Von Willebrand factor: a possible biomarker for disease activity in vasculitis

OBJECTIVE

Inflammation markers, e.g. C- reactive protein (CRP) and sedimentation rate, can be normal despite active vasculitis. Von Willebrand factor (vWF) is secreted from endothelial cells in response to vascular damage. Some reports suggest increased vWF levels in vasculitis. This study aimed to evaluate vWF serum concentration in vasculitis patients as a possible biomarker of disease activity and to review the current literature.

METHOD

Adult patients with systemic vasculitis were prospectively enrolled. Disease activity was recorded using the Birmingham Vasculitis Activity Score (BVAS) version 3. Blood group-adjusted vWF antigen serum level was evaluated at diagnosis and, when available, after treatment.

RESULTS

Twenty-five vasculitis patients were compared to 15 healthy controls. The mean age of patients was 56 ± 17 years and 56% were women. Forty percent had anti-neutrophil cytoplasmic autoantibody-associated vasculitis, 20% giant cell arteritis, 16% polyarteritis nodosa, 8% Takayasu arteritis, and the rest had other vasculitides. The mean disease duration was 3.4 ± 4.8 years. Mean vWF was higher in patients with active vasculitis than in healthy controls (212 ± 81% vs 106 ± 26%, p < 0.001). vWF levels directly correlated with BVAS. In 13 patients with active vasculitis who reached remission or low disease activity after treatment, vWF level at follow-up decreased significantly. In three out of five patients who were treated with interleukin-6 inhibitors, vWF was elevated despite normal CRP levels, while vasculitis was clinically active.

CONCLUSION

vWF antigen serum level is increased in active vasculitis and could potentially serve as a biomarker for active disease.

Outcomes in progressive systemic sclerosis treated with autologous hematopoietic stem cell transplantation compared with combination therapy

OBJECTIVES

Autologous hematopoietic stem cell transplantation (AHSCT) has been shown to improve long-term survival for early diffuse progressive systemic sclerosis (SSc) compared with cyclophosphamide. Cyclophosphamide, however, does not provide a long-term benefit in SSc. The combination of mycophenolate mofetil (MMF) and rituximab is a potent alternative regimen. We aimed to retrospectively compare the outcomes of SSc patients who underwent AHSCT to patients who met the eligibility criteria for AHSCT but received upfront combination therapy with MMF and rituximab.

METHODS

Repeated assessments of modified Rodnan Skin Score (mRSS), forced vital capacity (FVC), and diffusing capacity (DLCO) values were conducted. Clinical improvement was defined as an mRSS decrease > 25% or an FVC increase > 10%. Event-free survival (EFS) was defined in the absence of persistent major organ failure or death.

RESULTS

Twenty-one SSc patients in the combination therapy group were compared with sixteen in the AHSCT group. Age, sex and disease duration were similar between the two groups. Clinical improvement at 12 months was seen in 18 (86%) patients in the combination group compared with 13 (81%) in the AHSCT group (p= 0.7). The hazard ratio for EFS at 24 months favored the combination group (HR = 0.09, P= 0.04). During follow-up, both groups exhibited a significant and comparable reduction in mRSS and an increase in FVC values at each time interval up to 24 months.

CONCLUSION

MMF and rituximab compared with AHSCT in SSc patients eligible for AHSCT resulted in similar skin and lung clinical improvement with a better safety profile at 24 months.

Intravenous versus subcutaneous tocilizumab in Takayasu arteritis: multicentre retrospective study

OBJECTIVES

In this large multicentre study, we compared the effectiveness and safety of tocilizumab intravenous versus subcutaneous (SC) in 109 Takayasu arteritis (TAK) patients.

METHODS

We conducted a retrospective multicentre study in referral centres from France, Italy, Spain, Armenia, Israel, Japan, Tunisia and Russia regarding biological-targeted therapies in TAK, since January 2017 to September 2019.

