Replacement and Immunomodulatory Activities of 20% Subcutaneous Immunoglobulin Treatment: A Single-Center Retrospective Study in Autoimmune Myositis and CVID Patients

Shared and Distinctive Inflammation-Related Protein Profiling in Idiopathic Inflammatory Myopathy with/without Anti-MDA5 Autoantibodies

Purpose

Due to the heterogeneous nature of the diseases, treatment efficacy and prognosis vary for idiopathic inflammatory myopathy (IIM) patients with different myositis specific autoantibodies (MSAs). This study aimed to investigate the inflammation-related protein profiling of IIM patients with different MSAs. In addition, the shared and distinctive inflammation-related protein profiling in IIM with/without anti-MDA5 autoantibodies.

Methods

Seventy-seven patients with IIM of different MSAs and 53 gender/age matched healthy controls (HCs) were enrolled in this study. Ninety-two inflammation-related proteins were detected by Olink proteomics. We identified differentially expressed proteins (DEPs), and performed gene set enrichment analysis and KEGG pathway analysis. In addition, correlation between DEPs and serological parameters were performed. The least absolute shrinkage and selection operator (Lasso) regression algorithm of machine learning was used to screen biomarkers related to anti-MDA5+ DM.

Results

Compared with HCs, 36 inflammation-related proteins were identified as DEPs. The top 10 DEPs were CXCL10, CXCL11, CXCL9, CXCL8, S100A12, IL-6, CCL2, CCL8, IL-10 and CCL3. The inflammation-related proteins and cytokine-cytokine receptor interaction pathway were more strikingly expressed in patients with anti-MDA5+ DM patients than in anti-MDA5- IIM patients. In addition, multiple DEPs correlated with serum ferritin, KL-6, muscle enzymes. For the first time, we established that a multi-factor panel comprising CX3CL1, IL-17C, IL-18R1, CCL20, and TNF (AUC = 0.824) serves as a highly efficient diagnostic biomarker for anti-MDA5+ DM.

Conclusion

Plasma profiling revealed that inflammation and inflammatory pathways were extremely elevated in patients with IIM, especially in patients with anti-MDA5 autoantibodies. The shared and distinctive inflammation-related protein signature was demonstrated in patients with/without anti-MDA5 autoantibodies. The expression of CX3CL1 was significantly higher in anti-MDA5+ DM than in patients without anti-MDA5 autoantibodies. In addition, CX3CL1 correlated with ESR, serum ferritin, CK enzymes and disease activity, indicating that CX3CL1 participated in inflammation status of anti-MDA5+ DM.

Polyautoimmunity Reflecting Immune Dysregulation in Common Variable Immunodeficiency

Background: Common variable immunodeficiency (CVID) is the most frequent symptomatic inborn error of immunity (IEI) in adulthood. Other than recurrent infections, CVID may present with non-infectious complications such as enteropathy, lymphoproliferation, malignancy, and autoimmune diseases. Patients could have a single autoimmune disease (monoautoimmunity) or two or more autoimmune diseases (overt polyautoimmunity). "Latent polyautoimmunity" corresponds to the presence of autoantibodies without a clinically evident autoimmune disease. Methods: The aim of this retrospective study was to describe autoimmunity and polyautoimmunity in a population of 81 CVID adult patients, enrolled from January 2008 to July 2022 (mean follow-up: 8.5 years). Results: We documented at least one autoimmune disorder in 40 patients (49.4%). Moreover, 15 subjects (37.5% of patients with autoimmunity and 18.5% of all CVID population) presented polyautoimmunity. Despite the humoral immune deficiency, we detected different autoantibodies in CVID patients with or without a concomitant autoimmune disease. In both groups with monoautoimmunity and polyautoimmunity, cytopenias were the most common manifestation. Conversely, enteropathy was recorded only in patients with polyautoimmunity (27%, p = 0.006). Patients with polyautoimmunity showed a significantly lower mean age at diagnosis (-12 years, p = 0.018) compared to those with monoautoimmunity. We documented a higher frequency of autoimmunity in CVID patients who had increased diagnostic (+5.6 years) and therapeutic (+7.2 years) delay (p = 0.093 and 0.054, respectively). Conclusions: Polyautoimmunity is a frequent condition in patients affected by CVID. An early start of Ig replacement therapy could help prevent autoimmune complications.

