

Both vitamin D deficiency and inflammation have been linked to cardiovascular disease, the major cause of death in diabetes. In this study, the effects of daily intake of vitamin D-fortified yoghourt drink (doogh) on systemic inflammatory biomarkers in subjects with type 2 diabetes (T2D) were investigated.

SUBJECTS AND METHODS

In this 12-week randomized controlled trial, T2D subjects received either plain doogh (PD; containing 170 mg calcium and no detectable vitamin D/250 mL, n(1) = 50) or vitamin D3-fortified doogh (FD; containing 170 mg calcium and 500 IU/250 mL, n(2) = 50) twice a day. Glycemic status, body fat mass and systemic inflammatory biomarkers including serum highly sensitive C-reactive protein (hsCRP), serum amyloid A (SAA), interleukin(IL)-2, IL-6, IL-10 and tumour necrosis factor (TNF)-α were evaluated at the beginning and after the intervention. Data were expressed as either mean ± SD or median (interquartile range) whenever they had either normal or non-normal distribution, respectively.

RESULTS

In the patients receiving the vitamin D fortified drink, compared with those receiving the unfortified drink, a significant increase in serum 25(OH)D was accompanied by significant changes in TNF-α (-57.9 (-264.6) versus +106.3 (683.2), p = 0.044), IL-6 (-6.3 (-69.2), p = 0.002), hsCRP (-0.39 (-1.50) versus +0.8 (1.52), p < 0.001), SAA (-14.2 ± 44.5 versus +5.6 ± 37.5 mg/L, p = 0.022) and IL-10 (+38.7 ± 157.0 versus -51.9 ± 165.2 ng/L, p = 0.013). The between-group differences of hsCRP, SAA and IL-6 changes remained significant even after controlling for changes quantitative insulin check index (p < 0.001, p < 0.001 and p = 0.009, respectively).

CONCLUSIONS

Improvement of vitamin D status of T2D subjects resulted in amelioration of the systemic inflammatory markers. This may have preventive implications against cardiovascular disease and other diabetic complications.