AB1182 SPECIALIZED PRO-RESOLVING MEDIATORS (SPMS) AND INFLAMMATORY NETWORKS IN PATIENTS AFFECTED BY ADULT ONSET STILL’S DISEASE (AOSD) AND COVID-19

Background

Uncontrolled systemic inflammation characterizes COVID-19 and autoinflammatory diseases such as adult-onset Still’s disease (AOSD). Biosynthesis of pro-resolving mediators (SPMs), i.e. lipoxins (LX), resolvins (Rv), protectins (PD), and maresins (MaR), ensures inflammation shutdown and tissue repair, limiting neutrophils recruitment and stimulating macrophages to remove apoptotic cells. Among protectins, reduction of PD1 was found in the lungs of mice infected with the H5N1 influenza virus and experimental treatment with PD1 resulted in increased animals’ survival (Morita M et al 2013).

Objectives

We investigated the effects of SPMs in pathogenesis and clinical evolution of AOSD and compared these data with mild and severe COVID-19. Finally, we analyzed the potential role of PD1 in modulating the inflammatory response of macrophages obtained from AOSD patients, COVID-19 patients and healthy donors (HDs).

Methods

21 patients hospitalized for COVID-19 (10 ICU and 11 hospitalized in medical clinical unit) and 13 patients with AOSD were enrolled. Plasma PD1 levels from patients and controls were analyzed by ELISA, and monocytes-derived macrophages were polarized into M1 and M2 phenotype. We analyzed the effect of PD-1 on macrophages differentiation. At 10 days, macrophages were analyzed for surface expression of subtypes markers by flow cytometry. Cytokines production was measured in supernatants by Bio-Plex Assays. Peripheral blood mononuclear cells (PBMCS) from 3 AOSD patients, 2 COVID-19 patients and 3 HDs were obtained. Next-generation deep sequencing was then performed to identify the differences in PBMCs transcripts profiles.

Results

AOSD patients with systemic scored (SS) ≥1 showed an increase of PD1 levels compared to AOSD patients with lower systemic score (p=0.04) (Figure 1A). Similarly, plasma levels of PD1 were increased in COVID-19 patients independently from their clinical subsets, compared to HDs (p=0.02). In vitro treatment with PD1 of monocytes-derived macrophages from AOSD and COVID-19 patients induced a significant increase of M2 polarization vs control (p<0.05) (Figure 1B). Furthermore, a significant release of IL-10 and CCL4 from M2 macrophages was observed when compared to control (p<0.05) (Figure 1C). In the transcriptomes from 3 AOSD patients (2 mild and 1 severe), 2 COVID-19 patients (1 mild and 1 ICU) and 2 HDs, we observed that genes involved in inflammation, lipid catabolism and monocytes activation were specifically dysregulated in AOSD and COVID-19 patients when compared to HDs. Among them pla2g15, pla2g12a, pla2g2d, involved in mobilization of SPMs precursors, were significant upregulated in patients compared to HDs (p<.01, |log2FoldChange|>1.2) (Figure 1D). The largest part of the genes involved in inflammation, lipid catabolism, and monocytes activation are less expressed in AOSD patients when compared to COVID19 patients, as reported in Table 1.

Table 1.Gene symbolLog2 fold changepAdjusted pCounts COVID19Counts AOSDInflammation-related genesALOX50.980.0240.2116861.618562.92IL13RA11.280.0020.0537154.782938.95RTN30.720.0020.00699948.376045.92SSH21.056,78 E-70.0001618343.868848.67Lipid catabolism genesPLBD11.680.000110.008228051.888671.3CYP4F32.850.000340.0171996.63277.13STS1.530.0100.0361798.5623.9HADHA0.740.000140.009712766.447625.38Monocytes-related genesALDH21.462.48E-101.85E-079186.553340.87CD1632.379,99E-060.001466499.4512870.59MGST11.130.00260.0631385.54631.67RNASE42.480.00010.009286.6615.42Figure 1.

Conclusion

The counterbalance by SPMs during inflammation is still a largely unexplored pathway. Our study suggests that an imbalance of SPMs in autoinflammatory diseases as well as COVID-19. The modulation of SPMs as observed in our experiments, might represent a new possible therapeutic strategy during AOSD and COVID-19.

References

[1]Morita M et al. The lipid mediator protectin D1 inhibits influenza virus replication and improves severe influenza. Cell. 2013;153:112-25.

Disclosure of Interests

luca navarini Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, Paid instructor for: AbbVie, Eli Lilly, Consultant of: Philogen, Grant/research support from: AbbVie, Marta Vomero: None declared, Onorina Berardiucrti: None declared, Damiano Currado: None declared, Annalisa Marino: None declared, Alice Biaggi: None declared, Stefano Di Donato: None declared, Francesco Ursini: None declared, Piero Ruscitti: None declared, Riccardo Meliconi: None declared, Paola Cipriani: None declared, Annamaria Iagnocco Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, Antonella Afeltra Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, Roberto Giacomelli Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, SOBI, Consultant of: Philogen, Grant/research support from: AbbVie, SOBI

POS1375 THE EVALUATION OF OBESITY IN ADULT-ONSET STILL’S DISEASE, DATA FROM A LARGE MULTICENTRE COHORT

Background

Over the last few decades, obesity has become an increasing public health problem worldwide [1]. This is a complex disease characterised by as an abnormal or excessive fat accumulation which is usually assessed by body mass index (BMI). A value of BMI over 30 identifies the threshold to define the obesity. High BMI is common feature among patients with rheumatic disease and it is associated with higher disease activity and disability [2]. Thus, the presence of obesity may be considered as a negative prognostic factor in these patients. Against this background in rheumatic disorders, the prevalence of obesity in adult onset Still’s disease (AOSD) has not been entirely clarified so far. Similarly, the impact of being obese on disease features and outcomes has not been fully elucidated in these patients. AOSD is a rare inflammatory disease usually characterised by fever, arthritis, and evanescent skin rash associated with a typical hyperferritinemia [3].

Objectives

In this study, we aimed at evaluating the prevalence of obesity in patients with AOSD. Furthermore, we descriptively assessed the clinical characteristics of these patients. We also described the occurrence of life-threatening complications, the disease courses, and the rate of mortality of obese patients with AOSD than non-obese ones.

Methods

A retrospective assessment of prospectively followed patients, from January 2001 to April 2021, was provided to analyse clinical features of patients with AOSD characterised by a BMI≥30. AOSD patients were evaluated among those included in the multicentre Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort. This is a large cohort of patients with AOSD comprising almost 200 patients [4]. The presence of obesity was evaluated at the time of diagnosis of the disease. In this evaluation, only patients with available data about BMI were included.

