Congenital myasthenic syndromes in adults: clinical features, diagnosis and long-term prognosis

Congenital myasthenic syndromes (CMS) are clinically and genetically heterogeneous diseases caused by mutations affecting neuromuscular transmission. Even if the first symptoms mainly occur during childhood, adult neurologists must confront this challenging diagnosis and manage these patients throughout their adulthood. However, long-term follow-up data from large cohorts of CMS patients are lacking and the long-term prognosis of these patients is largely unknown. We report the clinical features, diagnostic difficulties, and long-term prognosis of a French nationwide cohort of 235 adult patients with genetically confirmed CMS followed in 23 specialized neuromuscular centres. Data were retrospectively analysed. Of the 235 patients, 123 were female (52.3%). The diagnosis was made in adulthood in 139 patients, 110 of whom presented their first symptoms before the age of 18. Mean follow-up time between first symptoms and last visit was 34 years (SD = 15.1). Pathogenic variants were found in 19 disease-related genes. CHRNE-low expressor variants were the most common (23.8%), followed by variants in DOK7 (18.7%) and RAPSN (14%). Genotypes were clustered into four groups according to the initial presentation: ocular group (CHRNE-LE, CHRND, FCCMS), distal group (SCCMS), limb-girdle group (RAPSN, COLQ, DOK7, GMPPB, GFPT1), and a variable-phenotype group (MUSK, AGRN). The phenotypical features of CMS did not change throughout life. Only four genotypes had a proportion of patients requiring intensive care unit (ICU) admission that exceeded 20%: RAPSN (54.8%), MUSK (50%), DOK7 (38.6%) and AGRN (25.0%). In RAPSN and MUSK patients most ICU admissions occurred before age 18 years and in DOK7 and AGRN patients at or after 18 years of age. Different patterns of disease course (stability, improvement and progressive worsening) may succeed one another in the same patient throughout life, particularly in AGRN, DOK7 and COLQ. At the last visit, 55% of SCCMS and 36.3% of DOK7 patients required ventilation; 36.3% of DOK7 patients, 25% of GMPPB patients and 20% of GFPT1 patients were wheelchair-bound; most of the patients who were both wheelchair-bound and ventilated were DOK7 patients. Six patients died in this cohort. The positive impact of therapy was striking, even in severely affected patients. In conclusion, even if motor and/or respiratory deterioration could occur in patients with initially moderate disease, particularly in DOK7, SCCMS and GFPT1 patients, the long-term prognosis for most CMS patients was favourable, with neither ventilation nor wheelchair needed at last visit. CHRNE patients did not worsen during adulthood and RAPSN patients, often severely affected in early childhood, subsequently improved.

Real-life effectiveness 1 year after switching to avalglucosidase alfa in late-onset Pompe disease patients worsening on alglucosidase alfa therapy: A French cohort study

INTRODUCTION

Late-onset Pompe disease (LOPD) is characterized by a progressive myopathy resulting from a deficiency of acid α-glucosidase enzyme activity. Enzyme replacement therapy has been shown to be effective, but long-term treatment results vary. Avalglucosidase alfa demonstrated non-inferiority to alglucosidase alfa in a phase 3 study, allowing in France compassionate access for advanced LOPD patients unresponsive to alglucosidase alfa.

METHODS

Data from the French Pompe registry were analyzed for patients who benefited from a switch to avalglucosidase alfa with at least 1 year of follow-up. Respiratory (forced vital capacity [FVC]) and motor functions (Six-Minute Walk Test [6MWT]) were assessed before and 1 year after switching. Individual changes in FVC and 6MWT were expressed as slopes and statistical analyses were performed to compare values.

RESULTS

Twenty-nine patients were included (mean age 56 years, 11 years of prior treatment). The FVC and 6MWT values remained stable. The individual analyses showed a stabilization of motor worsening: -1 m/year on the 6MWT after the switch versus -63 m/year the year before the switch (i.e., a worsening of 33%/year before vs. an improvement of 3%/year later). Respiratory data were not statistically different.

DISCUSSION

At the group level, gait parameters improved slightly with a stabilization of previous worsening, but respiratory parameters showed limited changes. At the individual level, results were discordant, with some patients with a good motor or respiratory response and some with further worsening.

CONCLUSION

Switching to avalglucosidase alfa demonstrated varied responses in advanced LOPD patients with failing alglucosidase alfa therapy, with a general improvement in motor stabilization.

Clinical and genetic features of patients suffering from CMT4J

Mutations in the FIG4 gene have been identified in various diseases, including amyotrophic lateral sclerosis, Parkinson's disease, and Charcot-Marie-Tooth 4 J (CMT4J), with a wide range of phenotypic manifestations. We present eight cases of CMT4J patients carrying the p.Ile41Thr mutation of FIG4. The patients were categorized according to their phenotype. Six patients had a pure CMT; whereas, two patients had a CMT associated with parkinsonism. Three patients had an early onset and exhibited more severe forms of the disease. Three others experienced symptoms in their teenage years and had milder forms. Two patients had a late onset in adulthood. Four patients showed electrophysiological evidence of conduction blocks, typically associated with acquired neuropathies. Consequently, two of them received intravenous immunoglobulin treatment without a significant objective response. Interestingly, two heterozygous patients with the same mutations exhibited contrasting phenotypes, one having a severe early-onset form and the other experiencing a slow disease progression starting at the age of 49. Notably, although 7 out of 8 patients in this study were compound heterozygous for the p.Ile41Thr mutation, only one individual was found to be homozygous for this genetic variant and exhibited an early-onset, severe form of the disease. Additionally, one patient who developed the disease in his youth was also diagnosed with hereditary neuropathy with pressure palsies. Our findings provide insights into the CMT4J subtype by reporting on eight heterogeneous patient cases and highlight the potential for misdiagnosis when conduction blocks or asymmetrical nerve conduction study results are observed in patients with FIG4 mutations.

Multidisciplinary team meetings in treatment of spinal muscular atrophy adult patients: a real-life observatory for innovative treatments

BACKGROUND

In 2017, a new treatment by nusinersen, an antisense oligonucleotide delivered by repeated intrathecal injections, became available for patients with spinal muscular atrophy (SMA), whereas clinical trials had mainly involved children. Since 2020, the oral, selective SMN2-splicing modifier risdiplam has been available with restrictions evolving with time. In this peculiar context of lack of data regarding adult patients, many questions were raised to define the indications of treatment and the appropriate follow-up in this population. To homogenize access to treatment in France, a national multidisciplinary team meeting dedicated to adult SMA patients, named SMA multidisciplinary team meeting, (SMDTs) was created in 2018. Our objective was to analyze the value of SMDTs in the decision-making process in SMA adult patients and to provide guidelines about treatment.

METHODS

From October 2020 to September 2021, data extracted from the SMDT reports were collected. The primary outcome was the percentage of cases in which recommendations on validating treatment plans were given. The secondary outcomes were type of treatment requested, description of expectations regarding treatment and description of recommendations or follow-up and discontinuation. Data were analyzed using descriptive statistics. Comparisons between the type of treatment requested were performed using Mann-Whitney test or the Student t test for quantitative data and the Fisher's exact test or the χ2 test for qualitative data.

