AB0522 EARLY DAMAGE AS MEASURED BY THE DAMAGE INDEX FOR ANTIPHOSPHOLIPID SYNDROME (DIAPS) IS NOT A PREDICTOR OF MORTALITY IN THROMBOTIC ANTIPHOSPHOLIPID SYNDROME

Background

Antiphospholipid syndrome (APS) patients experience damage accrual (1) but correlation with mortality is rarely reported. In systemic lupus erythematosus (SLE), early damage accrued in the first year of disease is a predictor of mortality (2).

Objectives

To determine whether damage accrued within the first year after APS onset as measured by the Damage Index for APS (DIAPS) predicts mortality.

Methods

Single-centre retrospective analysis of thrombotic APS patients (2006 Sydney criteria). The disease onset was determined as the time the first thrombotic event related to APS was diagnosed. Annual DIAPS assessments were determined for each patient. Early damage was considered to be a score ≥1 at the initial assessment (six months). DIAPS is shown as median (interquartile range [IQR]). Survival was analysed by the Kaplan-Meier method. Cox regression analysis was performed to investigate predictors of mortality.

Results

A total of 197 patients (71.1% female; 65.9% primary APS; 72.4% Caucasian) with a median age at APS onset of 40 years (IQR 51 - 28) were followed for up to 43 years (median 10 years). Cumulative damage developed in 143 (73.6%) patients with a median DIAPS of 1 (IQR 2 - 0) at the last visit. Early damage was present in 69 (35.0%) patients. Patients with early damage had similar sex distribution (p=0.733), age at disease onset (p=0.526) and median time of follow-up (p=0.181) comparing to those without early damage. Secondary APS (SAPS) (odds ratio [OR] 1.89, 95% CI 1.03 - 3.48, p=0.041) and having a first arterial event (OR 7.24, 95% CI 3.74 - 14.03, p<0.001) were associated with early damage. Twenty-three patients (11.7%) died. SAPS (p=0.009), male sex (p=0.008) and age at onset ≥40years (p=0.001) were risk factors for death (Table 1). Early damage was not associated with death (hazard ratio [HR] 1.65, 95% CI 0.73 - 3.78, p=0.231; Figure 1: survival curve) even after adjusting individually for APS category (secondary, p=0.446), sex (male, p=0.374), age at onset ≥40years (p=0.115) and type of event (arterial, p=0.555).

Table 1.

Predictors of mortality.

Crude analysisAdjusted analysis†HR (95% CI)p-valueHR (95% CI)p-valueMale sex3.14 (1.35 – 7.33)0.0081.46 (0.63 – 3.36)0.374Age at APS onset ≥ 40 years5.34 (1.9 – 14.53)0.0011.95 (0.85 – 4.50)0.115Caucasian0.95 (0.35 – 2.57)0.9181.61 (0.70 – 3.70)0.257Secondary APS3.07 (1.32 – 7.12)0.0091.38 (0.59 – 3.20)0.446First event (arterial)1.85 (0.79 – 4.27)0.1511.32 (0.53 – 3.32)0.555Early damage1.65 (0.73 – 3.78,0.231--

† In this column, we present the Early Damage hazard ratio and 95% confidence intervals for death adjusted for the variable in each row. Statistically significant values are presented in bold. APS, antiphospholipid syndrome; CI, confidence interval; DIAPS, Damage Index for Antiphospholipid Syndrome; HR, hazard ratio.

Figure 1.

Survival probability in patients with and without early damage.

Conclusion

Unlike SLE, early damage accrual accessed by DIAPS is not a predictor of mortality regardless of the nature of the thrombotic event, gender, APS category and age at APS onset.

References

[1]GRIKA EP, ZIAKAS PD, ZINTZARAS E, MOUTSOPOULOS HM, VLACHOYIANNOPOULOS PG: Morbidity, Mortality, and Organ Damage in Patients with Antiphospholipid Syndrome. J Rheumatol. 2012;39(3):516–23.

[2]RAHMAN P, GLADMAN DD, UROWITZ MB, HALLETT D, TAM LS: Early damage as measured by the SLICC/ACR damage index is a predictor of mortality in systemic lupus erythematosus. Lupus. 2001;10(2):93–6.