Results

In this assessment, 139 patients, who had BMI registered in our database, were evaluated. Out of those, 26 (18.7%) had a BMI≥30 and were defined as having obesity. These patients had a mean age of 39.3±13.6 years and were 46.2% male. Concerning main clinical features, obese patients with AOSD were characterised by fever (96.2%), skin rash (84.6%), arthralgia (76.9%), myalgia (65.4%), and arthritis (61.5%). An explorative comparison between obese and non-obese patients was performed. A lower rate of obese patients showed sore throat (38.5% vs 63.7%, p=0.026) than others. The prevalence of serositis was observed at lower frequency in obese patients with AOSD. Pericarditis (7.7% vs 29.2%, p= 0.024), and pleuritis (7.7% vs 25.7%, p=0.035) were less frequently recorded in obese patients when compared with non-obese ones. In addition, obese patients with AOSD showed higher values of C-reactive protein (CRP) [99.2 (117.0) mg/L vs 52.0 (84.3) mg/L, p=0.046] than others. Conversely, no significant differences were retrieved assessing systemic score, ferritin, erythrocyte sedimentation rate, life-threatening complications, disease patterns, and mortality in obese than non-obese patients.

Conclusion

Clinical features of obese patients with AOSD were described in our multicentre cohort. Almost 20% of patients with AOSD were obese at the time of diagnosis of the disease. These patients were characterised by a lower prevalence of sore throat, pericarditis and pleuritis, and by higher values of CRP. However, obesity did not appear to influence the main disease features and outcomes in AOSD, although further studies are needed to fully elucidate this issue.

References

[1]Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-253

[2]Vidal C, et al. J Rheumatol. 2015;42:2261-2269

[3]Giacomelli R, et al. J Autoimmun. 2018;93:24-36

[4]Ruscitti P, et al. Rheumatology (Oxford). 2022 25:keac027

Disclosure of Interests

None declared

POS1267 LONG-TERM SURVEY STUDY OF THE IMPACT OF COVID-19 ON SYSTEMIC AUTOIMMUNE DISEASES. LOW DEATH RATE DESPITE THE INCREASED PREVALENCE OF SYMPTOMATIC INFECTION. ROLE OF PRE-EXISTING INTERSTITIAL LUNG DISEASE AND ONGOING TREATMENTS

Background

Patients with autoimmune systemic diseases (ASDs) can be counted among frail populations as regards the predisposition to COVID-19 due to the frequent visceral organ involvement and comorbidities, as well as the ongoing immunomodulating treatments.

Objectives

Our long-term multicenter telephone survey prospectively investigated the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients during the first 3 pandemic waves.

Methods

A large series of 3,918 ASD patients (815 M, 3103 F; mean age 59±12SD years) was consecutively recruited at the 36 referral centers of COVID-19 & ASD Italian Study Group. In particular, ASD series encompassed the following conditions: rheumatoid arthritis (n: 981), psoriatic arthritis (n: 471), ankylosing spondylitis (n: 159), systemic sclerosis (n: 1,738), systemic lupus (172), systemic vasculitis (n: 219), and a miscellany of other ASDs (n: 178). The development of COVID-19 was recorded by means of telephone survey using standardized symptom-assessment questionnaire (1).

Results

A significantly increased prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) was observed in our ASD patients, while the cumulative death rate revealed statistically comparable to the Italian general population (3.65% vs 2.95%; p: ns). In particular, among the 328 ASD patients complicated by COVID-19, 57 (17%) needed hospitalization, while mild-moderate manifestations were observed in the large majority of individuals (83%). In addition, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular manifestations.

Interestingly, a significantly higher COVID-19-related death rate was observed in systemic sclerosis patients compared to the Italian general population (6.29% vs 2.95%; p=0.018). Other adverse prognostic factors to develop COVID-19 were the patients’ older age, male gender, pre-existing ASD-related interstitial lung involvement, and chronic steroid treatment. Conversely, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the chronic administration of low dose aspirin in a subgroup of SSc patients (with 5.57% vs without 27.84%; p=0.000).

Conclusion

The cumulative impact of COVID-19 on ASD patients after the first 3 pandemic waves revealed less severe than that observed during the first phase of pandemic (1), especially with regards to the death rate that was comparable to the Italian general population in spite of the increased prevalence of complicating COVID-19 in the same ASD series.

Ongoing long-term treatments, mainly csDMARDs, might usefully contribute to generally positive outcomes of in this frail patients’ population.

Of note, a significantly increased COVID-19-related mortality was recorded in only SSc patients’ subgroup, possibly favored by pre-existing lung fibrosis. Among different ASD, SSc deserves special attention, since it shares the main pathological alterations with COVID-19, namely the interstitial lung involvement and the endothelial injury responsible for diffuse microangiopathy.

Besides SSc, the patients’ subgroups characterized by older age, chronic steroid treatment, pre-existing interstitial lung disease, and/or impaired COVID-19 vaccine response (1-3), may deserve well-designed prevention and management strategies.

References

[1]Ferri C, et al. Ann Rheum Dis. 2020 Oct 14 doi: 10.1136/annrheumdis-2020-219113.

[2]Ferri C et al. J Autoimmun. 2021 Dec;125:102744. doi: 10.1016/j.jaut.2021.102744.

[3]Visentini M et al. Ann Rheum Dis. 2021 Nov 24. doi: 10.1136/annrheumdis-2021-221248

Disclosure of Interests

None declared

AB0261 CARDIOMETABOLIC COMORBIDITIES MAY IDENTIFY A MORE SEVERE SUBSET OF RHEUMATOID ARTHRITIS, RESULTS FROM A “REAL-LIFE” STUDY

Background

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease associated with a significant increased rate of cardiometabolic comorbidities contributing to an increased risk of morbidity and mortality of these patients [1,2]. RA patients with cardiometabolic comorbidities might differ from those without in their clinical presentation and prognosis.

Objectives

This “real-life” cross-sectional study was designed to describe disease features of RA consecutive participants affected by cardiometabolic comorbidities than those without, among those attending recruiting centres from January 1, 2021 to December 31, 2021. Our purpose was also the identification of possible associations between these diseases and clinical characteristics of patients (i.e. fulfilment of ACR1987 criteria, ACPA positivity, presence of extra-articular manifestations, remission, and bDMARD failure).

Methods

Consecutive RA patients were assessed, all fulfilling 2010 ACR/EULAR criteria for RA. We have defined the participant as having such comorbidities if affected by 2 or 3 among high blood pressure (HBP), type 2 diabetes (T2D), and/or dyslipidaemia. The presence of cardiometabolic comorbidities for each participant was verified by reviewing the clinical charts, interview, and extensive medical examinations. Patients with and without cardiometabolic comorbidities were grouped and compared. After that, regression models were built to assess the influence of the presence of cardiometabolic comorbidities on RA features of disease severity.

Results

757 consecutive RA participants were evaluated [(female 56.6%, age 64.7 ± 12.3 years, median disease duration 6 years (IQR 12)]. Among assessed participants, 13.5% showed cardiometabolic comorbidities. These were older (63.9 ± 13.1 vs 70.4 ± 9.0 years, p<0.001) and characterised by a longer disease duration with 64.7% between 5 and 10 years (p=0.003). They were more often affected by extra-articular manifestations (8.2% vs 17.7%, p=0.029) and frequently displayed smoking habit (36.6% vs 50.0%, p=0.003). A lower percentage of participants with these comorbidities was in remission (15.7% vs 8.5%, p=0.048) and they showed a higher prevalence of history of bDMARD failure (40.4% vs 78.4%, p<0.001).