RESULTS

Cases of 107 patients were discussed at the SMDTs with a mean age of 35.3 (16-62). Forty-seven were SMA type 2, and 57 SMA type 3. Twelve cases were presented twice. Out of 122 presentations to the SMDTs, most of requests related to the initiation of a treatment (nusinersen (n = 46), risdiplam (n = 54), treatment without mentioning preferred choice (n = 5)) or a switch of treatment (n = 12). Risdiplam requests concerned significantly older patients (p = 0.002), mostly SMA type 2 (p < 0.0001), with greater disease severity in terms of motor and respiratory function compared to requests for nusinersen. In the year prior to presentation to the SMDTs, most of the patients experienced worsening of motor weakness assessed by functional tests as MFM32 or other meaningful scales for the most severe patients. Only 12% of the patients discussed had a stable condition. Only 49/122 patients (40.1%) expressed clear expectations regarding treatment. The treatment requested was approved by the SMDTs in 72 patients (67.2%). The most common reasons to decline treatment were lack of objective data on the disease course prior discussion to the SMDTs or inappropriate patient's expectations. Treatment requests were more likely to be validated by the SMDTs if sufficient pre-therapeutic functional assessment had been performed to assess the natural history (55% vs. 32%) and if the patient had worsening rather than stable motor function (p = 0.029). In patients with approved treatment, a-priori criteria to define a further ineffectiveness of treatment (usually after 14 months of treatment) were proposed for 67/72 patients.

CONCLUSIONS

In the context of costly treatments with few controlled studies in adults with SMA, in whom assessment of efficacy can be complex, SMDTs are 'real-world observatories' of great interest to establish national recommendations about indications of treatment and follow-up.

Current clinical management of CIDP with immunoglobulins in France: An expert opinion

Treatment strategies in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) must be adapted on a case-to-case basis. Validated and reproducible tools for monitoring treatment response are required at diagnosis, when initiating treatment and throughout follow-up. A task force of French neurologists, experts in neuromuscular disease reference centers, was assembled to provide expert advice on the management of typical CIDP with intravenous immunoglobulins (Ig), and to harmonize treatment practices in public and private hospitals. The task force also referred to the practical experience of treating CIDP with Ig at the diagnostic, induction and follow-up stages, including the assessment and management of Ig dependence, and following the recommendations of the French health agency.

Characteristics of Patients With Late-Onset Pompe Disease in France: Insights From the French Pompe Registry in 2022

BACKGROUND AND OBJECTIVES

The French Pompe disease registry was created in 2004 for study of the natural course of the disease in patients. It rapidly became a major tool for assessing the long-term efficacy of enzyme replacement therapy (ERT) after the market release of alglucosidase-alfa.

METHODS

Approximately 10 years after publication of the baseline characteristics of the 126 initial patients of the French Late-Onset Pompe Disease registry, we provide here an update of the clinical and biological features of patients included in this registry.

RESULTS

We describe 210 patients followed at 31 hospital-based French neuromuscular or metabolic centers. The median age at inclusion was 48.67 ± 14.91 years. The first symptom was progressive lower limb muscle weakness, either isolated (50%) or associated with respiratory symptoms (18%), at a median age of 38 ± 14.9 years. At inclusion, 64% of the patients were able to walk independently and 14% needed a wheelchair. Positive associations were found between motor function measure, manual motor test, and 6-minute walk test (6MWT) results, and these parameters were inversely associated with the time taken to sit up from a lying position at inclusion. Seventy-two patients had been followed for at least 10 years in the registry. Thirty-three patients remained untreated a median of 12 years after symptom onset. The standard ERT dose was administered for 177 patients.

DISCUSSION

This update confirms previous findings for the adult population included in the French Pompe disease registry, but with a lower clinical severity at inclusion, suggesting that this rare disease is now diagnosed earlier; thanks to greater awareness among physicians. The 6MWT remains an important method for assessing motor performance and walking ability. The French Pompe disease registry provides an exhaustive, nationwide overview of Pompe disease and can be used to assess individual and global responses to future treatments.

Phenotype Presentation and Molecular Diagnostic Yield in Non-5q Spinal Muscular Atrophy

Background and Objectives

Spinal muscular atrophy (SMA) is mainly caused by homozygous SMN1 gene deletions on 5q13. Non-5q SMA patients' series are lacking, and the diagnostic yield of next-generation sequencing (NGS) is largely unknown. The aim of this study was to describe the clinical and genetic landscape of non-5q SMA and evaluate the performance of neuropathy gene panels in these disorders.

Methods

Description of patients with non-5q SMA followed in the different neuromuscular reference centers in France as well as in London, United Kingdom. Patients without a genetic diagnosis had undergone at least a neuropathy or large neuromuscular gene panel.

Results

Seventy-one patients from 65 different families were included, mostly sporadic cases (60.6%). At presentation, 21 patients (29.6%) showed exclusive proximal weakness (P-SMA), 35 (49.3%) showed associated distal weakness (PD-SMA), and 15 (21.1%) a scapuloperoneal phenotype (SP-SMA). Thirty-two patients (45.1%) had a genetic diagnosis: BICD2 (n = 9), DYNC1H1 (n = 7), TRPV4 (n = 4), VCP, HSBP1, AR (n = 2), VRK1, DNAJB2, MORC2, ASAH1, HEXB, and unexpectedly, COL6A3 (n = 1). The genetic diagnostic yield was lowest in P-SMA (6/21, 28.6%) compared with PD-SMA (16/35, 45.7%) and SP-SMA (10/15, 66.7%). An earlier disease onset and a family history of the disease or consanguinity were independent predictors of a positive genetic diagnosis. Neuropathy gene panels were performed in 59 patients with a 32.2% diagnostic yield (19/59). In 13 additional patients, a genetic diagnosis was achieved through individual gene sequencing or an alternative neuromuscular NGS.

Discussion

Non-5q SMA is genetically heterogeneous, and neuropathy gene panels achieve a molecular diagnosis in one-third of the patients. The diagnostic yield can be increased by sequencing of other neuromuscular and neurometabolic genes. Nevertheless, there is an unmet need to cluster these patients to aid in the identification of new genes.

Caveolinopathy: clinical, histological and muscle imaging features and follow-up in a multicenter retrospective cohort

BACKGROUND

CAV3 gene mutations, mostly inherited as an autosomal dominant trait, cause various skeletal muscle diseases. Clinical presentations encompass proximal myopathy, distal myopathy, or an isolated persistent high creatine kinase (CK) with a major overlapping phenotype.

METHODS

Twenty-three patients with CAV3 symptomatic mutations, from 16 different families, were included in a retrospective cohort. Mean follow-up duration was 24.2 ± 15.0 years. Clinical and functional data were collected during the follow-up. The results of muscle imaging, electroneuromyography and muscle histopathology and immunohistochemistry and caveolin-3 Western blot analysis were also compiled.

RESULTS

Exercise intolerance was the most common phenotype (52%). Eighty percent of patients had calf hypertrophy and only 65% of patients presented a rippling. One patient presented initially with camptocormia. A walking aid was required in only two patients. Electroneuromyography was mostly normal. CK level was elevated in all patients. No patient had cardiac or respiratory impairment. Muscle imaging showed fatty involvement of semimembranosus, semitendinosus, rectus femoris, biceps brachialis and spinal muscles. Almost all (87%) of the biopsies were abnormal but without any specific pattern. While a quarter of patients had normal caveolin-3 immunohistochemistry results, Western blots disclosed a reduced amount of the protein. We report nine mutations, including four not previously described. No phenotype-genotype correlation was evidenced.