RESULTS

A total of 109 TAK patients received at least 3 months tocilizumab therapy and were included in this study. Among them, 91 and 18 patients received intravenous and SC tocilizumab, respectively. A complete response (NIH <2 with less than 7.5 mg/day of prednisone) at 6 months was evidenced in 69% of TAK patients, of whom 57 (70%) and 11 (69%) patients were on intravenous and SC tocilizumab, respectively (p=0.95). The factors associated with complete response to tocilizumab at 6 months in multivariate analysis, only age <30 years (OR 2.85, 95% CI 1.14 to 7.12; p=0.027) and time between TAK diagnosis and tocilizumab initiation (OR 1.18, 95% CI 1.02 to 1.36; p=0.034). During the median follow-up of 30.1 months (0.4; 105.8) and 10.8 (0.1; 46.4) (p<0.0001) in patients who received tocilizumab in intravenous and SC forms, respectively, the risk of relapse was significantly higher in TAK patients on SC tocilizumab (HR=2.55, 95% CI 1.08 to 6.02; p=0.033). The overall cumulative incidence of relapse at 12 months in TAK patients was at 13.7% (95% CI 7.6% to 21.5%), with 10.3% (95% CI 4.8% to 18.4%) for those on intravenous tocilizumab vs 30.9% (95% CI 10.5% to 54.2%) for patients receiving SC tocilizumab. Adverse events occurred in 14 (15%) patients on intravenous route and in 2 (11%) on SC tocilizumab.

CONCLUSION

In this study, we confirm that tocilizumab is effective in TAK, with complete remission being achieving by 70% of disease-modifying antirheumatic drugs-refractory TAK patients at 6 months.

Giant Cell Arteritis: State of the Art in Diagnosis, Monitoring, and Treatment

Giant cell arteritis (GCA) is the most prevalent subtype of vasculitis in adults. In recent years, there has been substantial improvement in the diagnosis and treatment of GCA, mainly attributed to the introduction of highly sensitive diagnostic tools, incorporation of modern imaging modalities for diagnosis and monitoring of large-vessel vasculitis, and introduction of highly effective novel biological therapies that have revolutionized the field of GCA. This article reviews state-of-the-art approaches for the diagnosis, monitoring, and treatment options of GCA.

Autoinflammatory Diseases and Vasculitis: The Missing Link

Familial Mediterranean fever (FMF) has been reported to be associated with vasculitis, including polyarteritis nodosa (PAN), yet vasculitis is not considered a manifestation of FMF.1 A 29-year-old male, diagnosed with FMF (compound heterozygote for V726A/E148q) at the age of 10 years, was admitted to our ward due to a recent exacerbation of FMF attacks.

AB0646 G- CSF treatment for refractory digital ulcers in systemic sclerosis

Background

Digital ulcers (DU) are a common manifestation of systemic sclerosis (SSc). Despite combination vasodilator therapy, refractory DU are not rare. Granulocyte-colony stimulating factor (G-CSF) had not been evaluated for SSc DU heretofore.

Objectives

To evaluate the efficacy and safety of G-CSF for refractory SSc DU.

Methods

Adult SSc patients with chronic resistant DU despite treatment with maximal tolerated doses of prostacyclin analogue, endothelin receptor antagonist and PDE5 inhibitor, were treated with three consecutive daily doses of G-CSF. Evaluation of DU healing, DUCAS score, antibiotics use, side effects and hospitalizations, was performed.

Results

Ten patients (90% females), mean age 53.5 ± 11.1 years were treated. Fifty percent of the patients had a diffuse SSc disease. All patients suffered from chronic (80%), or recurrent (20%) DU. G-CSF treatment resulted in complete resolution of most DU, after an average of 1.57± 0.76 months. DU recurrence occurred in two patients, after a mean period of two months. The number of DU decreased from 2.23±2.20 at baseline, to 0.84±0.80 at one month (p value= 0.04), and 0.50±0.67 at 3 months (p value= 0.015). DUCAS score dropped from 6.84±1.62 before the treatment, to 1.76±2.00 and 1.16±2.55 at one and three months, respectively (p value <0.0001). No serious adverse events were observed.

Conclusion

G- CSF treatment was found to be beneficial for refractory SSc DU, resulting in DU healing and sustained remission in most cases. No significant side effects were observed. Future trials are needed to evaluate the efficacy and safety of this therapy.

References

[1]Denton CP, Khanna D. Systemic sclerosis. Lancet. 2017;390(10103):1685-1699.

[2]Mouthon L, Mestre-Stanislas C, Bérezné A, et al. Impact of digital ulcers on disability and health-related quality of life in systemic sclerosis. Annals of the Rheumatic diseases 2010; 69:214-217.

[3]Hughes M, Pauling JD. Exploring the patient experience of digital ulcers in systemic sclerosis. Semin Arthritis Rheum. 2019;48(5):888-894.

[4]Matucci-Cerinic M, Krieg T, Guillevin L, et al. Elucidating the burden of recurrent and chronic digital ulcers in systemic sclerosis: long-term results from the DUO Registry. Ann Rheum Dis. 2016;75(10):1770-1776.