Finally, regression models showed that cardiometabolic comorbidities were significantly correlated with RA features of disease severity. Participants with cardiometabolic comorbidities more frequently fulfilled ACR1987 criteria in both univariate (OR: 1.47, 95%CI: 1.15-1.89, p=0.002) and multivariate analyses (OR: 1.48, 95%CI: 1.15-1.91, p=0.002). These participants had a higher probability of ACPA positivity in both univariate (OR: 1.52, 95%CI: 1.10-2.09, p=0.009) and multivariate analyses (OR: 1.47, 95%CI: 1.06-2.04, p=0.020). Cardiometabolic comorbidities also predicted the presence of extra-articular manifestations in both univariate (OR: 3.26, 95%CI: 1.77-5.89, p<0.001) and multivariate analyses (OR: 2.41, 95%CI: 1.30-4.87, p=0.005). Participants with cardiometabolic comorbidities had a higher probability of previous bDMARD failure in both univariate (OR: 1.73, 95%CI: 1.24-2.43, p<0.001) and multivariate analyses (OR: 7.17, 95%CI: 3.61-14.2, p<0.001). Cardiometabolic comorbidities resulted to be a negative predictor of being in remission in both univariate (OR: 0.53, 95%CI: 0.39-0.97, p=0.041) and multivariate analyses (OR: 0.61, 95%CI: 0.41-0.96, p=0.035).

Conclusion

We described disease features of RA participants with cardiometabolic comorbidities, identifying a disease subset characterised by clinical features of disease severity and to be considered as “difficult-to-treat”. Thus, cardiometabolic comorbidities may represent a considerable burden for RA patients requiring an appropriate management which should focus, in addition to cardiovascular risk prediction, on targeting these metabolic components.

References

[1]England BR, et al. BMJ. 2018;361:k1036.

[2]Ferguson LD, et al. Nat Rev Rheumatol. 2019;15:461-474.

Disclosure of Interests

None declared

POS1337 ADULT-ONSET STILL’S DISEASE WITH ELDERLY ONSET, RESULTS FROM A MULTICENTRE STUDY AND ASSESSMENT OF AGE INFLUENCE ON CLINICAL FEATURES AND DISEASE OUTCOMES

Background

Aging is a physiological, multidimensional, and irreversible process, occurring in humans over time. Interestingly, multiple lines of evidence have recently suggested that some diseases, generally affecting young adults, are nowadays described in the elderly, although possibly associated with different symptoms or complications. In this context, a possible occurrence of adult onset Still’s disease (AOSD) in elderly has been suggested. This is a rare inflammatory disorder of unknown origin usually observed in young adults [1-3].

Objectives

In this study, we aimed at describing the clinical characteristics, life-threatening complications occurrence, and mortality of AOSD patients with an elderly onset. The manifestations of these patients were also compared with those with a younger onset. Furthermore, the predictive role of age was evaluated on clinical features and disease outcomes. Finally, in these patients, an assessment of associated comorbidities was also performed.

Methods

A retrospective assessment of prospectively followed patients, from January 2001 to April 2021, was provided to analyse clinical features, life-threatening complications occurrence, and mortality in AOSD patients with onset in elderly. AOSD patients, who were included in multicentre Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort, were evaluated.

Results

Out of 221 assessed patients, 37 (16.7%) had an onset of the disease aged over than 60 years. When compared with younger patients, these were characterised by a higher prevalence of pericarditis (p=0.008), comorbidities (p<0.0001), and mortality (p=0.023).

Additionally, our analysis showed that pleuritis and pericarditis positively correlated with age (coefficient=0.227, p=0.001; coefficient=0.213, p=0.001, respectively). Furthermore, the occurrence of parenchymal lung disease was significantly related with age (coefficient=0.168, p=0.012). The presence of comorbidities positively correlated with age (coefficient=0.443, p<0.0001). Moreover, age was negatively related to the polycyclic pattern (coefficient=-0.209, p=0.002). A correlation between mortality and age was also retrieved (coefficient=0.158, p=0.019).

Age predicted the presence of serositis in both univariate (HR: 1.02, 95%CI: 1.01-1.03, p=0.007) and multivariate analyses (HR: 1.02, 95%CI: 1.01-1.04, p=0.007). Age was also a significant predictor of parenchymal lung disease in both univariate (HR: 1.03, 95%CI: 1.01-1.05, p=0.017) and multivariate analyses (HR: 1.03, 95%CI: 1.00-1.05, p=0.048). No significant results were observed assessing the predictive role of age on occurrence of macrophage activation syndrome. Furthermore, age resulted to be a negative predictor of polycyclic pattern only in univariate analysis (HR: 0.99, 95%CI: 0.97-1.00, p=0.048). Finally, age significantly predicted the mortality in both univariate (HR: 1.03, 95%CI: 1.00-1.06, p=0.034) and multivariate analyses (HR: 1.05, 95%CI: 1.01-1.08, p=0.012).

Conclusion

Clinical features of AOSD patients with elderly onset were described in our multicentre cohort. Although the main clinical characteristics were similar comparing older and younger patients, patients aged over 60 years at disease onset were characterised by an increased prevalence of serositis, comorbidities, mostly cardiometabolic, and a higher mortality rate. Age predicted the presence of parenchymal lung disease and mortality, and it could be considered a further negative prognostic factor in AOSD.

References

[1]Mollaeian A, Chen J, et al. BMC Rheumatol. 2021;5(1):12.

[2]Maruyama A, et al. Mod Rheumatol. 2021;31(4):862-868.

[3]Suzuki E, et al. Tohoku J Exp Med. 2021;255(3):195-202.

Disclosure of Interests

None declared

OP0044 CYTOKINE PROFILE, HYPERFERRITINEMIA, AND MULTI-VISCERAL INVOLVEMENT CHARACTERISE MACROPHAGE ACTIVATION SYNDROME COMPLICATING ADULT ONSET STILL’S DISEASE. RESULTS FROM A MULTIDIMENSIONAL EVALUATION

Background

Adult-onset Still’s disease (AOSD) is a rare multigenic autoinflammatory disease of unknown aetiology burdened by life-threatening, such as macrophage activation syndrome (MAS) [1]. Considering the poor outcome of MAS patients, previous works tried to assess predictive factors of its occurrence during AOSD [2-4]. However, an integrated evaluation of clinical features with biomolecules, more reflecting the pathogenic mechanisms of the disease and its complications, is still missing.

Objectives

To multidimensionally characterise MAS complicating AOSD considering cytokine profile, inflammatory markers, and multi-visceral involvement of the disease. To perform a high-dimensional phenotypic analysis of circulating immune cells in AOSD patients with and without MAS. To assess interferon (IFN)-related pathways in AOSD synovial tissues by a bulky RNA sequencing.