CONCLUSIONS

Caveolinopathy have diverse clinical, muscle imaging and histological presentations but often have limited functional impact. Mild forms of the disease, an atypical phenotype and normal caveolin-3 immunostaining are pitfalls leading to misdiagnosis.

Neurolymphomatosis: involvement of peripheral nervous system revealing hematologic malignancy, a report of nine cases

BACKGROUND AND AIM

Neurolymphomatosis is defined as an infiltration of the peripheral nervous system (PNS) by malignant lymphoma cells. It is a rare entity and diagnosis is complicated especially when PNS involvement is the initial and leading symptom. To improve knowledge of the disorder and shorten the time to diagnosis, we report a series of nine patients without a history of hematologic malignancy, who were diagnosed with neurolymphomatosis after evaluation and workup of peripheral neuropathy.

METHODS

The patients were included from the Department of Clinical Neurophysiology at Pitié Salpêtrière and Nancy Hospitals over a period of 15 years. Diagnosis of neurolymphomatosis was confirmed by histopathologic examination for each patient. We characterized their clinical, electrophysiological, biological, imaging, and histopathologic features.

RESULTS

The neuropathy was characterized by pain (78%), proximal involvement (44%) or of all four limbs (67%), asymmetrical or with multifocal distribution (78%), abundant fibrillation (78%), a tendency to worsen rapidly, and significant associated weight loss (67%). Neurolymphomatosis was diagnosed principally on nerve biopsy (89%) identifying infiltration of lymphoid cells, atypical cells (78%), a monoclonal population (78%), and supported by fluorodeoxyglucose-positron emission tomography, spine or plexus MRI, cerebrospinal fluid analysis, and blood lymphocyte immunophenotyping. Six patients had systemic disease and three impairment limited to the PNS. In the latter case, progression could be unpredictable and may be diffuse and explosive, sometimes occurring years after a seemingly indolent course.

INTERPRETATION

This study provides better knowledge and understanding of neurolymphomatosis when neuropathy is the initial presentation.

Anti-Hu Antibodies in Patients With Neurologic Side Effects of Immune Checkpoint Inhibitors

BACKGROUND AND OBJECTIVES

To clinically characterize post-immune checkpoint inhibitor (ICI) Hu antibody (Ab) neurologic disorders, we analyzed Hu-Ab-positive patients with neurologic immune-related adverse events (n-irAEs) and compared them with patients with other n-irAEs, ICI-naive patients with Hu-Ab paraneoplastic neurologic syndromes (PNSs) identified in the same study center, and those with Hu-Ab n-irAEs reported elsewhere.

METHODS

Patients whose samples were sent to the French reference center for a suspicion of n-irAE (2015-2021) were identified; those with a final diagnosis of n-irAE and Hu-Ab were included. Control groups included patients with a final diagnosis of n-irAE occurring during the same period as the patients included (2018-2021) but without Hu-Ab, and ICI-naive patients with Hu-Ab PNS diagnosed during the same period; a systematic review was performed to identify previous reports.

RESULTS

Eleven patients with Hu-Ab and n-irAEs were included (median age, 66 years, range 44-76 years; 73% men). Ten patients had small cell lung cancer, and 1 had lung adenocarcinoma. The median follow-up from onset was 3 months (range 0.5-18 months). Compared with those with other n-irAEs (n = 63), Hu-Ab-positive patients had more frequently co-occurring involvement of both central and peripheral nervous systems (36% vs 8%, p = 0.02) and limbic (54% vs 14%, p < 0.01), brainstem (27% vs 5%, p = 0.02), and dorsal root ganglia (45% vs 5%, p < 0.01) involvement. The proportion of patients with severe disability (modified Rankin Scale score >3) at diagnosis was higher among Hu-Ab n-irAEs (91% vs 52%, p = 0.02). Patients with Hu-Ab had also poorer outcome (100% vs 28%, p < 0.01) and higher mortality (91% vs 46%, p < 0.01). There was no significant difference in terms of clinical features between Hu-Ab n-irAEs and ICI-naive Hu-Ab PNS (n = 92), but there was a poorer outcome (56/78, 71%, p < 0.01) and higher mortality (26%, p < 0.01) among the former. No significant difference was found between the patients reported herein and those in the literature.

DISCUSSION

The presence of Hu-Ab identifies a subgroup of n-irAEs that consistently reproduce the phenotypes of Hu-Ab-related PNS, supporting the hypothesis of ICI triggering or unmasking PNS. As these patients show high disability and mortality, further studies are required to investigate the underlying immunopathogenic mechanisms and to improve the outcome of Hu-Ab n-irAEs.

Anti-disialosyl-IgM chronic autoimmune neuropathies: a nationwide multicenter retrospective study

BACKGROUND & PURPOSE

In this retrospective study involving 14 University Hospitals from France and Switzerland, we aimed at defining the clinicopathologic features of chronic neuropathies with anti-disialosyl ganglioside IgM antibodies (CNDA).

RESULTS

Fifty-five patients with a polyneuropathy evolving for more than 2 months and with at least one anti-disialosyl ganglioside IgM antibody, i.e., anti-GD1b, -GT1b, -GQ1b, -GT1a, -GD2 and -GD3 were identified. Seventy-eight percent of patients were male, mean age at disease onset was 55 years (30-76), and disease onset was progressive (82%) or acute (18%). Patients presented with limb sensory symptoms (94% of cases), sensory ataxia (85%), oculomotor weakness (36%), limb motor symptoms (31%), and bulbar muscles weakness (18%). Sixty-five percent of patients had a demyelinating polyradiculoneuropathy electrodiagnostic profile, and 24% a sensory neuronopathy profile. Anti-GD1b antibodies were found in 78% of cases, while other anti-disialosyl antibodies were each observed in less than 51% of patients. Other features included nerve biopsy demyelination (100% of cases), increased cerebrospinal fluid protein content (75%), IgM paraprotein (50%), and malignant hemopathy (8%). Eighty six percent of CNDA patients were intravenous immunoglobulins (IVIg)-responsive, and rituximab was successfully used as second-line treatment in 50% of cases. Fifteen percent of patients had mild symptoms and were not treated. CNDA course was progressive (55%) or relapsing (45%), and 93% of patients still walked after a mean disease duration of 11 years.

CONCLUSION

CNDA have a recognizable phenotype, are mostly IgIV-responsive, and present with a good outcome in a majority of cases.

AB0651 Clinical Impact and Prognosis of cryoglobulinemia and cryofibrinogenemia in Systemic Sclerosis

Background

Systemic sclerosis (SSc) is reported to be a secondary cause of cryoglobulinemia as well as cryofibrinogenemia. However, prevalence, clinical implication and associated pronostic of cryoprecipitates in SSc are unknown.

Objectives

To describe the prevalence, the phenotype and evaluate the prognosis of cryoglobulinemia and/or cryofibrinogenemia associated with systemic sclerosis.