Disclosure of Interests

Pedro Gaspar: None declared, Filipa Farinha: None declared, Zara Sayar: None declared, Maria Efthymiou: None declared, Hannah Cohen Speakers bureau: Honoraria for lectures from Bayer Healthcare (outside the submitted work)., Consultant of: Consultancy fees from UCB Biopharma paid to University College London Hospitals Charity (outside the submitted work)., David Isenberg: None declared

AB0406 HUMAN PAPILLOMA VIRUS (HPV) VACCINATION SAFETY IN SYSTEMIC LUPUS ERYTHEMATOSUS COHORT - PORTUGUESE UNIVERSITY HOSPITAL SINGLE-CENTER COHORT STUDY

Background:

Cervical cancer is a potentially preventable consequence of Human Papillomavirus (HPV). HPV vaccination is recommended in most countries for all young women, preferentially before sexual activity begins. In Portugal, HPV vaccination is available in either bivalent (genotypes 6, 18) or tetravalent (6, 11, 16 e 18) vaccines. Both have aluminum as an adjuvant, a substance arguably capable of inducing inflammatory adjuvant syndromes. Systemic Lupus Erythematosus (SLE) mostly afflicts women of childbearing age, the very target population for HPV vaccination. There are conflicting reports in the literature regarding both the efficacy and safety of this vaccine in SLE patients. This question is particularly pressing as HPV infection prevalence seems to be increased in SLE patients.

Objectives:

To analyze the safety of HPV vaccination in a SLE patient cohort followed at a university hospital.

Methods:

Retrospective single-center (35 year long, 436 SLE patient cohort) review of all female SLE patients’ local and online national records on HPV vaccination and cervical cancer screening. Data on activity (using SLEDAI-2K scoring) and concomitant drug use were reviewed for the two years before and after vaccination date.

Results:

Of the 463 SLE patients, 420 were women (91%), of which 322 had clinical information about yes/no HPV vaccination. Twenty-seven of the patients (8%) had one of HPV vaccines, but only 13 (4%) had full information on activity before and after vaccination. Mean current age was 33,8 years and a minimum of 8,4 years of follow-up after HPV vaccination. Twenty-there (85%) were vaccinated with the tetravalent vaccine. Pre-vaccination mean SLEDAI score of was 5.9: due to arthritis (n= 5; 38,5%), low complement (n=4; 31%), dsDNA (n=4; 31%); with a medium dose of 10mg prednisolone/day and 265mg/day of hydroxychloroquine. Post-vaccination mean SLEDAI was 5.8: due to arthritis (n=6; 46%), rash (n= 5; 38,5%) and low complement (n=6; 46%); with a medium dose of 8mg prednisolone/day and 288mg/day of hydroxychloroquine. There was not a difference in organ involvement before and after vaccination, but rash was slightly more prevalent after vaccination.

Conclusion:

In our population, HPV vaccination didn’t significantly change disease activity and organ involvement or mean dose need of prednisolone or hydroxychloroquine. Although it is a small size SLE sample, it suggests that is safe to administer HPV vaccination to SLE patients.

References:

[1]eularSegal Yahel, Zabludowicz Center for Autoimmune Diseases, Tel Aviv (2017), “HPV and systemic lupus erythematosus: a mosai of potential crossreaction”, SLE Research and Clinical Update, 23 January 2017

[2]Geier David Institute of Chronic Illnesses, USA, (2016), “Quadrivalent human pappilomavirus vaccine and autoimmune adverse events: a case-control assessment of the vaccine adverse event reporting system (VAERS) database, Environment and Autoimmunity, 13 July 2016

Disclosure of Interests: :

None declared

AB1026 INFLAMMATORY MANIFESTATIONS IN PATIENTS WITH HUMAN LEUKOCYTE ANTIGEN-B*51 POSITIVE AND WITHOUT BEHÇET’S DISEASE

Background:

Human leukocyte antigen (HLA) B*51 allele is the most important genetic factor in susceptibility to Behçet’s disease (BD), an immune-mediated systemic disorder of unknown etiology, characterized by recurrent episodes of inflammatory manifestations. In fact there is a considerable clinical overlap of BD with autoinflammatory syndromes. As it’s known, the majority of HLA-B*51 positive individuals do not develop BD. But do these individuals also present inflammatory manifestations?