Methods

The present evaluation was designed to multidimensionally compare AOSD patients with or without MAS, considering cytokine profile, inflammatory markers, and multi-visceral involvement of the disease. Clinical and biologic data were collected and compared in AOSD patients with and without MAS. Sera biomolecules were analysed by Luminex multiplexing technology. Mass cytometry (CyTOF) was used to characterise circulating immune cells. A bulky RNA sequencing was performed in AOSD synovial tissues.

Results

In this study, 40 consecutive AOSD patients (47.7±15.0 years, 50.0% male gender) were assessed at the time of diagnosis before the administration of any immunosuppressive therapy. Out of those, 14 (35%) patients were complicated by MAS. Paralleling with increases of systemic score and ferritin, MAS patients were characterised by an increased concentration of IL-1α, IL-1β, IL-1Ra, IL-2Ra, IL-6, IL-10, IL-17A, IFN-γ, G-CSF, MCP-1, MIP-1α, SCF. Among these biomolecules, IL-1Ra, IFN-γ, MCP-1, and SCF were correlated with MAS.

Combining the discriminatory ability of these data in identifying MAS, the best model was composed by systemic score, ferritin, IFN-γ, and IL-10. This model was characterised by AUC=0.99 (Standard error: 0.008; 95%CI: 0.976–1.000), sensitivity=100%, specificity=95.45%. By CyTOF analysis, AOSD patients, who were complicated or not with MAS were characterised by a significant increase of circulating “classical monocytes” (CD14+CD38+). MAS patients were characterised by a significant reduction of NK cells (CD45RA+CD56dim) than AOSD patients. Finally, the transcriptomic profile, by RNA-sequencing analysis, showed that 3477 among type I, II, and III IFN-related genes (IRGs) were significantly different in AOSD synovial tissues.

Conclusion

A multidimensional characterisation of AOSD patients was provided suggesting that IFN-γ, IL-10, ferritin, and systemic score discriminated MAS, thus identifying the occurrence of the cytokine storm syndrome. The inflammatory milieu of AOSD and MAS may be associated with a signature of circulating immune cells. Finally, our results about IRGs reinforced the role of IFN-γ in these patients.

References

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

[2]Ruscitti P, et al. Macrophage Activation Syndrome in Patients Affected by Adult-onset Still Disease: Analysis of Survival Rates and Predictive Factors in the Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale Cohort. J Rheumatol. 2018;45:864-872.

[3]Di Benedetto P, et al. Ferritin and C-reactive protein are predictive biomarkers of mortality and macrophage activation syndrome in adult onset Still’s disease. Analysis of the multicentre Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort. PLoS One. 2020;15:e0235326.

[4]Wan L, et al. Total metabolic lesion volume of lymph nodes measured by 18F-FDG PET/CT: a new predictor of macrophage activation syndrome in adult-onset Still’s disease. Arthritis Res Ther. 2021;23:97.

Disclosure of Interests

None declared.

Maladaptive autophagy in the pathogenesis of autoimmune epithelitis in Sjӧgren's Syndrome

OBJECTIVE

Salivary gland epithelial cells (SGECs) are key cellular drivers in the pathogenesis of primary Sjӧgren's Syndrome (pSS); however, the mechanisms sustaining SGECs activation in pSS remain undetermined. The aim of this study is to determine the role of autophagy in the survival and activation of SGECs in pSS.

METHODS

Primary SGECs isolated from minor salivary glands (SG) of patients with pSS or sicca syndrome were evaluated by flow-cytometry, immunoblotting, and immunofluorescence to assess autophagy (autophagic-flux, LC3IIB, p62, LC3B+/LAMP1+ staining), apoptosis (annexin V/PI, Caspase-3) and activation (ICAM, VCAM). Focus score and germinal centers presence was assessed in SG from the same patients to correlate with histological severity. Human salivary gland (HSG) cells were stimulated in vitro with PBMCs and serum from pSS patients in the presence or absence of autophagy inhibitors to determine changes in autophagy and epithelial cell activation.

RESULTS

SGECs from pSS patients (n=24) exhibited increased autophagy (autophagic-flux p=0.001; LC3IIB p=0.02; p62 p=0.064; LC3IIB/LAMP1+ staining), increased expression of anti-apoptotic molecules (Bcl2 p=0.006), and reduced apoptosis (Annexin-V/PI p=0.002, Caspase-3 p=0.057) compared to sicca (n=16). Autophagy correlated with histologic disease severity. In vitro experiments on HSG cells stimulated with serum and PBMCs from pSS patients confirmed activation of autophagy and expression of adhesion molecules, which was reverted upon pharmacologic inhibition of autophagy.

CONCLUSIONS

In pSS SGECs, inflammation induces autophagy and pro-survival mechanisms, which promote SGEC activation and mirror histological severity. These findings indicate that autophagy is a central contributor to the pathogenesis of pSS and a new therapeutic target.

AB0467 EFFECTIVENESS OF GOLIMUMAB AFTER TNF-INHIBITOR FAILURE IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, OR AXIAL SPONDYLOARTHRITIS: RESULTS AT 3 MONTHS FROM THE GO-BEYOND ITALY STUDY

Background:

Golimumab showed trial efficacy in subjects with active rheumatoid arthritis (RA) previously treated with TNF-inhibitors (TNFi); no trial data are available for psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA).

Objectives:

To assess the effectiveness of golimumab after TNFi failure in patients with RA, PsA, or axSpA in a real-world setting.

Methods:

GO-BEYOND-Italy is an ongoing, multicenter, prospective, observational study of RA, PsA, or axSpA patients starting golimumab after TNFi failure. Patients were enrolled between July 2017 and December 2019, and followed for 1 year, with evaluations at 3, 6, and 12 months. This interim analysis estimates the effectiveness after 3 months of golimumab therapy. Differences from baseline were tested by paired t-tests.

Results:

193 patients were enrolled: 38 (19.7%) with RA (median age 54 years; median disease duration 9.5 years), 91 (47.2%) with PsA (median age 53 years; median disease duration 9.0 years) and 64 (33.2%) with axSpA (median age 54 years; median disease duration 7.2 years). Majority of the RA (73.7%), PsA (51.6%) and axSpA (53.1%) were females. Previous TNFi treatment included etanercept (44.6% of patients), adalimumab (42.0%), infliximab (8.8%) and certolizumab (4.7%). The main reason for switching to golimumab was loss of efficacy of TNFi (78.9% in RA, 83.5% in PsA, 75% in axSpA). Comorbidities were highly prevalent (RA 65.8%, PsA 65.9%, axSpA 75%); hypertension (31.1%), dyslipidaemia (13.5%), fibromyalgia (10.4%) were the most common ones. DAS28-CRP significantly reduced in RA and PsA (p<0.01) after 3 months of treatment. In RA, rates of DAS28-CRP remission and low disease activity (LDA) were 29.6% and 22.2%, respectively, and 65.2% of patients achieved good/moderate EULAR response. As for PsA, good/moderate EULAR response was observed in 78.8% of patients and 28% of patients achieved minimal disease activity. In axSpA, ASDAS-CRP (p<0.01), BASDAI (p<0.01) and ASAS-HI (p=0.032) significantly reduced; rates of ASDAS-CRP inactive disease and LDA were 15.2% and 26.1%, respectively; 14% of patients had a ≥50% improvement in baseline BASDAI. After 3 months of golimumab treatment, there was a decrease in the prevalence of enthesitis (32.9% to 16.5%), nail (17.6% to 12.9%) and skin psoriasis (42.4% to 34.1%) in PsA patients; the frequency of extra articular manifestations tended to decrease also in axSpA patients.