Methods

We included all adult (≥18 years) consecutive SSc patients from the Systemic Scleroderma Toulouse Cohort (SSTC) [1] for whom a cryoglobulin and/or cryofibrinogen measurement was carried out at the immunology laboratory of the Toulouse University Hospital between June 1, 2005 and May 31, 2018 and at least one follow-up visit. We compared SSc-patients characteristics’ with and without cryoglobulinemia > 50 mg/l and with and without cryofibrinogenemia. Survival analysis based on presence of cryoglobulin cryofibrinogen was performed using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazards models (ascending step-by-step method) were used to determine baseline variables associated with cryoglobulin or cryofibrinogen presence.

Results

166 patients were included in the study. 74.6% of patients were women, with a average age at diagnosis of 51.2 years-old. 24% were diffuse cutaneous subtypes and 71.6% limited cutaneous subtypes. Anti-centromere and anti-Scl70 were respectively positive in 44.5% and 21.6% of cases. All these patients were assessed for cryoglobulin detection and 75 cryofibrinogen detection in serum. 43.3% had a cryoglobulinemia >50 mg/l. 46.6% had cryofibrinogenemia. Patients with cryoglobulinemia >50 mg had more cardiac diastolic involvement (22.8% vs. 5.1% p=0.0395). In the multivariate analysis, diastolic involvement (HR=6.23; p=0.0331) was an independent predictor of cryoglobulin >50 mg/l. Survival at 10 years was better for patients with cryoglobulinemia >50 mg/l (log-rank 0.0363) (Figure 1). Survival at 5 and 10 years was 97.6% and 88.8% respectively in patients with cryoglobulinemia >50 mg/l versus 91.9% and 78.4% in patients with cryoglobulinemia <50 mg/l. In cox regression model adjusted for gender, age and type of systemic sclerosis, cryoglobulin >50 mg/l was negatively associated with mortality (HR: 0.09; p=0.03). The presence of cryofibrinogenemia was not associated with any clinical, biological or morphological features. In the multivariate analysis, no variable was predictive of the presence of cryofibrinogenemia in patients with SSc. The presence of cryofibrinogenemia had no influence on the mortality of these patients.

Conclusion

In SSc patients, the presence of cryoglobulin >50 mg/l is an independent predictive factor of cardiac diastolic involvement and is associated with a better survival. However, cryofibrinogenemia does not influence clinical phenotype or impact mortality in SSc patients.

References

[1]De Almeida Chaves S, Porel T, Mounié M, Alric L, Astudillo L et al. Sine scleroderma, limited cutaneous, and diffused cutaneous systemic sclerosis survival and predictors of mortality. Arthritis Res Ther. 2021 Dec 7;23(1):295. doi: 10.1186/s13075-021-02672-y.

Disclosure of Interests

None declared

POS0884 DESCRIPTIVE EPIDEMIOLOGY OF SEVERE CARDIAC INVOLVEMENT IN SYSTEMIC SCLEROSIS: A BICENTRIC RETROSPECTIVE STUDY ON 459 PATIENTS

Background

The prevalence of cardiac involvement in systemic sclerosis (SSc) varies in the literature between 3% and 44% and represents a leading cause of mortality in this disease. The incidence of severe cardiac involvement and the factors associated with the occurrence of severe cardiac involvement are not known in the literature.

Objectives

The objective of this study was to evaluate the incidence, prognosis and factors associated with the occurrence of severe cardiac involvement during SSc course.

Methods

We conducted a retrospective, bi-centric study from January 1, 1966 to December 31, 2018. The patients included had a diagnosis of SS according to the ACR/EULAR 2013 criteria. The primary endpoint was the occurrence of severe cardiac involvement. Cardiac involvement was defined by the presence of at least one of the following elements: death of cardiovascular origin, left ventricular ejection fraction less than or equal to 50%, abnormality of at least 3 measurement parameters of diastolic function, global longitudinal strain less than or equal to 18 in absolute value, ventricular tachycardia, ventricular extrasystoles requiring intervention or elevated troponin. Patients with associated myositis and whose only criterion for cardiac involvement was elevated troponin were not included in the group with cardiac involvement. Severe cardiac involvement was defined by the occurrence of hospitalization for cardiovascular reasons or by death of cardiovascular origin. Univariable and multivariable Cox proportional hazards models were used to determine variables associated with severe cardiac involvement occurrence. Survival analysis was performed using the Kaplan-Meier method with comparisons performed using the log rank test.

Results

Four hundred and fifty-nine patients with SSc were included and were followed for a median of 7.1 years [3.1; 13.3]. The median age of our population was 54 years old. There were 81% of women, 77% of patients had limited cutaneous SSc, 15% diffuse cutaneous SSc and 8% SSc sine scleroderma. Of the 459 patients, 105 (23%) had cardiac involvement and 56 (12%) severe cardiac involvement. The incidence of severe cardiac involvement was 2.42 per 100 patient years. Ninety-six hospitalizations were recorded, including 40 (42%) for acute heart failure, 19 (20%) for arrhythmia, 5 (5%) for acute pericarditis, 6 (6%) for acute myocarditis and 14 (15 %) for coronary artery disease (acute coronary syndrome, myocardial infarction or coronary revascularization). The independent factors associated with severe cardiac involvement in SSc were age over 54 years at SSc-diagnosis (OR = 3.21 95% CI [1.73; 5.95], p < 0.001), the presence of myositis (OR = 5.01 95% CI [1.89; 13.28], p = 0.001), pericardial involvement (OR = 3.79 95% CI [2.05; 7.03]; p < 0.001) or scleroderma renal crisis (OR = 4.72 95% CI [2.05; 10.92], p < 0.001). The survival rate of patients with severe cardiac involvement was 70% at 5 years and 53% at 10 years. Patients with severe cardiac involvement had a mortality risk three times greater than patients without severe cardiac involvement, HR = 3.1 (95% CI [1.7; 5.7], p<0.0001) (Figure 1). Pericardial involvement was an independent risk factor for mortality, HR = 2.0 (95% CI [1.02; 4.0], p=0.04).

Figure 1.

Survival of patients with severe cardiac involvement of systemic scleroderma. HR: Hazard ratio; 95% CI: 95% Confidence interval; Nb at risk: Number at risk

Conclusion

We need to focus our clinical attention on diagnosing and manage cardiac involvement in SSc, as severe cardiac involvement is not uncommon and is responsible for a poor prognosis.

Disclosure of Interests

None declared

POS0711 TOLERANCE AND EFFICACY OF TARGETED THERAPIES PRESCRIBED FOR OFF-LABEL INDICATIONS IN REFRACTORY SYSTEMIC AUTOIMMUNE DISEASES: DATA OF THE FIRST 100 PATIENTS ENROLLED IN THE TATA REGISTRY (TARGETED THERAPY IN AUTOIMMUNE DISEASES)

Background

The low prevalence of systemic autoimmune diseases and the diversity of their clinical manifestations make complex to conduct randomised clinical trials to assess the potential efficacy of targeted treatments.

Objectives

To assess the tolerance and efficacy of targeted therapies prescribed off-label in refractory autoimmune diseases.