Objectives:

Characterize the group of individuals in our hospital with positive HLA-B*51, without BD diagnosis and review whether inflammatory manifestations are present in these individuals.

Methods:

A retrospective study of HLA-B*51 positive patients between 2000 and 2019. Genomic DNA was obtained from peripheral blood and HLA genotyping was performed using a PCR with Sequence Specific Primers (PCR–SSP) methodology. From the group of 289 B*51 positive patients, BD diagnosis were excluded. Demographic and clinical data were collected by review of clinical files in December 2019.

Results:

176 patients, mean age of 48.5 ± 16.5 years (5 to 84 years). Most were female (68%). The HLA study was motivated by multiple diagnostic suspicions: spondyloarthritis (SpA, 25.0%), BD (22.7%) and systemic sclerosis (SSc, 10.8%). The mean time elapsed since the immunogenetic study was 8.3 years, with 12 deaths recorded. 69 (39.2%) subjects had no diagnosis for immune-mediated disease (IMD). Of the other 107 patients, the majority had 1 IMD (64.5%), and the rest were diagnosed with 2 to 4 IMD. The most frequent IMD were SpA (20.8%), psoriasis (10.4%), psoriatic arthritis (9.7%), SSc (9.7%) and rheumatoid arthritis (7.1%). Autoantibodies were detected in 94 individuals (53.4%): antinuclear antibodies (64 patients), rheumatoid factor (26 patients) and CCP antibodies (11 patients). In 55 individuals no inflammatory manifestation was identified but the 68.8% of them presented between 1 to 7 manifestations:

System involvedClinical manifestationFrequencyEars, nose and throatChronic rhinitis32 (13.2%)∑ = 76 (31.4%)Recurrent tonsillitis20 (8.3%)Other24 (9.9%)Cutaneous, mucous and serousRecurrent oral aphtous ulcers34 (14.0%)∑ = 57 (23.6%)Serositis10 (4.1%)Other13 (5.4%)NeurologicalChronic headache34 (14.0%)∑ = 36 (14.9%)Asseptic meningitis2 (0.8%)OcularOcular inflammation31 (12.8%)∑ = 31 (12.8%)UrinaryRecurrent cystitis15 (6.2%)∑ = 15 (6.2%)VascularVenous thromboembolism7 (2.9%)∑ = 14 (5.8%)Aneurysm6 (2.5%)Spontaneous coronary dissection1 (0.4%)RheumaticArthromyalgia6 (2.5%)∑ = 9 (3.7%)Gout3 (1.2%)ConstitutionalRecurrent fever syndrome1 (0.4%)∑ = 1 (0.4%)DigestiveRecurrent abdominal pain1 (0.4%)∑ = 1 (0.4%)LymphaticAxillary and inguinal adenopathies1 (0.4%)∑ = 1 (0.4%)PulmonaryChronic pulmonary infiltrate1 (0.4%)∑ = 1 (0.4%)

Conclusion:

Inflammatory manifestations are common in HLA-B*51 positive individuals, even in those without BD diagnosis. Further research is needed, considering other HLA alleles associated with increased risk of BD and including control groups.

References:

[1]Burillo-Sanz S, Montes-Cano M, García-Lozano J,et al. Behçet´s disease and genetic interactions between HLA-B*51 and variants in genes of autoinflammatory syndromes.Sci Rep2019;9:2777.

[2]McGonagle D, McDermott MF. A Proposed Classification on the Immunological Diseases.PLoS Med2006;3(8):e297.

[3]Tong B, Liu X, Xiao J, Su G. Immunopathogenesis of Behcet´s Disease.Front. Immunol2019;10:665.

Disclosure of Interests:

None declared

FRI0165 RISK OF CKD IN MEMBRANOUS AND PROLIFERATIVE LUPUS NEPHRITIS - ANALYSIS OF A NATIONWIDE MULTICENTRE COHORT

Background:

Lupus nephritis (LN) is one of the most severe manifestations of Systemic Lupus Erythematosus.