Conclusion:

Preliminary results of the GO-BEYOND-Italy study showed a good short-term effectiveness of golimumab in RA, PsA and axSpA after TNFi failure.

Table 1.

Effectiveness of golimumab at 3 months in the GO-BEYOND-Italy study

Rheumatoid arthritis (n=38)Psoriatic arthritis (n=91)Axial spondyloarthritis (n=64)DAS28-CRP, mean (SD)n=27DAS28-CRP, mean (SD)n=47ASDAS-CRP, mean (SD)n=44V0 / V14.05 (0.8) / 3.10* (1.0)V0 / V13.66 (1.0) / 2.79* (1.2)V0 / V12.86 (1.0) / 2.33* (1.0)V1: DAS28-CRP disease activity, n (%)n=27V1: EULAR response, n (%)n=33V1: ASDAS-CRP disease activity, n (%)n=46Remission8 (29.6)Good16 (48.5)Inactive disease7 (15.2)Low disease activity6 (22.2)Moderate10 (30.3)Low disease activity12 (26.1)Moderate disease activity13 (48.1)No response7 (21.2)High disease activity22 (47.8)Very high disease activity5 (10.9)V1: EULAR response, n (%)n=23V1: MDA, n (%)n=75Good7 (30.4)Yes21 (28.0)BASDAI, mean (SD)n=50Moderate8 (34.8)V0 / V15.99 (2.1) / 4.92 (2.3)*No response8 (34.8)V1: BASDAI50, n (%)7 (14.0)ASAS-HI, mean (SD)n=48V0 / V110.67 (3.8) / 9.68 (4.6)^

*p value for the difference from V0 <0.01. ^ p for the difference from V0=0.032

Abbreviations: ASDAS: Ankylosing Spondylitis Disease Activity Score; ASAS-HI: Assessment of SpondyloArthritis international society Health Index; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CRP: C-reactive protein; DAS: disease activity score; EULAR: European League Against Rheumatism; MDA: Minimal Disease Activity; SD: standard deviation; V0: baseline; V1: 3 months evaluation.

Disclosure of Interests:

Salvatore D’Angelo Speakers bureau: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB, Enrico Tirri Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Angela Maria Giardino Employee of: MSD Italia, Marco Matucci-Cerinic Speakers bureau: BMS, Pfizer, Actelion, Consultant of: Eli-Lilly, Celgene, Chemomab, CSL Behring, Grant/research support from: BMS, Pfizer, Celgene, CSL Behring, Lorenzo Dagna Consultant of: Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI, Leonardo Santo: None declared., francesco ciccia: None declared., Bruno Frediani: None declared., Marcello Govoni: None declared., Francesca Bobbio Pallavicini: None declared., Rosa Daniela Grembiale: None declared., Andrea Delle Sedie: None declared., Stefania Cercone Employee of: MSD Italia, RITA MULE’: None declared., Francesco Paolo Cantatore Speakers bureau: Pfizer, Sanofi Genzyme and Roche, Consultant of: Pfizer, Sanofi Genzyme and Roche outside this work., Rosario Foti: None declared., Elisa Gremese: None declared., Roberto Perricone: None declared., Fausto Salaffi: None declared., Ombretta Viapiana Speakers bureau: Novartis, UCB, Abbvie, MSD, Fresenius kabi, Gilead, Biogen, Consultant of: Novartis, Abbvie, Fresenius kabi, Gilead, Biogen, Alberto Cauli Speakers bureau: Abbvie, Alfa-Sigma, BMS, Celgene, Galapagos, Glaxo, MSD, Novartis, Janssen, Pfizer, Sanofi, UCB, Consultant of: Abbvie, Alfa-Sigma, BMS, Celgene, Galapagos, Glaxo, MSD, Novartis, Janssen, Pfizer, Sanofi, UCB, Rorberto Giacomelli: None declared., Luisa Arcarese: None declared., Giuliana Guggino Speakers bureau: Novartis, Celgene, Abbvie, Sandoz, Eli Lilly, Pfizer, Jansen, ROMUALDO RUSSO: None declared., Domenico Capocotta: None declared., Francesca Nacci: None declared., Maria Grazia Anelli: None declared., valentina picerno: None declared., Florenzo Iannone Speakers bureau: Pfizer, AbbVie, Janssen, Celgene, Novartis, MSD, BMS, UCB, Roche, Consultant of: Pfizer, AbbVie, Janssen, Celgene, Novartis, MSD, BMS, UCB, Roche outside this work.

POS1349 THE JOINT INVOLVEMENT IN ADULT ONSET STILL’S DISEASE IS CHARACTERISED BY A PECULIAR MAGNETIC RESONANCE IMAGING AND A SPECIFIC TRANSCRIPTOMIC PROFILE

Background:

Adult onset Still’s disease (AOSD) is a rare systemic autoinflammatory disease and joint involvement is one of its clinical manifestations [1]. Arthritis, either oligoarthritis or bilateral symmetrical rheumatoid arthritis-like polyarthritis, is another common clinical feature of AOSD, with a migrating pattern at the beginning and becoming stable over the time [1].

Objectives:

The aims of the study were to assess joint involvement in AOSD by using magnetic resonance imaging (MRI), to describe main patterns of involvement, and associated clinical characteristics, and to evaluate the global transcriptomic profile of synovial tissues in AOSD to elucidate possible pathogenic pathways involved with.

Methods:

AOSD patients, who underwent to magnetic resonance imaging (MRI) exam on joints, were assessed to describe patterns of joint involvement and associated clinical characteristics. Some synovial tissues were collected for RNA-sequencing purposes.

Results:

In this study, 31 patients with AOSD (mean age 42.3 ± 15.2 years, 54.8% male gender), who underwent to at least one MRI exam on joints, were assessed. The most common MRI finding was the presence of synovitis on 60.5%, mainly in peripheral affected joints. MRI revealed a mild to moderate proliferative synovitis, as thickening of the synovial membrane, with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-fat saturated weighted and STIR images, suggesting the presence of a hyperplastic than of a hypertrophied synovial tissue. Bone oedema and bone erosions were reported on 34.9% and 25.6% MRI exams, respectively. In all patients but one, bone erosions were synchronous with bone oedema, overlapping completely the locations. Assessing clinical characteristics in patients with MRI-erosions, a higher prevalence of splenomegaly, a more frequent chronic disease course, lower levels of erythrocyte sedimentation rate and ferritin was observed.

Assessing the synovial tissues of some AOSD patients, a moderate perivascular mononuclear infiltrate in the sub-lining stroma of hip synovial tissues was observed, whereas the lining cells were relatively unremarkable. In addition, interleukin (IL)-1β, IL-6, TNF, and heavy ferritin subunit (FeH) were found on AOSD synovial tissues.