[5] Steen V, Denton CP, Pope JE, Matucci-Cerinic M. Digital ulcers: overt vascular disease in systemic sclerosis. Rheumatology (Oxford). 2009;48 Suppl 3:iii19-24.

[6]Roberts AW. G-CSF: a key regulator of neutrophil production, but that's not all! Growth Factors. 2005;23(1):33-41.

[7]Phillipson M, Kubes P. The Healing Power of Neutrophils. Trends Immunol. 2019;40(7):635-647.

[8]Giuggioli D, Magistro R, Colaci M, Franciosi U, Caruso A, Ferri C. The treatment of skin ulcers in systemic sclerosis: use of granulocyte-colony stimulating factor (G-CSF) in 26 patients. Reumatismo. 2006;58(1):26-30.

Table 1.

Patients’ characteristics:

ParameterSSc IDUMean age at DU onset (years) ±SD53.5 ± 11.1Female gender (N, %)9, 90%AntibodiesATA (N, %)3, 30%ACA (N, %)5, 50%Negative2, 20%Diffuse SSc subtype (N, %)5, 50%Treatment (N, %)bosentan10, 100%sildenafil6, 60%CCB2, 20%iloprost10, 100%Mean Number of DU- baseline2.23 ± 2.20Mean Number of DU – 1 month ±SD0.84 ± 0.80Mean Number of DU – 3 months ±SD0.50 ± 0.67Mean DU duration before G-CSF (months)±SD4.77 ± 4.53Mean time to heal- (months)±SD1.57 ± 0.75Mean DUCAS before ±SD6.84 ± 1.62Mean change in DUCAS- 1M ±SD5.07 ± 2.75Mean change in DUCAS- 3M ±SD5.58 ± 2.53Adverse reactions (N, %)0, 0%

Abrreviations: SD- standard deviation, DU- digital ulcers, SSc- systemic sclerosis, ATA- anti topoisomerase antibodies, ACA- anti centromere antibodies, CCB- calcium channel blockers, G- CSF- Granulocyte-colony stimulating factor, DUCAS- digital ulcer clinical assessment score.

Disclosure of Interests

None declared

The association between elevated serum interleukin-22 and the clinical diagnosis of axial spondyloarthritis: A retrospective study

OBJECTIVE

There is an unmet need for a reliable biomarker for the differentiation of axial spondyloarthritis (AxSpA) from its mimickers. Serum levels of interleukin-22 (IL-22) have previously been found to be significantly elevated in patients with AxSpA compared with healthy individuals or persons with osteoarthritis.

METHODS

Consecutive patients with established or suspected AxSpA were enrolled. The clinical data, as well as results of laboratory and imaging studies, were acquired from patients' charts. The final diagnosis of definite or probable SpA, or an alternative diagnosis, was determined, and the serum levels of IL-22 were examined by enzyme-linked immunosorbent immunoassay.

RESULTS

Interleukin-22 levels were significantly higher in patients with definite AxSpA (29 patients) compared with patients with alternative diagnoses (14 patients) and healthy volunteers (16 individuals; P < 0.001 for both comparisons). The sensitivity and specificity of the serum IL-22 for the AxSpA diagnosis were 0.68 (95% CI 0.49-0.84) and 0.86 (95% CI 0.68-0.95), respectively, for the cut-off value of 5 pg/mL. In patients with AxSpA, serum IL-22 levels did not correlate with modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS), or serum C-reactive protein.

CONCLUSION

Serum IL-22 levels are elevated in patients with the clinical diagnosis of AxSpA and can potentially serve as an independent biomarker for the differentiation of AxSpA from its non-inflammatory mimickers.

Efficacy and safety of TNF-α antagonists and tocilizumab in Takayasu arteritis: Multicenter retrospective study of 209 patients

OBJECTIVE

To assess safety and efficacy of TNF-α antagonists and tocilizumab in patients with Takayasu arteritis (TAK).