Objectives:

1) To compare proliferative (PLN), membranous (MLN) and mixed LN regarding clinical and laboratory presentation. 2) To investigate predictors of progression to chronic kidney disease (CKD).

Methods:

Multicentre observational study, with retrospective analysis of a prospective cohort, using data from the Portuguese registry of rheumatic diseases – Reuma.pt. Patients with biopsy-proven PLN, MLN and mixed LN were included. Groups were compared using Pearson’s Chi-Square for categorical variables and One-Way ANOVA or Kruskal-Wallis for numerical variables. COX regression analysis was used to investigate predictors of CKD (defined as estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73m2for at least 3 months) and Kaplan-Meier curves were drawn.

Results:

236 patients were included. Median follow-up was 8 years (IQR 11; maximum 35 years). As seen in table 1, the level of proteinuria did not differ between groups; however, MLN patients presented with significantly lower serum creatinine. Levels of complement C3 and C4 were reduced in PLN but normal in MLN patients, and there were fewer patients with positive anti-dsDNA antibodies in the MLN group (p<0.001). On univariable COX regression, mixed histology was associated with progression to CKD (HR 26 [95% CI 3 - 255], p 0.005) (figure 1), however, it lost significance after adjusting for eGFR. In fact, eGFR≤75 at one year after the renal biopsy (HR 21 [95% CI 7 - 65], p<0.001) was the strongest predictor of CKD, even after adjusting for hypertension or histology.

Table 1.

Comparative description of the Reuma.pt cohort of patients with proliferative, membranous and mixed LN

PLNMLNMixedPTotal, N186428Females, N (%)157 (85)39 (95)4 (50)0.004EthnicityWhite European, N (%)163 (90)31 (78)7 (88)0.115Other, N (%)19 (10)9 (23)1 (13)Age LN diagnosis(y), median (IQR)30 (20)34 (16)42 (25)0.409SLEDAI at LN diagnosis, median (IQR)16 (9)10 (10)21 (17)0.006*uPCR at LN diagnosis, median (IQR)1675 (2598)1698 (2153)2160 (3320)0.629Creatinine at LN diagnosis, median (IQR)0.80 (0.32)0.70 (0.20)1.00 (0.95)0.006*eGFR at LN diagnosis, mean ± SD98 ± 33112 ± 1782 ± 450.019*Albumin at LN diagnosis, mean ± SD34 ± 734 ± 730 ± 60.390C3 at LN diagnosis, mean ± SD0.65 ± 0.260.90 ± 0.350.53 ± 0.30<0.001*Positive anti-dsDNA LN diagnosis, N (%)115 (91)11 (48)6 (86)<0.001*Use of antimalarials, N (%)166 (94)36 (92)8 (100)0.688Use of immunosuppressants, N (%)163 (94)33 (87)8 (100)0.245Use of corticosteroids, N (%)145 (84)33 (85)7 (100)0.511CKD after LN diagnosis, N (%)27 (15)1 (3)3 (38)0.018*ESRD, N (%)7 (4)1 (3)2 (25)0.016Deaths, N (%)14 (8)2 (5)00.610

uPCR: urinary protein-creatinine ratio, mg/g; y: years; Creatinine presented in mg/dL, eGFR in mL/min/1.73m2,albumin in g/L and C3 in g/L

Note: Baseline data (LN diagnosis) in grey; other data refer to the course of disease

*Significant difference between the proliferative and membranous groups

Figure 1.

Kaplan-Meir curves showing cumulative survival free of CKD in patients with PLN, MLN and mixed LN

Conclusion:

Our results support previous findings from single-centre studies suggesting that MLN has a different serological profile than PLN, possibly reflecting different pathogenesis. Renal function at one year predicts long-term outcome in LN.