An RNA-sequencing analysis assessed the global transcriptomic profile of synovial tissues on AOSD patients and matched-controls. Assessing IL-1 pathway, we found an increased expression of il1a, il1b, il1rap, il1r1, il18r1, and Il18bp on AOSD tissues when compared with controls. In IL-6 pathway, we found an increased expression of il6 and il6st/gp130 on AOSD synovial tissues whereas an increased expression of il6r was shown on the controls. Among genes involved in TNF pathway, tnf, traf1, traf2, tnfaip3 and tnfrsf1a resulted to be more expressed in AOSD synovial tissues than in controls. Finally, fth1 and ftl were more expressed in AOSD patients than controls, when we explored the iron uptake and transport pathway.

Conclusion:

A peculiar MRI pattern of joint involvement in AOSD was reported; the most common finding was the presence of synovitis, characterised by intermediate to high signal intensity on T2-fat-saturated weighted and STIR images. Bone erosions and bone oedema were also observed. This MRI pattern was associated with a hyper-activation of IL-1, IL-6, and TNF pathways together with a hyper-expression of ferritin genes on AOSD synovial tissues.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

Disclosure of Interests:

None declared

POS0177 POTENTIAL INVOLVEMENT OF IL-40 AND IL-40-PRODUCING CELLS IN PRIMARY SJOGREN’S SYNDROME (pSS) AND pSS-ASSOCIATED LYMPHOMA

Background:

The pathogenesis of pSS relies on a complex interplay between both innate and adaptive immune responses in which B cells play a pivotal role. Their chronic aberrant hyperactivation may drive clonal escape and consequent lymphomagenesis [1]. In the last few years, B cells have emerged as potential effector cells, able to release a wide range of cytokines that actively contribute to shape the microenvironment they act in. Recently, IL-40, a novel B cell associated cytokine encoded by an uncharacterized gene (C17orf99; chromosome 17 open reading frame 99) was described. Naïve B cells can express IL-40 at both tissue and peripheral level and the stimulation of B cells with IL-4 and TGF-β significantly increases IL-40 release. In addition, human B cells lymphomas are able to constitutively produce IL-40 [2]. Taking into account this emerging evidence and considering the well-known role of IL-4 and TGF-β in pSS pathogenesis, as well as the association with lymphomas, we decided to focus our attention on IL-40 in pSS patients.

Objectives:

The aim of the present study was to investigate IL-40 expression in the salivary glands of patients affected by pSS and pSS-associated non-Hodgkin’s lymphoma (NHL).

Methods:

Minor salivary gland biopsies were obtained from 22 patients with pSS and 12 patients with non-specific chronic sialoadenitis (nSCS), included as controls. Paraffine-embedded samples of parotid glands from patients with a previous diagnosis of pSS-associated NHL (n=10) were selected from the biopsy bank of the Pathology Unit of the Ospedale Cervello (Palermo, Italy). Quantitative gene expression analysis by TaqMan real-time PCR and immunohistochemistry (IHC) for IL-40, IL-4, TGF-β1 was performed on salivary glands from patients and controls. The cellular sources of IL-40 among infiltrating inflammatory cells were determined by fluorescence-activated cell sorting (FACS) analysis and immunofluorescence (IF). Serum IL-40 levels were measured by ELISA in both patients (n=10) and controls (n=9).

Results:

IL-40 was significantly increased at both protein and mRNA level in the inflamed salivary glands of patients with pSS where a positive strong correlation between the IL-40 mRNA levels and the focus score (FS) was evidenced. The expression of IL-40 in parotid glands of pSS-associated NHL was also markedly increased (Figure 1). IL-40 expression correlated with the presence of IL-4 and TGF-β; both cytokines were significantly increased in pSS at mRNA and protein level. Among infiltrating immune cells, CD19+ B cells resulted the major source of IL-40. However, we identified CD4+, CD8+ T cells and CD68+ macrophages as additional producers of IL-40 in both FACS and IF analysis. The ELISA test also showed a significant increase of serum IL-40 concentration in pSS patients (p value = 0.0190), compared to controls.

Conclusion:

Our preliminary results suggest that IL-40 may play a role in the pathogenesis of pSS and pSS-associated NHL. To the best of our knowledge, this is the first demonstration of the overexpression of this cytokine in salivary gland tissue and sera in pSS. Moreover, we demonstrated that IL-40 is produced by several cellular types, such as T cells and macrophages, and is not exclusively released by B cells. Further studies are necessary to clarify IL-40 pathways and functions in order to unravel IL-40 possible role in pSS development.

References:

[1]Mariette X, Criswell LA. Primary Sjogren’s Syndrome. N Engl J Med. 2018;379(1):97.

[2]Catalan-Dibene J, Vazquez MI, Luu VP, Nuccio SP, Karimzadeh A, Kastenschmidt JM, et al. Identification of IL-40, a Novel B Cell-Associated Cytokine. J Immunol. 2017;199(9):3326-35.

Figure 1.

IL-40 overexpression in pSS and pSS-associated lymphoma A, Salivary gland biopsies stained for IL-40 showing a marked increase in IL-40 expression in presence of higher focus score. B, Parotid gland specimens of pSS-associated lymphoma showing intense staining for IL-40.

Disclosure of Interests:

Chiara Rizzo: None declared, Marianna Lo Pizzo: None declared, Leila Mohammadnezhad: None declared, Vincenzo Luca Lentini: None declared, Diana Di Liberto: None declared, Giulia Grasso: None declared, Piero Ruscitti Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, Rorberto Giacomelli Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, francesco ciccia Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, Giuliana Guggino Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly

OP0310 GENDER AND FIBROMYALGIA SEVERITY: REAL LIFE DATA FROM THE ITALIAN REGISTRY

Background:

Fibromyalgia (FM) patients report chronic widespread pain, fatigue, cognitive difficulties and sleep disturbances, often associated with anxiety and/or depression (1). FM syndrome more frequently affects women and many papers describe gender-related differences in the perception, description and expression of pain (2), but up to now, the impact of gender on the clinical severity of FM is still a controversial topic.

Objectives:

The aim of this study was to analyse the data from a web-based registry of FM patients in order to detect a relationship between gender and disease severity.

Methods:

Adult patients with FM, diagnosed on the basis of the 2010/2011 American College of Rheumatology (ACR) diagnostic criteria (3), were recruited at 19 Italian rheumatology centres between November 2018 and April 2019. Those affected by other conditions that could interfere with the assessment of FM, e.g. psychiatric disorders, were excluded from the study. The severity of the disease was evaluated by validated FM-specific questionnaires: the revised Fibromyalgia Impact Questionnaire (FIQR) (4), the modified Fibromyalgia Assessment Status (ModFAS) questionnaire (5), and the Polysymptomatic Distress Scale (PDS) (6). The data obtained were collected in the Italian Fibromyalgia Registry, an online registry created with the support of the Italian Society of Rheumatology (SIR).