METHODS AND RESULTS

Two-hundred nine patients with TAK [median age of 29 years [7-62], and 186 (89%) females] were included. They received either TNF-α antagonists [n = 132 (63%) with 172 lines; infliximab (n = 109), adalimumab (n = 45), golimumab (n = 8), certolizumab (n = 6) and etanercept (n = 5)], or tocilizumab [n = 77 (37%) with 121 lines; intravenous and subcutaneous in 95 and 26 cases, respectively]. A complete response at 6 months was evidenced in 101/152 (66%) on TNF-α antagonists and 75/107 (70%) on tocilizumab, respectively. Age ≥ 30 years [OR = 2.09 [1.09; 3.99]] was associated with complete response, whereas vascular signs [0.26 [0.1; 0.65]], baseline prednisone ≥ 20 mg/day [0.51 [0.28; 0.93]] were negatively associated with the complete response to TNF-α antagonists or tocilizumab. During a median follow-up of 36 months, 103 relapses were noted. Supra-aortic branches and thoracic aorta involvements [HR 2.44 (1.06; 5.65) and 3.66 (1.18; 11.4), respectively], and systemic signs at baseline [HR 2.01 (1.30; 3.11)] were significantly associated with relapse. The cumulative incidence of treatment discontinuation and relapse were similar in TNFα antagonists and tocilizumab. Fifty-eight (20%) adverse effects occurred on biological-targeted therapies of whom 37 (21%) and 21 (17%), (p= 0.4) on TNF-α antagonists and tocilizumab, respectively.

CONCLUSION

This large multicentre study shows high efficacy of biological-targeted treatments in refractory TAK. Efficacy, relapse and drug retention rate were equivalent with TNF-α antagonists and tocilizumab.

EP03 An audit of glucocorticoid prescription in patients with giant cell arteritis

Background

Giant cell arteritis (GCA) is treated with high dose glucocorticoids and progressively reduced over months to years. We undertook an audit to evaluate self-reported adherence to the original recommended glucocorticoid course and explored reasons for any variation.

Methods

We recruited patients attending a single rheumatology department over 18 months. Respondents were given two self-administered questionnaires to record information regarding their use of glucocorticoids during the last 7 days and during the last 6 months. We retrieved 132 questionnaires (of whom 6 were discarded as incomplete). All data was analysed using SPSS Statistics v22.

Results

Of the 126 patients (mean age 74.9 ± 7.7 years), 59% were female. The mean duration of disease was 22.5 ± 19.1 months in patients with GCA and 32.9 ± 29.9 months in those with GCA and polymyalgia rheumatica (PMR). The mean daily number of medications taken was 9.2 ± 5.2 (range: 1 - 30); the mean number of types of daily tablets taken was 5.0 ± 2.1 (range: 1 - 10). The mean daily number of glucocorticoid tablets taken was 3.2 ± 2.6 (range: 0 - 12), with a mean daily dose of 11.1 ± 10.3 mg (range: 0 - 60 mg). Overall, in the last 7 days, 22% and in last 6 months, 40% of patients were not following their original recommended steroid regimens (Table 1). The total mean glucocorticoid dose in the last 7 days group (n = 81) was 77.8 ± 70.1 mg/week (11.1 ± 10.1 mg/day) whilst the total mean glucocorticoid dose in the last 6 months group (n = 45) was 1782.0 ± 1543.3 mg/6 month (9.9 ± 8.6 mg/day). Most respondents stated their glucocorticoid non-adherence was due to medical advice; other reasons included forgetting, fear of side effects, or confusion about different preparations of prescribed glucocorticoids. The presence of PMR did not influence glucocorticoid adherence.

Conclusion

There is significant variation in the use of glucocorticoids compared to the original starting regimen in patients with GCA, with or without PMR. However, the amount of the discrepancy is small. The commonest reason for non-adherence was medical advice received from either primary or secondary care.

Disclosures

H. Ariff: None. A. Awisat: None. J. Arnold: None. H. Al ani: None. L. O' neill: None. M. Rodriguez: None. R. Luqmani: None.

Lysyl oxidase-a possible role in systemic sclerosis-associated pulmonary hypertension: a multicentre study

OBJECTIVE

Lysyl oxidase (LOX) is an extracellular enzyme that cross-links collagen fibrils. LOX was found to be increased in serum of SSc patients and was suggested to be related to skin fibrosis, yet a vascular source of LOX has been demonstrated in idiopathic pulmonary arterial hypertension (iPAH). We aimed to validate elevated LOX serum levels in SSc and to study its correlation with clinical characteristics and investigate its main source at the tissue level.

METHODS

A total of 86 established SSc patients were compared with 86 patients with very early diagnosis of systemic sclerosis (VEDOSS), 110 patients with primary RP (PRP) and 80 healthy controls. LOX serum levels were determined by ELISA. Five lung and 12 skin biopsies from SSc patients were stained for LOX and compared with controls.