Disclosure of Interests:

Filipa Farinha: None declared, Sofia C Barreira: None declared, Maura Couto: None declared, Margarida Cunha: None declared, Diogo Fonseca: None declared, Raquel Freitas: None declared, Luís Inês: None declared, Mariana Luis: None declared, Carla Macieira: None declared, Ana Rita Prata: None declared, Joana Rodrigues: None declared, Bernardo Santos: None declared, Rita Pinheiro Torres: None declared, Ruth J. Pepper: None declared, Anisur Rahman: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer

OP0006 ABNORMAL IRON METABOLISM AND MITOCHONDRIAL DYSFUNCTION: INVESTIGATING A NOVEL PATHOLOGICAL MECHANISM IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Iron is vital for numerous essential physiological processes including erythropoiesis and energy metabolism (as iron is found in the mitochondrial electron transport chain, the central site of ATP production). Iron homeostasis is tightly controlled by a number of regulators including; 1. Hepcidin, which prevents iron release from stores (under the influence of IL6 and IL1β); 2. Ferritin, an iron storage protein; 3. Lipocalin-2 (LCN2), which is released upon innate immune activation that induces iron sequestration; 4. Transferrin, which binds circulating iron and enables its transport to effector cell targets; 5. Haptoglobin, which binds free haemoglobin and assisting iron recycling; 6. Erythropoietin (EPO), which stimulates erythropoiesis as a result of hypoxia.

Chronic inflammation may result in dysregulation of iron metabolism and in turn impair mitochondrial function yet little is known regarding how these processes change in systemic lupus erythematosus (SLE).

Objectives:

In this study, we investigated how dysregulation of iron metabolism may occur in SLE and subsequently sought to identify how a lack of iron may ultimately induce abnormal mitochondrial function.

Methods:

1. Investigating abnormal iron metabolism in SLE.Serum samples from patients with SLE (n=39) and healthy controls (HC, n=17) were assessed hepcidin, IL-1ß, IL-6, ferritin, LCN2, EPO, haptoglobin and transferrin levels by ELISA. Hierarchical cluster analysis of normalised data (converted to Z-scores) was performed using MeV software in order to characterise patient groups based upon iron metabolism profile. Anti-dsDNA antibody titres, complement C3 levels and SLEDAI-2K were excluded to limit the influence of these variables on cluster analysis. Results were presented as a heatmap.

2. Studying mitochondrial function in iron deficiency and SLE. Peripheral blood mononuclear cells (PBMCs) from HCs and patients with SLE were analysed using Seahorse Respirometry, which measures mitochondrial oxygen consumption rate (a measure of energy metabolism dependent upon oxidative phosphorylation). To assess differences between health, iron deficiency and SLE 3 groups were assessed; 1. PBMCs derived from HCs; 2. PBMCs from patients with SLE; 3. Healthy PBMCs cultured in iron deficient condition, in which cells were treated with the potent iron chelator, Deferiprone.

Results:

Figure 1a demonstrates that four groups were identified following cluster analysis. In spite of excluding markers of disease activity, these groups showed significant differences in SLEDAI-2K (shown in Figure 1b). In summary, patients with more active disease (Groups C and D) showed higher levels of hepcidin (which prevents the release of iron from stores, under the influence of IL-1ß and IL-6) and reduced transferrin thus suggesting that iron is inefficiently transported when compared with those with less active disease (in Groups A and B).

Figure 2a demonstrates that basal mitochondrial respiration is significantly reduced in PBMCs derived from healthy controls when grown in iron deficiency conditions (following treatment with Deferiprone and is lower still in those with SLE. Figure 2b shows that PBMCs from patients with SLE have reduced maximal mitochondrial respiration capacity that is comparable to the levels seen in iron deficient healthy PBMCs.

Conclusion:

Patients with SLE demonstrate abnormalities in iron metabolism that results in cellular iron deficiency as iron is not released from stores, nor adequately transported at the rate required to meet physiological demands. Furthermore, PBMCs derived from patients with SLE who impaired basal and maximal respiration that is comparable with healthy PBMCs treated potent iron chelation. This suggests that abnormal iron metabolism may in turn limit mitochondrial energy metabolism in SLE and represents a potential future therapeutic target.

References:

Nil

Acknowledgments:

Versus Arthritis (Grant No 594143) and LUPUS UK

Disclosure of Interests:

None declared

AB0407 HUMAN PAPILLOMA VIRUS (HPV) INFECTION AND CERVICAL CANCER PREVALENCE IN A PORTUGUESE UNIVERSITY HOSPITAL SINGLE-CENTER SYSTEMIC LUPUS ERYTHEMATOSUS COHORT

Background:

About 12% of women worldwide are infected with Human Papillomavirus (HPV), the most frequent cause of cervical cancer (CC) - very prevalent (~ 7,5%) and preventable. National screening efforts are in use in several countries, including Portugal. Patients with Systemic Lupus Erythematosus (SLE) are at increased risk of HPV infection and CC when compared to the healthy population.