Methods

The TATA registry (TArgeted Therapy in Autoimmune Diseases) is a prospective, observational, national and independent cohort follow-up. The inclusion criteria in the registry are as follows: age > 18 years; rare systemic autoimmune disease (systemic lupus erythematosus, Sjögren’s syndrome, systemic scleroderma, inflammatory myopathy, vasculitis) or other refractory rheumatism treated with off-label drugs started after 1st January 2019.

Results

Hundred (100) patients (79 females) were enrolled. The median age was 52.5 years [49;56], the median disease duration before enrolment was 5 years [3;7]. The targeted therapies at enrolment were as follows: JAK/STAT inhibitors (44%), anti-IL6R (22%), anti-IL12/23, anti-IL23 and anti-IL17 (9%), anti-BAFF (5%), abatacept (5%), other targeted treatments (9%), and combination of targeted treatments (6%). 73% of patients were receiving corticosteroid therapy at enrolment (median dose 10 mg/day). The current median follow-up time is 9 months [8;10].

Safety: 11 serious infections (incidence rate of 14.8 /100 patient-years) and 1 cancer (1.3 cancers/100 patient-years) were observed. Two patients died from severe COVID-19 (2.7 deaths/100 patient-years).

Efficacy: The targeted treatment was considered effective by the clinician in 56% of patients and allowed in responders a median reduction of oral corticosteroids of 15 [9-21] mg/day.

Conclusion

These initial results of the TATA registry confirm the diversity of targeted treatments prescribed off-label in refractory autoimmune diseases and their corticosteroid-sparing effect when effective. Tolerance was acceptable in these refractory patients with a long history of treatment with immunosuppressive drugs.

References

[1]B. Terrier et al., Safety and efficacy of rituximab in systemic lupus erythematosus: results from 136 patients from the French AutoImmunity and Rituximab registry. Arthritis Rheum 62, 2458-2466 (2010).

[2]J. E. Gottenberg et al., Efficacy of rituximab in systemic manifestations of primary Sjogren’s syndrome: results in 78 patients of the AutoImmune and Rituximab registry. Ann Rheum Dis 72, 1026-1031 (2013).

[3]J. E. Gottenberg et al., Risk factors for severe infections in patients with rheumatoid arthritis treated with rituximab in the autoimmunity and rituximab registry. Arthritis Rheum 62, 2625-2632 (2010).

[4]F. R. S. S. S. C. I. consortium, contributors, Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients. Ann Rheum Dis, (2020).

[5]R. Felten et al., B-cell targeted therapy is associated with severe COVID-19 among patients with inflammatory arthritides: a 1-year multicentre study in 1116 successive patients receiving intravenous biologics. Ann Rheum Dis 81, 143-145 (2022).

[6]D. J. Wallace et al., Baricitinib for systemic lupus erythematosus: a double-blind, randomised, placebo-controlled, phase 2 trial. Lancet 392, 222-231 (2018).

[7]J. J. Paik et al., Study of Tofacitinib in Refractory Dermatomyositis: An Open-Label Pilot Study of Ten Patients. Arthritis Rheumatol 73, 858-865 (2021).

[8]S. Cole et al., Integrative analysis reveals CD38 as a therapeutic target for plasma cell-rich pre-disease and established rheumatoid arthritis and systemic lupus erythematosus. Arthritis Res Ther 20, 85 (2018).

[9]S. J. Bowman et al., Safety and efficacy of subcutaneous ianalumab (VAY736) in patients with primary Sjogren’s syndrome: a randomised, double-blind, placebo-controlled, phase 2b dose-finding trial. Lancet 399, 161-171 (2022).

Acknowledgements

French networks (FAI2R, CRI, IMIDIATE, SFR, SNFMI) focused on rare systemic autoimmune diseases contributed this work by the contribution of network-affiliated physicians.

Disclosure of Interests

Jacques-Eric Gottenberg Consultant of: Abbvie, BMS, Gilead, Galapagos, Novartis, Lilly Roche Chugai, Sanofi, Janssen, Pfizer, Grant/research support from: BMS.

Lilly and Pfizer for this register (with no access to data)., Aurore Chaudier: None declared, Yves Allenbach: None declared, Arsene Mekinian: None declared, Zahir Amoura: None declared, Patrice cacoub: None declared, Divi Cornec: None declared, Eric Hachulla: None declared, Pierre Quartier: None declared, isabelle melki: None declared, Christophe Richez: None declared, Raphaèle Seror: None declared, Benjamin Terrier: None declared, Valerie Devauchelle-Pensec: None declared, Julien Henry: None declared, MARC GATFOSSE: None declared, LAURENCE BOUILLET: None declared, Emeline GAIGNEUX: None declared, Vincent ANDRE: None declared, Gildas BAULIER: None declared, Aurélie SAUNIER: None declared, Marie Desmurs: None declared, Antoine POULET: None declared, Mathieu ETE: None declared, Marie-Elise Truchetet: None declared, Martin Michaud: None declared, Claire Larroche: None declared, AZEDDINE DELLAL: None declared, Amelie LEURS: None declared, Sebastien Ottaviani: None declared, Hubert NIELLY: None declared, Guillaume VIAL: None declared, Roland JAUSSAUD: None declared, Benedicte ROUVIERE: None declared, Pierre-Yves JEANDEL: None declared, Aurelien GUFFROY: None declared, Anne-Sophie Korganow: None declared, Mathieu JOUVRAY: None declared, alain meyer: None declared, Emmanuel Chatelus: None declared, Christelle Sordet: None declared, Renaud FELTEN: None declared, Jean Sibilia: None declared, Samira AHMED YAHIA: None declared, Jean François Kleinmann: None declared, Xavier Mariette Consultant of: BMS, Galapagos, GSK, Janssen, Novartis, Pfizer, Sanofi, UCB

Neuromyotonia: a skin-deep problem

A 45-year-old woman was evaluated for right-sided hemicorporal scar-like skin lesions on her arm and thoracic and inguinal areas that appeared shortly after reduction mammoplasty. Five years later, she developed spontaneous cramps and involuntary abnormal, painful, twitching movements in the same areas. With time, the cramps worsened and disabled the patient. The use of her right arm triggered contractures of muscles and abnormal movements. A diagnosis of neuromyotonia (NMT) was established on the basis of clinical findings and on electromyographic findings of a burst of high-frequency motor unit potentials recorded in the right triceps in the area of skin lesions. The results of medullary, encephalic MRI as well as a comprehensive metabolic panel were normal. She was positive for antinuclear antibodies without specificity. Neither antineural antibodies nor antivoltage-gated potassium channel complex antibodies (specifically, leucine-rich glioma inactivated protein 1 and contactin-associated protein-like-2) were detected. Her skin lesions were diagnosed as morphea. Two combined strategies of treatment were initiated: antiepileptic drugs for NMT and corticosteroids and methotrexate for morphea. NMT is a rare, debilitating neurological complication of morphea.

Motor and respiratory decline in patients with Late-onset Pompe disease after cessation of enzyme replacement therapy during COVID-19 pandemic

BACKGROUND

Data on interruption of enzyme replacement therapy are scarce in late-onset Pompe disease. Due to the COVID-19 crisis, 8 neuromuscular reference centers in France were obligated to stop the treatment for 31 patients.