Results:

We analyse data from 2.381 patients affected by FM, 2.184 females (91.7%) and 197 males. No significant differences in mean age, disease duration, or BMI between the two genders were reported. The women expressed greater disease burden as indicated by higher scores for each completed test: higher mean ModFAS score (25.23 ± 8.83 Vs 23.37 ± 9.22; p = 0.005), mean FIQR score (58.62 ± 23.22 Vs 51.68 ± 23.06; p <0.001), and mean PDS score (18.77 ± 7.34 Vs 17.19 ± 7.25; p = 0.004). Figure 1 shows the mean scores of each item of the FIQR divided by gender. Women reported significantly higher values on all the items of FIQR except three (feeling overwhelmed, FIQR-11; depression, FIQR-16; and anxiety, FIQR-18). It is interesting to note that men self-reported higher levels of depression (FIQR-16).

Figure 1.

Mean scores for each FIQR item by gender.

Conclusion:

Our findings demonstrate that women with FM are globally more impaired than men (even if some psychological aspects of the disease are comparable), thus reinforcing the idea that gender plays a role in symptoms and functional impairments associated with the disease.

References:

[1]Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311:1547-55.

[2]Nascimento, et al. Gender role in pain perception and expression: an integrative review. BrJP. 2020; 3: 58-62

[3]Wolfe F, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol 2011;38:1113–22.

[4]Burckhardt CS, et al. The fibromyalgia impact questionnaire: development and validation. J Rheumatol 1991;18:728–33.

[5]Salaffi F, et al. Diagnosis of fibromyalgia: comparison of 2011/2016 ACR and AAPT criteria and validation of the modified Fibromyalgia Assessment Status. Rheumatol 2020; 0:1-8.

[6]Wolfe F, et al. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res. 2013; 65:777–85

Disclosure of Interests:

None declared.

AB0716 FIBROMYALGIA SYNDROME SEVERITY ACCORDING TO AGE CATEGORIES: RESULTS FROM A NATIONAL REGISTER

Background:

Fibromyalgia syndrome (FM) is characterised by a complex symptom spectrum, dominated by the presence of chronic widespread pain, fatigue and unrefreshing sleep. FM affects between 2 and 3% of the general population. It is a condition that mainly involves middle-aged women, although it is increasingly being diagnosed in younger people. The severity of symptoms can vary greatly between individual patients, and is influenced by many factors (e.g. sex, body mass index) [1]. To date, there is little information about changes in severity in accordance with patient age.

Objectives:

The aim of this study was to investigate variations in symptom severity in FM patients according to age categories.

Methods:

A cross-sectional study of adult FM patients diagnosed according to the American College of Rheumatology 2010/2011 criteria was performed. The case series was included from an Italian national registry [2]. Patients were grouped according to five age categories: 18-40 years, 41-50 years, 51-60 years, 61-70 years, over 71 years. Symptom severity was assessed through the revised Fibromyalgia Impact Questionnaire (FIQR) and domains, including FIQR physical function (items 1-9), FIQR health status (items 10-11), and FIQR symptoms (items 12-21). Between-group characteristics were analysed using one-way analysis of variance (ANOVA).

Results:

This study included a total of 2889 patients, 403 aged 18-40 years, 756 aged 40-50 years, 1035 aged 50-60 years, 528 aged 60-70 years, and 167 over 70 years, respectively. The mean (standard deviation [SD]) score of the total FIQR was 52.68 (11.82). Total FIQR and individual domains all showed a normal distribution. Analysing the data by age category, there were statistically significant differences between the categories for the total FIQR (p = 0.030). The age categories with the highest disease severity were those above 71 years (FIQR 62.14, SD 22.45), and between 51-60 years (FIQR 60.31, SD 22.89) (Table 1). Significant differences between age categories were also found for the domains physical function (p = 0.006) and health status (p = 0.012), but not for the domain symptoms (p = 0.164).

Table 1.

Mean values of FIQR total score and domains according to age categories.

FIQR and domains18-40 years41-50 years51-60 years61-70 years≥71 yearsp*FIQR total, mean (SD)57.90 (21.76)59.25 (23.30)60.31 (22.89)57.13 (23.59)62.14 (22.45)0.030FIQR physical function, mean (SD)15.51 (7.56)16.44 (7.77)16.77 (7.51)15.96 (7.82)17.68 (7.26)0.006FIQR health status, mean (SD)11.19 (5.85)11.24 (5.99)11.49 (5.93)10.57 (6.11)12.21 (5.97)0.012FIQR symptoms, mean (SD)31.32 (10.48)31.56 (11.32)32.10 (11.01)30.68 (11.47)32.24 (11.34)0.164

Abbreviations and legend. FIQR = revised Fibromyalgia Impact Questionnaire; SD = standard deviation; * = one-way analysis of variance (ANOVA).

Conclusion:

Distinguishing the disease severity in FM patients according to age categories, a bimodal distribution emerges, with the disease severity being greatest in patients over 71 years and in the 51-60 years decade. The main differences in severity, according to what can be detected through the FIQR, are attributable to the domains physical function and health status, which show higher scores in the two classes with higher severity.

References:

[1]Sarzi-Puttini P et al., Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol 2020; 16: 645–660.

[2]Salaffi F et al., The Italian Fibromyalgia Registry: a new way of using routine real-world data concerning patient-reported disease status in healthcare research and clinical practice. Clin Exp Rheumatol 2020; Suppl 123: 65-71.

Acknowledgements:

Società Italiana di Reumatologia (SIR) and Italian Ministry of Health

Disclosure of Interests:

None declared

POS0326 ROLE OF THE IL-25 / IL-17RB AXIS IN TH9 POLARIZATION IN PATIENTS WITH PROGRESSIVE SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is an inflammatory connective tissue disease leading to chronic and progressive fibrosis, typically affecting the skin and internal organs. The alteration of both innate and adaptive immune responses plays a pivotal role in SSc pathophysiology, although it has not yet been fully elucidated [1].

Recent findings have demonstrated interleukin (IL)-9 overexpression and significant group 2 innate lymphoid cells (ILC2) expansion in patients with SSc. Th9-ILC2-mast cells axis seems to be involved in SSc tissue damage and in the induction of fibrosis [2]. Activation and production of IL-9 by Th9 cells are promoted by transforming growth factor (TGF)-β, thymic stromal lymphopoietin (TSLP), IL-25 and IL-33. Thus, the IL-25 / IL-17RB pathway would act as a key player in SSc.

Objectives:

The purpose of this study was to evaluate the role of the IL-25 / IL-17RB axis as a driver in Th9 polarization and ILC2 expansion and polarization in SSc patients.

Methods:

26 patients were enrolled in this study. Peripheral blood and skin biopsy specimens were obtained from SSc patients. PBMCs were isolated and incubated with and without recombinant (r)IL-25 for 24-48-72 hours and the frequencies of Th9 cells, Th17 cells and ILC2 were assessed by flow cytometry analysis. Moreover, the ex vivo expression of IL-17RB in ILC2 was also assessed. Immunofluorescence analysis was performed on biopsy skin samples to evaluate IL-17RB expression in ILC2.