Objectives:

To evaluate the prevalence of HPV infection and rate of incidence of cervical neoplastic lesions in a SLE patient cohort followed at a university hospital.

Methods:

Retrospective single-center (35 year long, 463 SLE patient cohort) review of all female SLE patients’ local and online national health care records on HPV vaccination and CC screening.

Results:

Of the 463 SLE patients, 420 were women (91%), of which 322 had records on of HPV infection or CC developed. Mean patients’ current age was 48 years and all had screening for cervical pathology in the last 3 years. Thirty-three patients (11%) had HPV infection diagnosed at a mean age of 44 years. Twenty-seven (8%) of SLE patients were vaccinated for HPV: 8 (22%) of the infected patients had the vaccine, half after the HPV infection. Despite HPV infection, 49 patients (15%) had developed some cervical lesion, of which 41 (84% of cervical lesion) were suggestive of malignancy, and ultimately CC was diagnosed in 20 women (41%; 6% of total women), with a mean age at diagnosis of 45 years. All CC patients had history of HPV infection, but only 3 women (15%; 0,9% of total women) had been vaccinated against HPV, 2 after the diagnoses of CC and 1 before.

Conclusion:

In our population the prevalence of HPV was higher than reported for the general population using the World Health Organization database, conforming the higher risk of HPV infection in SLE patients. The prevalence of cervical cancer, however, was similar to the healthy population.

References:

[1]https://www.who.int/immunization/diseases/hpv/en/

[2]Forman David (2012); “Global Burden of Human Papillomavirus and Related Diseases”, Vaccine, Elsevier Volume 30, Supplement 5, 20 November 2012

[3]Grein Ingrid (2016), Department of Pediatric Immunology and Rheumatology, Netherland (2016), HPV infection and vaccination in Systemic Lupus Erythematosus patients: what we really should know, Pediatric Rheumatology, 2016

Disclosure of Interests: :

None declared

Alveolar hemorrhage in systemic lupus erythematosus: a cohort review

Diffuse alveolar hemorrhage (DAH) is a rare but potentially catastrophic manifestation with a high mortality. Among rheumatologic diseases, it occurs most frequently in patients with systemic lupus erythematosus (SLE) and systemic vasculitis. Despite new diagnostic tools and therapies, it remains a diagnostic and therapeutic challenge. The aim of this work was to characterize the SLE patients with an episode of alveolar hemorrhage followed in our Clinical Immunology Unit (CIU). A retrospective chart review was carried out for all patients with SLE followed in CIU between 1984 and the end of 2013. We reviewed the following data: demographic characteristics, clinical and laboratory data, radiologic investigations, histologic studies, treatment, and outcome. We identified 10 episodes of DAH, corresponding to seven patients, all female. These represent 1.6% of SLE patients followed in our Unit. The age at DAH attack was 42.75 ± 18.9 years. The average time between diagnosis of SLE and the onset of DAH was 7.1 years. Three patients had the diagnosis of SLE and the DAH attack at the same time. Disease activity according to SLEDAI was high, ranging from 15 to 41. All patients were treated with methylprednisolone, 37.5% cyclophosphamide and 28.6% plasmapheresis. The overall mortality rate was 28.6%.

Tophaceous Gout: a tragic course for a preventable disease

A 66-year-old man, with a history of chronic tophaceous gout since the age of 30, presented with multiple tophi and significant deformity of all fingers that caused substantial function loss. Due to osteomyelitis refractory to antimicrobial therapy, he underwent disarticulation of several fingers. Finally, both his hands were amputated.