A comprehensive review of dermatomyositis treatments - from rediscovered classics to promising horizons

INTRODUCTION

Dermatomyositis (DM) is a rare inflammatory disease with diverse cutaneous and systemic manifestations, often associated with myositis-specific antibodies. Managing patients with refractory DM, or individuals presenting pecific complications, like calcinosis or rapidly progressive interstitial lung disease, presents unique challenges.

AREAS COVERED

This review explores current and promising treatment options for DM, drawing from clinical studies, case series, and case reports that consider the underlying disease pathophysiology.

EXPERT OPINION

Recent advancements have improved our understanding and management of DM. The discovery of distinct DM autoantibodies and their correlation with specific clinical phenotypes has transformed patient categorization and enhanced our knowledge of the pathogenesis of the disease. Intravenous immunoglobulin, a well-established treatment in dermatomyositis, has regained prominence and a large randomized clinical trial has reaffirmed its efficacy, confirming it as an effective therapeutic option in this group of patients. Identification of the type I interferon pathway as a key pathogenic mechanism in DM has opened up new avenues for more effective treatment strategies. Blocking the JAK/STAT pathway offers potential for improved management of refractory patients and prevention of highly morbid complications. These recent advancements have significantly impacted the management and care of dermatomyositis patients, enabling tailored approaches, targeted interventions, and improved outcomes for individuals affected by this complex condition.

Plasma proteomic profiling reveals KRT19 could be a potential biomarker in patients with anti-MDA5+ dermatomyositis

OBJECTIVE

To investigate the immune response-related protein profiling in plasma of patients with idiopathic inflammatory myopathies (IIMs), especially in anti-MDA5+ dermatomyositis (DM).

METHODS

A total of 166 IIM patients and 107 healthy controls (HCs) were enrolled in our study. Ninety-two plasma immune response-related proteins were detected by Olink proteomics in 36 IIM patients and 25 HCs. The expression of plasma KRT19 was validated in another 130 IIM patients, 82 HCs, and 55 other rheumatic diseases.

RESULTS

A total of 46 differentially expressed proteins were detected, including 12 upregulated proteins and 34 downregulated proteins in IIM patients compared with HCs. Pathway analysis revealed lactoferrin danger signal response pathway, TLR4 signaling and tolerance, infection, and IL-10 signaling pathway were activated. The immune response-related protein profiling significantly altered in anti-MDA5+ DM patients, with LAMP3, HSD11B1, and KRT19 significantly increased, while SH2D1A, ITGA11, TRIM21, CD28, ITGB6, and HEXIM1 tremendously decreased. In addition, KRT19 was significantly increased in IIM patients, especially in anti-MDA5+ DM patients with the diagnostic value of a significant area under the ROC curve of 0.881.

CONCLUSION

Immune response-related proteins are significantly altered in patients with anti-MDA5+ DM patients. KRT19 could be a potential biomarker for anti-MDA5+ DM patients. Key Points • What is already known on this topic? Anti-MDA5+ DM is a distinctive subtype of IIM. Plasma immune response-related proteins panel needs to be investigated. • What this study adds? Plasma protein profiling of immune response-related proteins significantly altered in patients with idiopathic inflammatory myopathies (IIM), especially in anti-MDA5+ DM patients. • How this study might affect research, practice, or policy? KRT19 could be a potential biomarker in patients with anti-MDA5+ dermatomyositis.

A machine learning analysis to evaluate the outcome measures in inflammatory myopathies

OBJECTIVE

To assess the long-term outcome in patients with Inflammatory Idiopathic Myopathies (IIM), focusing on damage and activity disease indexes using artificial intelligence (AI).

BACKGROUND

IIM are a group of rare diseases characterized by involvement of different organs in addition to the musculoskeletal. Machine Learning analyses large amounts of information, using different algorithms, decision-making processes, self-learning neural networks.