METHOD

We collected the motor and respiratory data from our French registry, before COVID-19 and at treatment restart.

RESULTS

In 2.2 months (mean), patients showed a significant deterioration of 37 meters (mean) in the 6-minute walk test and a loss of 210 mL (mean) of forced vital capacity, without ad integrum restoration after 3 months of ERT restart.

CONCLUSION

This national study based on data from the French Pompe registry shows that the interruption of enzyme replacement therapy, even as short as only few months, worsens Pompe patients' motor and respiratory function.

A multicenter cross-sectional French study of the impact of COVID-19 on neuromuscular diseases

BACKGROUND

Due to their health condition, patients with neuromuscular diseases (NMD) are at greater risk of developing serious complications with COVID-19. The objective of this study was to analyze the prevalence of COVID-19 among NMD patients and the risk factors for its impact and severity during the first wave of the pandemic. Clinical data were collected from NMD-COVID-19 patients, between March 25, 2020 and May 11, 2020 in an anonymous survey carried out by expert physicians from the French Health Care Network Filnemus.

RESULTS

Physicians reported 84 patients, including: 34 with myasthenia gravis, 27 with myopathy and 23 with neuropathy. COVID-19 had no effect on NMD for 48 (58%) patients and 48 (58%) patients developed low COVID-19 severity. COVID-19 caused the death of 9 (11%) NMD patients. Diabetic patients were at greater risk of dying. Patients with diabetes, hypertension or severe forms of NMD had a higher risk of developing a moderate or severe form of COVID-19. In our cohort, corticosteroids and other immunosuppressants were not significantly associated with higher COVID-19 severity for acquired NMD.

CONCLUSION

During this period, a small percentage of French NMD patients was affected by COVID-19 compared to the general French population and COVID-19 had a limited short-term effect on them. Diabetes, hypertension and a severe degree of NMD were identified as risk factors of unfavorable outcome following COVID-19. Conversely, in our cohort of patients with acquired NMD, corticosteroids or other immunosuppressants did not appear to be risk factors for more severe COVID-19.

A recurrent RYR1 mutation associated with early-onset hypotonia and benign disease course

The ryanodine receptor RyR1 is the main sarcoplasmic reticulum Ca²⁺ channel in skeletal muscle and acts as a connecting link between electrical stimulation and Ca²⁺-dependent muscle contraction. Abnormal RyR1 activity compromises normal muscle function and results in various human disorders including malignant hyperthermia, central core disease, and centronuclear myopathy. However, RYR1 is one of the largest genes of the human genome and accumulates numerous missense variants of uncertain significance (VUS), precluding an efficient molecular diagnosis for many patients and families. Here we describe a recurrent RYR1 mutation previously classified as VUS, and we provide clinical, histological, and genetic data supporting its pathogenicity. The heterozygous c.12083C>T (p.Ser4028Leu) mutation was found in thirteen patients from nine unrelated congenital myopathy families with consistent clinical presentation, and either segregated with the disease in the dominant families or occurred de novo. The affected individuals essentially manifested neonatal or infancy-onset hypotonia, delayed motor milestones, and a benign disease course differing from classical RYR1-related muscle disorders. Muscle biopsies showed unspecific histological and ultrastructural findings, while RYR1-typical cores and internal nuclei were seen only in single patients. In conclusion, our data evidence the causality of the RYR1 c.12083C>T (p.Ser4028Leu) mutation in the development of an atypical congenital myopathy with gradually improving motor function over the first decades of life, and may direct molecular diagnosis for patients with comparable clinical presentation and unspecific histopathological features on the muscle biopsy.

AB0358 ABATACEPT AS A bDMARD IN STEROID-REFRACTORY POLYMYALGIA RHEUMATICA

Background:

polymyalgia rheumatica (PMR) is a chronic inflammatory disorder affecting elderly people. Glucocorticoids (GC) are the mainstay of therapy for PMR. Despite this treatment, the disease may relapse or GC dosage cannot be tapered. Methotrexate (MTX) may be helpful in these cases. Blockade of IL-6 has an effective steroid-sparing effect in patients with giant cell arteritis (GCA) and may improve the clinical symptoms of patients with PMR. The pathophysiology of PMR still remains uncertain but there are evidences for a participation of Th1 and Th17 lymphocytes. Recently, blockade of the costimulatory pathway by abatacept (ABA) gave favorable results in GCA.

Objectives:

to report our experience (efficacy and safety) of ABA in the treatment of patients with isolated PMR who required longstanding GC and who failed to respond to MTX and/or IL-6 receptor blocking agents.

Methods:

a call for observations of all cases of patient with PMR who received at least one dose (SC or IV) of ABA was sent to the members of the French specialist network “Club Rhumatismes & Inflammation” (CRI: www.cri-net.com)(rheumatologist and internal medicine). Patients must satisfy the EULAR/ACR criteria for PMR and have isolated PMR without associated GCA.

Results:

4 cases were declared during a 12 months period: 2 men and 2 women; age (median [range]): 60.7 [50-68] years; disease duration 30 [7-48] months; duration of GC treatment before starting ABA: 60 [10-72] months. They all required prednisolone with a daily dosage of 14.5 mg [10-20]. Before ABA administration, they all received MTX while 2 patients were treated by IL-6R inhibitor (tocilizumab 6 months and sarilumab 3 months, respectively) without improvement. ABA was given as a monthly infusion (10 mg/kg) in one case and subcutaneously (every week) in 3 cases. ABA treatment duration ranged from 3 to 18 months. Two patients responded to the treatment with a progressive decline of DAS-PMR and GC dosage tapering during a 12 month follow-up, while there was no improvement for the 2 others (Table 1). CRP levels also decreased for one responder. The safety was excellent for all. ABA was still maintained in one responder. Among the non-responders, one patient was switched to tocilizumab and the second still received high GC dosage.

Conclusion:

ABA may be effective in certain PMR patients who were unable to taper GC, with a good safety profile. A randomized controlled trial is required in order to determine its place in the treatment of PMR and to select the appropriate patients who could potentially benefit from this biological agent.

References:

[1]Langford CA et al. Vasculitis Clinical Research Consortium. A Randomized, Double-Blind Trial of Abatacept (CTLA-4Ig) for the Treatment of Giant Cell Arteritis. Arthritis Rheumatol. 2017; 69: 837-845

Table 1.

changes in DAS-PMR and CRP levels in 4 patients with PMR while receiving abatacept (M: months; CRP in mg/L).

CasesDAS- PMR M0DAS- PMR M3DAS-PMR M6DAS -PMR M12CRP M0CRP M3CRP M6CRP M121202121NA58.68.4NA231.130.5NANA2125NANA310.78.3551337.222.722224182217.2121.23.33.53

Disclosure of Interests:

None declared

AB0772 JAK INHIBITORS IN REFRACTORY ADULT AND CHILDHOOD ONSET STILL’S DISEASE

Background:

Excessive and inappropriate production of pro-inflammatory cytokines such as interleukin (IL)-1, IL-6 or IL-18, is a pathogenic cornerstone in adult and childhood onset Still’s disease. Beyond therapies targeting IL-1 or IL-6, Janus kinases (JAK) inhibitors have been proposed for adult-onset Still’s disease (AOSD) patients refractory to or intolerant of treatment with biologicals. Recently, it has been suggested that JAK inhibitors might be efficient in refractory AOSD patients1.