RESULTS

Serum levels of LOX in SSc were significantly higher than in VEDOSS, PRP and healthy controls (P < 0.001). LOX inversely correlated with the diffusing capacity of the lung for carbon monoxide diffusing capacity (DLCO) in diffuse SSc (r = -0.376, P = 0.02). Patients with moderate to severe estimated systolic PAH had higher LOX levels (P < 0.01). Lung biopsies demonstrated intense LOX staining in SSc patients with PAH that was predominantly located in the endothelium of the remodelled pulmonary vessels.

CONCLUSION

Serum LOX levels are increased in established SSc and inversely correlate with the DLCO. LOX is elevated in patients with moderate to severe PAH and is located in the proliferating endothelium in lung arterioles, suggesting a possible role for LOX in SSc-associated PAH.

Crowned dens syndrome, yet another rheumatic disease imposter

OBJECTIVE

Crowned dens syndrome (CDS) is defined as acute cervical or occipital pain due to a local inflammatory reaction related to calcifications in the ligaments surrounding the odontoid process. Virtually, all previous descriptions of CDS have related to calcium pyrophosphate dehydrate (CPPD) arthropathy.

METHODS

We prospectively identified a total of twenty-four consecutive inpatients with Crowned dens syndrome from January 2016 to December 2017 in our institution.

RESULTS

All patients (age range 54 to 87 years, 67% females) presented with acute onset pain in the upper neck and/or occiput accompanied with extreme neck stiffness. Most patients (79%) had elevated inflammatory markers. Four patients underwent temporal artery biopsy, which was negative for arteritis in all cases, and one was subjected to lumbar puncture, which was non-contributory. Seventeen patients (71%) had known rheumatic disease on presentation: 10 patients had the diagnosis of calcium pyrophosphate dehydrate arthropathy, 3 patients had ankylosing spondylitis, 2 patients had rheumatoid arthritis, 1 patient had Behcet's disease, and 1 suffered from Familial Mediterranean Fever. In 4 more patients, crowned dens syndrome was the presenting symptom of calcium pyrophosphate dehydrate disease. All patients were treated with glucocorticoids as 0.5 mg/kg prednisone plus colchicine 0.5 mg bid resulting in dramatic improvement in both clinical (head/neck pain alleviated and cervical spinal mobility regained) and laboratory measures.

CONCLUSIONS

Crowned dens syndrome should be considered, and craniocervical junction imaged in the context of acute cervical or occipital pain with stiffness and elevated inflammation markers not only in patients previously diagnosed with calcium pyrophosphate dehydrate arthropathy but also in diverse clinical settings.Key Points• This report highlights that crowned dens syndrome should be considered in various clinical setting besides calcium pyrophosphate dehydrate (CPPD) arthropathy.• Vigilance to this syndrome allows rapid treatment and may spare the patient unnecessary invasive procedures (i.e., temporal artery biopsy or lumbar puncture).

Infliximab for the treatment of refractory polyarteritis nodosa

Polyarteritis nodosa (PAN) is a necrotizing vasculitis predominantly affecting medium and small size arteries. Cyclophosphamide, a drug with narrow therapeutic range and poor safety profile, constitutes the treatment of choice for PAN vasculitis with major organ involvement. To describe our clinical experience in treating refractory PAN with infliximab (a TNF inhibitor), a drug with good tolerability and better safety profile than cyclophosphamide. Twenty-six PAN patients were admitted to our rheumatology unit between 2006 and 2017, of whom nine patients, with severe and refractory disease, were treated with infliximab after failure of standard treatment. We describe herein the patients' characteristics, clinical manifestations, severity and response to infliximab treatment and review the current literature. Complete remission was defined as the absence of features of active disease and withdrawal of prednisone therapy. Significant improvement was defined as clinical improvement and prednisone dose reduction of at least 50% or a 50% reduction in immune modulatory medications other than prednisone. After 4 months of treatment, 8/9 (89%) patients achieved significant improvement, with two of them achieving complete remission. We suggest that anti-TNF agents, and in particular infliximab, are relatively safe and efficacious treatment options in refractory PAN. A randomized controlled trial should be done in order to objectively evaluate infliximab in PAN.

Ankylosing Spondylitis and Neck Pain: MRI Evidence for Joint and Entheses Inflammation at the Craniocervial Junction

BACKGROUND

Magnetic resonance imaging (MRI), which has recently become the leading imaging modality in the study of ankylosing spondylitis (AS), has not been evaluated in the assessment of disease-specific changes at the craniocervical junction (CCJ) in patients with AS.