METHODS

We evaluate the long-term outcome of 103 patients with IIM, diagnosed on 2017 EULAR/ACR criteria. We considered different parameters, including clinical manifestations and organ involvement, number and type of treatments, serum creatine kinase levels, muscle strength (MMT8 score), disease activity (MITAX score), disability (HAQ-DI score), disease damage (MDI score), and physician and patient global assessment (PGA). The data collected were analysed, applying, with R, supervised ML algorithms such as lasso, ridge, elastic net, classification, and regression trees (CART), random forest and support vector machines (SVM) to find the factors that best predict disease outcome.

RESULTS AND CONCLUSION

Using artificial intelligence algorithms we identified the parameters that best correlate with the disease outcome in IIM. The best result was on MMT8 at follow-up, predicted by a CART regression tree algorithm. MITAX was predicted based on clinical features such as the presence of RP-ILD and skin involvement. A good predictive capacity was also demonstrated on damage scores: MDI and HAQ-DI. In the future Machine Learning will allow us to identify the strengths or weaknesses of the composite disease activity and damage scores, to validate new criteria or to implement classification criteria.

Autoimmune inflammatory myopathies

The autoimmune inflammatory myopathies constitute a heterogeneous group of acquired myopathies that have in common the presence of endomysial inflammation and moderate to severe muscle weakness. Based on currently evolved distinct clinical, histologic, immunopathologic, and autoantibody features, these disorders can be best classified as dermatomyositis, necrotizing autoimmune myositis, antisynthetase syndrome-overlap myositis, and inclusion body myositis. Although polymyositis is no longer considered a distinct subset but rather an extinct entity, it is herein described because its clinicopathologic information has provided over many years fundamental information on T-cell-mediated myocytotoxicity, especially in reference to inclusion body myositis. Each inflammatory myopathy subset has distinct immunopathogenesis, prognosis, and response to immunotherapies, necessitating the need to correctly diagnose each subtype from the outset and avoid disease mimics. The paper describes the main clinical characteristics that aid in the diagnosis of each myositis subtype, highlights the distinct features on muscle morphology and immunopathology, elaborates on the potential role of autoantibodies in pathogenesis or diagnosis , and clarifies common uncertainties in reference to putative triggering factors such as statins and viruses including the 2019-coronavirus-2 pandemic. It extensively describes the main autoimmune markers related to autoinvasive myocytotoxic T-cells, activated B-cells, complement, cytokines, and the possible role of innate immunity. The concomitant myodegenerative features seen in inclusion body myositis along with their interrelationship between inflammation and degeneration are specifically emphasized. Finally, practical guidelines on the best therapeutic approaches are summarized based on up-to-date knowledge and controlled studies, highlighting the prospects of future immunotherapies and ongoing controversies.

Severe digital ischemia as an unrecognized manifestation in patients with antisynthetase autoantibodies: Case series and systematic literature review

Objective

Severe digital ischemia, including digital ulcers and gangrene, is considered rare in patients with antisynthetase antibodies. This study aimed to elucidate the clinical features of antisynthetase-positive patients complicated with digital ulcers and/or gangrene using a systematic literature review and case series in a single-center cohort.

Methods

A systematic literature review was conducted to identify reports describing antisynthetase-positive cases with digital ulcers and/or gangrene. Our cohort of consecutive patients with antisynthetase antibodies was stratified by the history of severe digital ischemia. Demographic and clinical features and outcomes in patients with severe digital ischemia identified in the systematic literature review and our cohort were compared with those in patients without severe digital ischemia in our cohort.

Results

The systematic literature review revealed 12 antisynthetase-positive patients with severe digital ischemia from one case series and eight case reports. Seven (7%) of 100 patients with antisynthetase antibodies in our cohort had a record of severe digital ischemia. Severe digital ischemia was often found at presentation and was associated with the classification of systemic sclerosis with or without myositis overlap. Clinical features associated with severe digital ischemia in antisynthetase-positive patients included Raynaud's phenomenon (p < 0.001), digital pitting scars (p = 0.001), and nailfold capillary abnormality (p = 0.02). Outcomes of severe digital ischemia were generally favorable with vasodilators.