Baastrup's Disease: a poorly recognised cause of back pain

A 56-year-old male complained about progressive mechanical back pain for more than 10 years, which worsened with prolonged orthostatism and spine extension and improved in fetal position. His lumbar spine radiography revealed enlargement and sclerosis of the spinous processes which was confirmed by computed tomography, suggesting Baastrup's disease. This condition is characterized by enlargement, close approximation and impingement of one spinous process on another ("kissing spines"). There are few studies on Baastrup´s disease epidemiology and their results are inconsistent. Patients often complain of back pain, typically increased with extension and relieved by flexion. Radiographically, spinous process impingement leads to reactive sclerosis, enlargement, flattening, and remodeling of the involved vertebral spines. Physicians frequently miss it on radiographs due to lack of knowledge and overexposure of spinous processes in most X rays. Both conservative and surgical options are available for treatment. Baastrup's disease should be considered in differential diagnosis of back pain, although one must be aware the typical radiographic changes appear to be common with aging and may not be the cause of patient's symptoms.

Association between vitamin D receptor (VDR) gene polymorphisms and systemic lupus erythematosus in Portuguese patients

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown origin, in which both genetic and environmental factors are involved. One such environmental factor is vitamin D, a vital hormone that plays a specific function in the immune system homeostasis, acting through a nuclear receptor ( VDR) expressed in all immune cells. Several polymorphisms of the gene that encodes this receptor have been described. Though inconsistently, these polymorphisms have been associated with clinical manifestations and SLE development.

The aim of this study was to determine the possible association between VDR gene polymorphisms (BsmI, ApaI, TaqI e FokI) and SLE susceptibility and severity, in a cohort of lupus patients from the north of Portugal.

A total of 170 patients (F = 155, M = 15; age = 45 ± 13.4 years) with SLE (diagnosed according the American College of Rheumatology criteria) with at least five years of disease evolution and followed in the Autoimmune Disease Clinical Immunology Unit of Centro Hospitalar do Porto were studied. Patients and 192 ethnicity-matched controls were genotyped for BsmI (rs1544410), ApaI (rs7975232), TaqI (rs731236) and FokI (rs2228570) polymorphisms by TaqMan allelic discrimination assay. Disease severity was assessed by SLICC damage score, number of affected organs, number of severe flares and pharmacological history.

SLE patients with the CT genotype of FokI polymorphism have a higher SLICC value ( p = 0.031). The same result was observed for the group of patients with the TT genotype of TaqI polymorphism ( p = 0.046). No differences were observed in VDR genotype between patients and controls. Also, we observed that the other clinical features analysed were not influenced by VDR polymorphisms.

Our study confirms a possible role of VDR gene polymorphisms in SLE. A positive association was found between VDR polymorphisms and SLE severity (chronic damage). The presence of CT genotype of FokI and TT genotype of TaqI seems to confer a worse prognosis and may constitute a risk factor for higher long-term cumulative damage in SLE patients.

CCR5-Delta32: implications in SLE development

Systemic lupus erythematosus (SLE) is a prototypical autoimmune disease with strong genetic and environmental components. Previous studies have shown increased levels of several chemokines in active SLE. C-C chemokine receptor type 5 (CCR5) is involved in the recruitment of inflammatory cells into tissues, and mechanisms modulating CCR5 expression and function may interfere in SLE development, influencing the clinical course of the disease. The aim of this study was to evaluate the possible association between the CCR5∆32 base-pair deletion polymorphism and SLE disease in a group of Portuguese patients. A total of 219 patients with SLE and 205 healthy individuals were studied. The frequency of CCR5/∆32 heterozygotes was lower in patients with SLE than in controls (8% vs. 15% OR = 0.5162; P = 0.0319), suggesting a protective association between CCR5∆32 allele and SLE. These results highlight the protective role of Th1 cells that express CCR5 in SLE pathogenesis.

Hemophagocytic syndrome as one of the main primary manifestations in acute systemic lupus erythematosus - case report and literature review

Hemophagocytic syndrome is an unusual but fatal disorder characterized by pancytopenia and activation of macrophages. We describe one case of acute systemic lupus erythematosus with an unusual presentation of hemophagocytic syndrome not related to infection. The patient presented with pancytopenia related to increasing hemophagocytic activity of histiocytes in the bone marrow. Concomitant class IV World Health Organization lupus nephritis, serositis, high titer of antinuclear factor and positive test for anti-DNA antibody fitted the diagnostic criteria of systemic lupus erythematosus. She also presented with alveolar hemorrhage and lupus myocarditis. She underwent immunosuppressive therapy with recovery from the hemophagocytic syndrome. Therefore, diagnosis of acute lupus hemophagocytic syndrome was made. The clinical presentation, laboratory diagnosis, and management of the patient are discussed and the literature was reviewed and presented, with emphasis on a possible distinct lupus subset, which includes a more aggressive systemic disease with heart involvement.