Objectives:

To assess the efficacy and safety of JAK inhibitors in the treatment of refractory systemic juvenile idiopathic arthritis (sJIA) or AOSD.

Methods:

This retrospective study was based on a national survey of the departments of rheumatology, paediatric rheumatology and internal medicine in all French hospitals from an online call of the “Club Rhumatismes et Inflammation” (www.cri-net.com). The data were collected using a standardized questionnaire, and analyzed at different time points (treatment initiation, M1, M3, M6 and end of the follow-up). The response to JAK inhibitors was categorized as: complete remission (resolution of all clinical and biologic signs), partial remission (clinical improvement with persistence of a few symptoms) or failure (lack of clinical or biological improvement).

Results:

6 patients (5 adults and 1 child) were recruited (Table 1). Mean age at treatment start was 39.6 years for the AOSD patient and 6 years for the sJIA patient, and mean disease duration was 5.3 years. The clinical expression was predominantly systemic in 5 five patients and chronic articular in one. Response to corticosteroids, conventional synthetic or biological Disease Modifying Anti-Rheumatic Drugs had been considered inadequate in all patients. Baricitinib was used in 3 patients, ruxolitinib in 2, and tofacitinib in 1. Steroids were concurrently used in all patients, anakinra in one, methotrexate and anakinra in one. At a mean (SD) follow-up of 9.5 months, partial response was observed in 4 (66.7%) cases (patients with ruxolitinib, tofacitinib or baricitinib) and failure in 2 (33.3%) (patients with baricitinib). No patient achieved complete remission. At the last visit, steroids could be decreased but not stopped in all patients. Patients with partial response had an average decrease of 72,8% (90% for tofacitinib, 70% for baricitinib, 58.5% for ruxolitinib between the start and the follow-up end date) and non-responder patients were yet able to reduce steroids by 60,5% (Table 1). Tolerance of JAK inhibitors was excellent, however patient 4 experienced an episode of infectious pulmonary disease.

Conclusion:

JAK inhibitors therapy may be helpful for some patients with refractory Still’s disease. However, no complete response was observed in this short series of cases. There might be a difference of response between the molecules, although the number of patients is too low to draw conclusions. Additional information is thus needed to evaluate more precisely the risk-benefit ratio of this treatment, and a possible difference in efficacy among the different groups of JAK inhibitors.

References:

[1]Hu Q, Wang M, Jia J, et al. Ann Rheum Dis 2020;0:1–3. doi:10.1136/annrheumdis-2019-216

Table 1.

Characteristics of the AOSD patient

No.SexAge (year)Main symptomsTreatments before JAKi onsetJAK inhibitorsSteroids at onset (mg/day)Concomitant treatmentResponse at last F-USteroids at the end of F-U (mg/day)F-U (months)1F6Fever, polyarthritis, rashAINS, ANAKI, TOCI, CANAKI, ADA, THALI, INFLIXRUXOLITINIB 5mgx2/day30P1232M28Fever, polyarthritis, rashANAKIBARICITINIB 4mg/day800N1013M32Fever, polyarthritis, rashTOCI+MTX, ANAKI+MTX, CANAKI+MTX, ADA, CICLO, IgIVBARICITINIB 4mg/day16MTX 20 mg/week ANAKINRA 100mg/dayP12194F40Fever, polyarthritis, rashMTX, IMUREL, CICLO, ETANERCEPT, ANAKI+MTX, TOCI+MTX, IgIVRUXOLITINIB 15mgx2/day60ANAKI 200mg/dayP3045F48Fever, polyarthritis, rashTOCI, ANAKI, CICLO, CANAKI, IMURELTOFACITINIB 5mgx2/day500P7.596F50Fever, polyarthralgia, rashANAKIBARICITINIB 4mg/day600N401

F-U: Follow-up

N: No response

P: Partial response

Acknowledgements:

I thank all the coauthors, particularly Stéphane Mitrovic and Bruno Fautrel. Also, a special thank to the CRI.

Disclosure of Interests:

None declared

Ganglionopathies Associated with MERRF Syndrome: An Original Report

Neuropathies in Myoclonic Epilepsy with Ragged Red Fibers (MERRF) syndrome are frequent but ganglionopathies have never been reported. We retrospectively identified 24 patients with MERRF mutations in the neuromuscular center Nord/Est/Ile de France (Pitié-Salpêtrière, Paris, France). Seventeen nerve conduction studies (NCS) were available. Five patients had MERRF syndrome and ganglionopathy, a pure sensory neuropathy. All of them displayed ataxia and mild clinical sensory abnormalities. Ganglionopathies have been reported in mitochondrial diseases but never in MERRF syndrome. We suggest that patients presenting with ganglionopathy, especially if associated with myopathy, lipomatosis or epilepsy, should be screened for MERRF mutations.

Discontinuation of disease-modifying treatments for multiple sclerosis in patients aged over 50 with disease Inactivity

BACKGROUND

Treatments may become redundant in older patients with multiple sclerosis (MS). Our aim was to explore whether stopping treatments might be possible in patients aged over 50 with disease inactivity.

METHODS

Patients over 50 were included from the population-based MS Lorraine registry if they had a relapsing-remitting course at onset and had experienced no relapse for ≥ 3 years. Patients who stopped treatments were defined as "stoppers", and the others as "stayers". The outcomes were the time to first relapse, to first disability progression, and to the occurrence of EDSS score of 6, assessed by multivariate analysis using a propensity score.

RESULTS

132 stoppers and 366 stayers had a median follow-up of 7 years. There was no difference in Log-rank tests for the times to first relapse (p = 0.61) and to first disability progression (p = 0.22). In Cox models, stopping treatments was not associated with an increased risk of relapse (adjusted Hazard ratio (aHR) = 0.92 [0.72-1.16; p = 0.47]) or of an increase in EDSS score (aHR = 0.89 [0.71-1.13; p = 0.34]). However, stopping was associated with a higher risk of occurrence of EDSS score of 6 (aHR = 3.29 [2.22-4.86; p < 0.0001]), with a significant difference for the time to occurrence of EDSS score of 6 (p = 0.003).

CONCLUSION

Our study suggests that stopping injectable disease-modifying treatments, in patients over 50 with disease inactivity, is not associated with an increased risk of relapse or EDSS progression, but there might be a higher risk of reaching EDSS 6. These results have to be confirmed by interventional studies.

SAT0339 NERVOUS SYSTEM INVOLVEMENT IN SYSTEMIC SCLEROSIS: A COHORT STUDY

Background:

Nervous system involvement is considered to be rare in systemic sclerosis (SSc). Its prevalence is highly variable in SSc cohort studies and its prognosis is not well established.

Objectives:

To determine the frequency, clinical characteristics, associations, and outcomes of different types of peripheral nervous system (PNS) and central nervous system (CNS) disease in a cohort of systemic sclerosis patients.