Conclusion

Severe digital ischemia is an overlooked complication in antisynthetase-positive patients. Antisynthetase antibodies should be measured in patients presenting with digital ulcers or gangrene, especially in those with systemic sclerosis phenotype and features associated with antisynthetase antibodies in the absence of systemic sclerosis-specific autoantibodies.

A machine learning analysis to predict the response to intravenous and subcutaneous immunoglobulin in inflammatory myopathies. A proposal for a future multi-omics approach in autoimmune diseases

OBJECTIVE

To evaluate the response to treatment with intravenous (IVIg) and subcutaneous (20%SCIg) immunoglobulin in our series of patients with Inflammatory idiopathic myopathies (IIM) by the means of artificial intelligence.

BACKGROUND

IIM are rare diseases mainly involving the skeletal muscle with particular clinical, laboratory and radiological characteristics. Artificial intelligence (AI) represents computer processes which allows to perform complex calculations and data analyses, with the least human intervention. Recently, the use an AI in medicine significantly expanded, especially through machine learning (ML) which analyses huge amounts of information and accordingly makes decisions, and deep learning (DL) which uses artificial neural networks to analyse data and automatically learn.

METHODS

In this study, we employed AI in the evaluation of the response to treatment with IVIg and 20%SCIg in our series of patients with IIM. The diagnoses were determined on the established EULAR/ACR criteria. The treatment response was evaluated employing the following: serum creatine kinase levels, muscle strength (MMT8 score), disease activity (MITAX score) and disability (HAQ-DI score). We evaluated all the above parameters, applying, with R, different supervised ML algorithms, including Least Absolute Shrinkage and Selection Operator, Ridge, Elastic Net, Classification and Regression Trees and Random Forest to estimate the most important predictors for a good response to IVIg and 20%SCIg treatment.

RESULTS AND CONCLUSION

By the means of AI we have been able to identify the scores that best predict a good response to IVIg and 20%SCIg treatment. The muscle strength as evaluated by MMT8 score at the follow-up is predicted by the presence of dysphagia and of skin disorders, and the myositis activity index (MITAX) at the beginning of the treatment. The relationship between muscle strength and MITAX indicates a better action of IVIg therapy in patients with more active systemic disease. Considering our results, Elastic Net and similar approaches were seen to be the most viable, efficient, and effective ML methods for predicting the clinical outcome (MMT8 and MITAX at most) in myositis.

Common Variable Immunodeficiency in Elderly Patients: A Long-Term Clinical Experience

Background: Common variable immunodeficiency (CVID) is a complex, predominantly antibody deficiency usually diagnosed between 20−40 years. Few data about elderly patients are reported in the literature. Our aim was to evaluate the clinical phenotypes of elderly patients with CVID. Method: A retrospective analysis of adult patients with CVID was performed in our Referral Centre, focusing on the main differences between “older” patients (≥65 years at the diagnosis) and “younger” patients (<65 years). Results: The data from 65 younger and 13 older patients followed up for a median period of 8.5 years were available. At diagnosis, recurrent infections represented the only clinical manifestation in 61% and 69% of younger and older patients, respectively. The incidence of autoimmune diseases was higher in elderly patients compared with younger ones (30 vs. 18%, respectively). During the follow-up, the incidence of autoimmune disorders and enteropathy increased in the younger patients whereas neoplasia became the most prevalent complication in the elderly (38%). All patients received a replacement therapy with immunoglobulin, with good compliance. Conclusion: CVID occurrence in elderly patients is rarely described; therefore, the clinical characteristics are not completely known. In our series, neoplasia became the most prevalent complication in the elderly during the follow-up. In elderly patients, 20% SCIg was as safe as in the younger ones, with good compliance. A genetic analysis is important to confirm the diagnosis, identify specific presentations in the different ages, clarify the prognosis and guide the treatment. Future clinical research in this field may potentially help to guide their care.