Tremor as the first neurological manifestation of Sneddon's syndrome

We report on a 54-year-old woman with Sneddon's syndrome manifested by livedo reticularis, fetal losses, hypertension, and high antinuclear antibody titres. At the age of 42 years she developed tremor of the trunk, limbs, and head only in the standing position that interfered with walking, followed some years later by cognitive decline and a parkinsonian syndrome. T2-weighted brain magnetic resonance imaging showed high signal in cortical areas, basal ganglia, midbrain, and cerebellum.

Lupus nephritis: a retrospective review of 78 cases from a single center

Lupus nephritis (LN) is a frequent and serious manifestation of systemic lupus erythematosus. However, the outcome has progressively improved in the last 3 decades and this was due to more efficient and early treatment of LN and comorbid situations. The aim of our study was to analyze our experience and outcome in LN, to evaluate clinicopathologic and clinicolaboratory correlations and to search for risk factors for renal and patient survival.

PATIENTS AND METHODS

We conducted a retrospective study of 78 patients with biopsy-proven LN.

RESULTS

Acute renal failure and subnephrotic proteinuria with microhematuria occurred each one in 39.7% of the patients, nephrotic syndrome in 16.7% and nephritic syndrome in 3.8%. The mean serum creatinine at presentation was 1.45 +/- 1.03 mg/dl and the creatinine clearance was 68.2 +/- 40.3 ml/min. Class IV LN existed in 71.8%, Class III in 20.5%, Class V in 6.4% and Class VI in 1.3%. The treatment included steroids and cytotoxic agents in 87.5% of the patients with proliferative LN. Hypertension, serum creatinine and acute renal failure at presentation, as well as significant chronicity on renal biopsy, were significantly correlated with the progression to chronic renal failure in our population. Males were more prone to develop renal flares. 3.8% of the patients died, 9% lost their renal function, 26.9% are in remission, 33.3% still have subnephrotic proteinuria and microhematuria, 7.7% have nephrotic syndrome and 19.2% have chronic renal failure. The mean global follow-up was 102 +/- 74 months and 96.2% of the patients survived. The actuarial renal survival was 96.1% in the first year; 89.9% at 5 years; and 83.7% at 10 and 20 years.

CONCLUSION

We can say that hypertension, serum creatinine and acute renal failure at the onset and significant chronicity on renal biopsy, proved to be risk factors for chronic renal failure in our study population. Male gender was a risk factor for renal flares. The achieved global outcome can be considered a good result.

[Scleredema, acanthosis nigricans and IgA/Kappa multiple myeloma]

BACKGROUND

Scleredema is an uncommon disease of unknown origin. Characteristic thick skin with symmetrical diffuse induration develops. The infiltration begins on the face and neck then extends to the root of the upper limbs and trunk. There are three clinical types of scleredema. The first is preceded by an upper airway infection and progresses rapidly before regressing spontaneously within a few months. The second type is associated with chronic diabetes. The third type is associated with monoclonal gammapathy, rarely of myelomatous type, and develops insidiously. Acanthosis nigricans can be a paraneoplastic syndrome, often associated with a gastrointestinal cancer. Few cases associating scleredema and acanathosis nigricans have been reported.

CASE REPORT

A 56-year old woman had developed scleredema over the last 6 years when acanthosis nigricans appeared together with IgA kappa multiple myeloma. Treatment with melphalan and prednisolone was effective against the myeloma as well as the scleredema and acanthosis nigricans.

DISCUSSION

Only five cases of associated scleredema and multiple myeloma have been reported, four with kappa IgG myeloma and one with IgA myeloma. An association between acanthosis nigricans and sclerederma could be coincidental although the fact that the different manifestations regressed together after the myeloma treatment would suggest some relationship between these three diseases.