OBJECTIVES

To describe the spectrum of active inflammatory lesions at the CCJ using MRI in a cohort of patients with AS and neck pain.

METHODS

The study included 18 patients with AS presenting with neck pain and a control group of 9 fibromyalgia patients matched for age and levels of neck pain. All patients underwent a focused rheumatologic examination, X-ray of the cervical spine, and a 3T MRI study, which included STIR, CUBE T2, FSE and FSE FAT SAT sequences before and after administration of gadolinium.

RESULTS

The median age of AS patients was 43 years with a median disease duration of 7 years. Fifteen of 18 patients were under biologic treatment. Seven of 18 AS patients had evidence of cervical syndesmophytes on X-ray films. Active inflammatory lesions of atlanto-occipital joints and apical and alar ligaments were detected in MRIs in 2 out of the 18 patients with AS and in none of the patients with fibromyalgia. Both AS patients with active inflammation of CCJ detected on MRI received treatment with biological agents prior to and during the study.

CONCLUSIONS

Active inflammation of both entheses and joints of the CCJ can be demonstrated by MRI in patients with AS.

[THE ROLE OF SEMAPHORIN 7A IN SYSTEMIC SCLEROSIS]

INTRODUCTION

Semaphorins are a large group of membrane bound and secreted proteins. The semaphorins were first recognized for their important role in neurodevelopment and specifically their repulsive axonal growth guidance during embryonic development. Recently, semaphorins have also been found to have an important role in the regulation of the immune system, thus denoted as "immune semaphorins". Semaphorin 7A is a membrane bound protein which mediated its effect by two receptors: the β1 integrin subunit and plexin C1. Interactions between semaphorin 7A and its receptors contribute to inflammation and immunity by the stimulation of macrophage chemotaxis and cytokine production, regulation of dendritic cell migration and modulation of T cell function. Recently, semaphorin 7A has been found to have a role in the induction of fibrosis by tumor growth factor β1 (TGF β1). TGFβ1 activates semaphorin 7A and its receptors plexin C1 and β1 integrin subunit and induces proliferation of fibroblasts, lung fibrosis and remodeling in mice. A small study of 4 patients with systemic sclerosis (SSc) has recently demonstrated increased expression of semaphorin 7A mRNA on fibroblasts and B lymphocytes in peripheral blood.

AIMS

To evaluate the expression of semaphorin 7A on regulatory T cells and B cells from peripheral blood of patients with SSc compared to healthy controls and to try and correlate the expression of semaphorin 7A with pulmonary fibrosis, skin fibrosis and other clinical characteristics of SSc patients.

METHODS

Twenty six SSc patients were compared to 10 healthy controls. The expression of semaphorin 7A was evaluated by flow cytometry analysis of B cells using monoclonal antibodies to CD 108 and CD 19 and on peripheral regulatory T cells using monoclonal antibodies to CD 3 and CD 108. The analysis was conducted using flow-cytometry. Demographic, clinical and laboratory data were prospectively collected. Further data collection included: Systolic pulmonary artery pressure as assessed by echocardiography, lung function tests including diffusing capacity, nailfold video capillaroscopy pattern, modified Rodnan skin score (MRSS), Valentini activity index and Medsger severity score. Pulmonary involvement was determined by high resolution CT scan if it was suspected, according to impaired lung functions or auscultatory findings.

RESULTS

Ten patients with diffused SSC (8 of whom suffered from pulmonary fibrosis) and 16 patients with limited disease were compared with 10 healthy controls. There was no difference between the groups with regard to age, gender, BMI or smoking habits. Semaphorin 7A expression on regulatory T cells was not different between SSc patients and healthy controls 4.2±6.5 % vs. 2.3±1.1 % (p< 0.35) nor was a difference found between SSC patients with diffuse disease compared to limited disease 2.5±8 % vs. 5.1±14 % (p< 0.3). Comparing the expression of semaphorin 7A on B cells did not reveal a difference between SSc patients and healthy controls as well 9.7±9.4 % vs. 4.9±1.7% (p< 0.12). No correlation was found between skin score, activity score or severity score and levels of expression of sempahorin 7A on B cells or regulatory T cells.

CONCLUSIONS

In this small scale study we were not able to validate the role of semaphorin 7A as a mediator of fibrosis in SSc, as was suggested by a previous pilot study. Larger scale studies and investigation of semaphorin 7A on other peripheral cells and in tissues are needed in order to delineate the exact role of semaphorin as a mediator of fibrosis in SSc.