Methods:

We have carried out a retrospective observational study by systematically analyzing the medical records of patients diagnosed with SSc in Toulouse University Hospital and Ducuing Hospital, south west France. We included patients who met the following inclusion criteria: being over 18 years of age on diagnosis, meeting the ACR /EULAR 2013 classification criteria, being diagnosed after 01/01/1966 and before 31/12/2018, at least 12 months of follow-up. Patients were followed until 31/12/2019. Nervous system involvement associated with SSc was included when there was involvement on or after diagnosis and after exclusion of all other causes. Only symptomatic clinical involvement was included. Ischemic or hemorrhagic strokes were excluded. We calculated the incidence of CNS and/or PNS disease during the follow-up period per 1,000 person-years. Kaplan-Meier curves were plotted to determine the cumulative incidence of nervous system disease. We evaluated associated factors of CNS and/or PNS disease using multivariable Cox regression.

Results:

Of 447 SSc patients, 79.8% were female, 68 (15%) were diffuse cutaneous SSc, 342 (77%) were limited cutaneous SSc and 37 (8%) were sine scleroderma SSc. The mean ± SD age at diagnosis was 52.9 ± 14.3 years.

During the study period, 82 (18%) patients experienced a PNS disease, 29 (6%) a CNS disease. The incidence was 28 per 1,000 patient-years of any nervous system disease, with 22 per 1,000 patient-years and 6 per 1,000 patient-years of PNS disease and CNS disease, respectively. The most frequent were carpal tunnel syndrome (63%) and polyneuropathies (12%) for PNS disease, and headache (45%) and seizures (10%) for CNS disease.

Three significant independent associated factors with PNS disease occurrence were identified using multivariable Cox regression: BMI>23.1kg/m2(HR = 1.06 [1.01-1.12]), joint involvement (HR = 2.7 [1.3-5.5]), and an alteration in the left ventricular ejection fraction (HR = 3.8 [1.4-10.3]).

Four significant independent associated factors with CNS disease occurrence were identified: age > 54 years (HR = 2.5 [1.1-6.0]), positive anti-PmScl testing (HR = 6.4 [1.5-28.2]), Caucasian origin (HR = 0.2 [0.1-0.5]) and hemoglobin < 12g/dl (HR = 0.2 [0.04-0.8]).

Nervous system disease occurrence did not appear to have a negative impact on the survival of SSc patients (log-rank p=0.56).

Conclusion:

This study shows that specific nervous system disease in SSc is not uncommon and does not appear to increase mortality, but it could have an impact on functional prognosis and needs to be monitored.

Disclosure of Interest:

None declared

Development and Validation of a New Risk Prediction Score for Life-Threatening Ventricular Tachyarrhythmias in Laminopathies

BACKGROUND

An accurate estimation of the risk of life-threatening (LT) ventricular tachyarrhythmia (VTA) in patients with LMNA mutations is crucial to select candidates for implantable cardioverter-defibrillator implantation.

METHODS

We included 839 adult patients with LMNA mutations, including 660 from a French nationwide registry in the development sample, and 179 from other countries, referred to 5 tertiary centers for cardiomyopathies, in the validation sample. LTVTA was defined as (1) sudden cardiac death or (2) implantable cardioverter defibrillator-treated or hemodynamically unstable VTA. The prognostic model was derived using the Fine-Gray regression model. The net reclassification was compared with current clinical practice guidelines. The results are presented as means (SD) or medians [interquartile range].

RESULTS

We included 444 patients, 40.6 (14.1) years of age, in the derivation sample and 145 patients, 38.2 (15.0) years, in the validation sample, of whom 86 (19.3%) and 34 (23.4%) experienced LTVTA over 3.6 [1.0-7.2] and 5.1 [2.0-9.3] years of follow-up, respectively. Predictors of LTVTA in the derivation sample were: male sex, nonmissense LMNA mutation, first degree and higher atrioventricular block, nonsustained ventricular tachycardia, and left ventricular ejection fraction (https://lmna-risk-vta.fr). In the derivation sample, C-index (95% CI) of the model was 0.776 (0.711-0.842), and the calibration slope 0.827. In the external validation sample, the C-index was 0.800 (0.642-0.959), and the calibration slope was 1.082 (95% CI, 0.643-1.522). A 5-year estimated risk threshold ≥7% predicted 96.2% of LTVTA and net reclassified 28.8% of patients with LTVTA in comparison with the guidelines-based approach.

CONCLUSIONS

In comparison with the current standard of care, this risk prediction model for LTVTA in laminopathies significantly facilitated the choice of candidates for implantable cardioverter defibrillators.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03058185.

Clinical follow-up of 411 patients with relapsing and progressive multiple sclerosis 10 years after discontinuing mitoxantrone treatment: a real-life cohort study

BACKGROUND AND PURPOSE

Mitoxantrone (MITOX) has been used to treat patients with aggressive multiple sclerosis (MS) for decades. We aimed to describe the effectiveness and adverse events over 10 years post-MITOX in patients with relapsing and progressive MS from an exhaustive real-life database.

METHODS

Data from patients who received MITOX before 1 January 2006 were collected from the MS Lorraine registry. Expanded Disability Status Scale (EDSS) scores and annual relapse rates (ARRs) year by year during follow-up and the year prior to MITOX were compared. Time to the first relapse and a 1-point increase in EDSS score were used in Cox multivariate models to find associations with potential predictive factors.

RESULTS

A total of 411 patients were included. The ARR for the 155 relapsing patients had decreased from 2.0 (SD 1.20) the year before treatment to 0.3 (SD 0.31) by year 10 (P < 0.0001). The EDSS score increased from 2.8 (SD 1.44) to 4.8 (SD 1.90) by year 10 (P < 0.0001). A high ARR at MITOX initiation was associated with a longer time to a 1-point increase in EDSS score (hazard ratio, 0.81; 95% confidence interval, 0.67-0.99; P = 0.04). The EDSS score in 256 progressive patients increased from 5.0 (SD 1.33) to 6.5 (SD 1.26) by year 10 (P < 0.0001). We identified four cases of acute myeloid leukemias.

CONCLUSIONS

Patients with the most active forms of MS are the most likely to benefit from MITOX in the long term.

Generational changes in multiple sclerosis phenotype in North African immigrants in France: A population-based observational study

Background

The incidence of multiple sclerosis (MS) changes from generation to generation in ethnically different immigrants compared with native-born people. We aimed to determine whether there are generational changes in MS phenotypes among North African immigrants in France.

Methods

Cohort study with data from a population-based MS registry to compare the clinical characteristics of 80 first (NAG1) and 167 second (NAG2) generation North Africans with MS living in France with 5200 native-born Europeans. Adjusted Cox models were used to test the association between scores of 3 and 6 on the expanded disability status scale (EDSS) and the “origin/generation” variable.

Results

Cox models for EDSS scores 3 and 6 showed a higher risk of score 3 (hazard ratio = 1.738, 95% confidence interval 1.237 to 2.444; P = .002) and 6 (hazard ratio = 2.372, 95% confidence interval 1.626 to 3.462; P<.0001) for NAG1 than Europeans. Being NAG2 was not significantly associated with higher hazards of scores 3 and 6.

Conclusions

We found two different phenotypes among NAG1 and NAG2 MS patients in France. NAG1, but not NAG2, have a higher risk of disability than Europeans. This raises the question of environmental factors in MS expression, and advocates appropriate patient management according to generation in immigrants.