Anti-CD20 therapy in patients with refractory systemic lupus erythematosus: a longitudinal analysis of 52 Hispanic patients

The objective of this study was to investigate the efficacy and safety of anti-CD20 treatment in Hispanic patients with refractory systemic lupus erythematosus and to determine whether baseline parameters predict disease flare. Fifty-two patients with systemic lupus erythematosus, 13 with active lupus nephritis, eight with thrombocytopenia, three with leukocytopenia, 25 with severe musculoskeletal involvement and three with skin involvement) refractory to conventional therapy were treated with anti-CD20 treatment (rituximab; MabThera, Roche) plus ongoing immunosuppressive treatment. Disease activity was assessed monthly using the SLEDAI validated for the Mexican population with a follow-up period of 6 months. At 6 months of follow-up, significant clinical improvements were detected, with a reduction in the global SLEDAI validated for the Mexican population score. Five of the 13 patients with lupus nephritis (38.4%) had a complete renal response and five (38.4%) had a partial response. Rituximab was also effective in patients with autoimmune thrombocytopenia, inducing a significant increase in platelet counts (p = 0.012). Nineteen of 25 patients with severe musculoskeletal involvement had remission of arthritis. Only one of the three patients with skin involvement had no lesions at 6 months. Rituximab treatment also allowed a reduction of the oral prednisone dose in the majority of patients. No baseline predictors of flare were found. Treatment was discontinued after the first infusion in two patients due to serum sickness and in another due to pulmonary infection. In conclusion, the addition of rituximab to conventional immunosuppressive therapy may be an effective strategy for lupus nephritis, autoimmune thrombocytopenia and inflammatory polyarthritis in patients with refractory systemic lupus erythematosus.

Relationship of oncogenes (sFas, Bcl-2) and cytokines (IL-10, alfa-TNF) with the activity of systemic lupus erythematosus

BACKGROUND

Different oncogenes (Fas and bcl-2) and diverse cytokines (IL-10 and alfa-TNF) may have an effect on the regulation of apoptosis. The majority of studies to date have evaluated only one or two of these elements independently and it is difficult to obtain a global view of apoptosis disregulation in the pathogenesis of systemic lupus erythematosus (SLE) and their role in disease activity. The aim of this study was to evaluate serum levels of sFas, bcl-2, IL-10 and alfa-TNF in human SLE patients and to analyze their relationship with disease activity and with regulation of the apoptotic process.

PATIENTS AND METHODS

Serum levels of sFas and cytokines IL-10 and alfa-TNF were studied by enzyme-linked immunoabsorbent assay. Bcl-2 antigen expression was analyzed in lysated lymphocytes from 51 SLE patients. The disease activity was analyzed according to the SLE disease activity index (SLEDAI).

RESULTS

SLE patients had higher levels of sFas (p=0.0006) and alfa-TNF (p<0.0001) than the control group. No relationship was found between the levels of bcl-2 and IL-10 from SLE patients and the control group. However, there was a significant correlation between SLEDAI and bcl-2 (p<0.001) and IL-10 levels (p=0.004). In contrast, we found that sFas and alfa-TNF were not related with disease activity. A significant correlation of sFas with alfa-TNF serum levels (p=0.003, R= +0.41) and bcl-2 antigen expression (p=0.02, R=+0.32) was observed.

CONCLUSION

sFas and alfa-TNF serum levels are increased in SLE patients. sFas levels seems to be secondary to alfa-TNF action, which is enhanced in inflammatory conditions such as SLE. Bcl-2 antigen expression and IL-10 serum levels are related to the maintenance of SLE activity. These alterations may interfere with the apoptotic process, promoting lymphocyte hyperactivity secondary to increased cytokine levels, and causing the characteristic features of SLE.

Catastrophic antiphospholipid syndrome: clinical description and triggering factors in 8 patients

In 1992, an attempt to single out a different and important group of patients was adopted by introducing the term "catastrophic" antiphospholipid syndrome (APS) to describe their potentially life threatening clinical course, characterized by acute multiorgan failure (3 or more organ systems damaged). Patients previously described in the literature showed certain differences that appear to distinguish this minority group of patients with catastrophic APS from the majority of APS patients. We describe 8 patients with catastrophic APS, focusing especially on the possible extrinsic factors (mainly infections) that might trigger this "catastrophic" situation.

Bcl-2 oncogene (B cell lymphoma/leukemia-2) levels correlate with systemic lupus erythematosus disease activity

OBJECTIVE

Bcl-2 translocation or overexpression is found in many types of malignancy, possibly through alteration of the apoptosis mechanism. It has also been suggested that similar apoptotic alterations may be important in the pathogenesis of systemic lupus erythematosus (SLE). It is believed that a process of apoptosis at the stage of maturation or differentiation of lymphocytes may be related to the beginning of an autoimmune event, due to the non-elimination of autoreactive lymphocytes. The aim of this study is to test bcl-2 antigen expression in human SLE peripheral blood and to analyze its relationship with disease activity.

MATERIALS AND METHODS

Serum levels of bcl-2 were studied by enzyme-linked immunoabsorbent assay in whole blood samples in 68 patients with SLE and its correlation with disease activity according to SLE disease activity index (SLEDAI).

RESULTS

No significant differences were found in bcl-2 levels between all SLE patients and controls. We observed increased levels of bcl-2 in active SLE patients in relation to inactive (p = 0.0003) and controls (p = 0.02). Our results show a significant correlation between bcl-2 levels and SLEDAI values (R = 0.46, P < 0.001).

CONCLUSIONS

These results suggest that bcl-2 levels are related to disease activity and that this protein may play a role in the pathogenesis of SLE.

Optic neuropathy in a child with primary Sjögren's syndrome

An eight-year-old girl developed optic neuritis followed by primary Sjögren's syndrome confirmed by a lip biopsy. Glucocorticoid therapy combined during six months with monthly intravenous pulse cyclophosphamide ensured resolution of the sicca syndrome but failed to improve the visual impairment. This is the second pediatric case of optic neuritis associated with primary Sjögren's syndrome, and the first pediatric case in which optic neuritis was the only neurologic manifestation.

Osteocalcin and bone morphometric parameters in adults without bone disease

Serum bone Gla-protein (s-BGP or osteocalcin) and other serum biochemical parameters were measured in 19 subjects (8 women and 11 men, aged 20-82 years) without any bone disease. Each subject simultaneously underwent an iliac crest biopsy; tetracycline double-labeling was performed in 11 subjects, allowing correlations between s-BGP and bone histomorphometric parameters. s-BGP was significantly correlated with static bone parameters: trabecular bone volume (r = 0.74; P less than 0.001), osteoid surfaces (r = 0.69; P less than 0.001), osteoblastic surfaces (r = 0.68; P less than 0.002); dynamic bone formation parameters: total labeled surfaces (r = 0.72; P less than 0.01); and the bone formation rate (r = 0.69; P less than 0.01). We conclude that s-BGP is a valuable marker for evaluating bone formation in healthy adult subjects.