Results:

In SSc samples, Th9 cells frequency progressively increased after stimulation with rIL-25, compared to healthy controls in which IL-9 frequency decreased over time regardless of rIL-25.

Simultaneously, we evaluated the role of the IL-25 / IL-17RB axis in Th17 cells.

In the SSc pool, the initially low rate of IL-17 increased at 72 hours after stimulation with rIL-25. In unstimulated SSc samples, the initially higher IL-17 rate decreased at 72 hours; conversely, it was consistently low in healthy controls, at both baseline and stimulated conditions.

Our results confirmed the presence of IL-25-dependent clonal ILC2 expansion, suggesting a greater and progressive expansion over time in patients with SSc, compared to controls.

Interestingly, increased IL-17RB expression was found in circulating ILC2 from SSc patients supporting the characterization of ILC2 inflammatory phenotype.

Consistently, immunofluorescence on the skin of SSc patients showed a marked infiltrate of CD3-GATA3+ IL-17RB+ cells, confirming the presence of the activated inflammatory phenotype ILC2, absent in skin biopsies of healthy controls (Figure 1).

Conclusion:

These preliminary data suggest an active role of the IL-25/IL-17RB axis in SSc. It results in Th9 polarization and Th17 clonal expansion, inducing the production of IL-9 and, to a lesser extent, IL-17. Moreover, in addition to promoting Th9-mediated ILC2 differentiation, IL-25 directs the polarization of ILC2 towards the inflammatory phenotype.

References:

[1]Denton CP, & Khanna D. (2017). Systemic sclerosis. Lancet (London, England), 390(10103), 1685–1699.

[2]Guggino G, Ciccia F, Di Liberto D, Lo Pizzo M, Ruscitti P, Cipriani P, Ferrante A, Sireci G, Dieli F, Fourniè JJ, Giacomelli R, Triolo G. s.l. Interleukin-9 over-expression and T helper 9 polarization in systemic sclerosis patients. Clin Exp Immunol, 2016 Dec.

Figure 1.

Immunofluorescence on biopsy skin samples of SSc patients (top) and healthy control (bottom).

Disclosure of Interests:

Lidia La Barbera: None declared, Marianna Lo Pizzo: None declared, Diana Di Liberto: None declared, Claudia Schinocca: None declared, Piero Ruscitti Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie, Rorberto Giacomelli Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie, Francesco Dieli: None declared, francesco ciccia Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie, Giuliana Guggino Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie

Endothelial-to-mesenchymal transition in systemic sclerosis

Systemic sclerosis (SSc) is an autoimmune disease characterized by significant vascular alterations and multi-organ fibrosis. Microvascular alterations are the first event of SSc and injured endothelial cells (ECs) may transdifferentiate towards myofibroblasts, the cells responsible for fibrosis and collagen deposition. This process is identified as endothelial-to-mesenchymal transition (EndMT), and understanding of its development is pivotal to identify early pathogenetic events and new therapeutic targets for SSc. In this review, we have highlighted the molecular mechanisms of EndMT and summarize the evidence of the role played by EndMT during the development of progressive fibrosis in SSc, also exploring the possible therapeutic role of its inhibition.

Clinical features and prognosis of COVID-19 in people with spinal cord injury: a case-control study

Study design

Observational case–control study.

Objective

Individuals with spinal cord injury (SCI) develop systemic physiological changes that could increase the risk of severe evolution of coronavirus disease 2019 (COVID-19) and result in atypical clinical features of COVID-19 with possible delay in both diagnosis and treatment. We evaluated differences in clinical features and evolution of COVID-19 between people with SCI and able-bodied individuals.

Setting

The study was conducted in an Italian inpatient rehabilitation referral center for individuals with SCI during the lockdown for the COVID-19 pandemic.

Methods

We compared clinical information between patients with SCI and able-bodied healthcare workers of the same center who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasopharyngeal swab polymerase chain reaction.

Results

Overall, 15 out of the 25 SCI patients admitted to the center and 17 out of the 69 healthcare workers tested positive for SARS-CoV-2. Patients with SCI exhibited a significantly more advanced age and a higher prevalence of comorbidities. Nevertheless, no significant differences in clinical expression of COVID-19 and treatment strategies were observed between the two groups. All hospitalized subjects were treated in nonintensive care units and no deaths occurred in either group.

Conclusions

This study does not support the supposed notion that COVID-19 could exhibit atypical clinical features or a worse evolution in the frail population of people with SCI.

THU0265 THYMIC STROMAL LYMPHOPOIETIN (TSLP) AS A BIOMARKER OF PRIMARY SJÖGREN’S SYNDROME (PSS) AND RELATED LYMPHOMA: VALIDATION IN INDEPENDENT COHORTS

Background:

Thymic stromal lymphopoietin (TSLP) has been implicated in primary Sjögren’s syndrome (pSS) and related B-cell lymphoproliferation/lymphoma (NHL) by tissue studies on salivary glands (SG) (1). It resulted significantly higher in the serum of pSS patients compared to non-pSS sicca and to healthy subjects, with the highest levels found in NHL.

Objectives:

The purpose of this work was to confirm that serum TSLP is elevated in pSS by the study of independent cohorts.

Methods:

Serum TSLP levels were measured by ELISA in 91 pSS patients (F=86, 94.5%; mean age 57.2 years, 25-80) from the Udine cohort (cohort 1, UD), Italy. One additional multicentre cohort (cohort 2) from the Italian SS Study Group (GRISS) was studied, including 125 pSS patients from the Universities of Roma (RO), L’Aquila (L’AQ), Pisa (PI) and Perugia (PG). pSS patients with active NHL (n=12 in cohort 1; n=1 in cohort 2) were excluded from comparative analyses to avoid bias. Secondly, additional serum samples from pSS-related NHL in stable and complete remission, from both cohort 1 and 2, were analysed in a separate subgroup (n = 12). Thirdly, a preliminary evaluation of serum TSLP was performed in pSS patients from a different geographical area (University of Athens, Greece; cohort 3).

Results:

Cohort 2 included 125 pSS patients (F=114, 91.2%; mean age 58.1 years, 23-84): 124 benign, 1 with NHL. In this cohort, serum TSLP levels were confirmed to be high (mean 30.26 pg/mL, 0.41-95.21) and comparable to cohort 1 (mean 33.81 pg/mL, 0-140.8; p=ns). No difference was found by the separate analysis of pSS from each single Centres (RO n=49, mean 33.21, 1.4-95.21; L’AQ n=34, mean 38.6, 16.31-85.11; PI n=28, mean 20.23, 0.41-56.67; PG n=13, mean 19.39, 1.03-68.38; p=ns), and vs cohort 1 (p=ns). The only patient in cohort 2 with NHL showed serum TSLP of 160.91 pg/mL, comparable to the mean TSLP in the 12 UD pSS-NHL (151.96 pg/mL). Importantly, in pSS-related NHL in stable remission, serum TSLP resulted undetectable (7/13) or detectable at very low levels (6/13) (mean 10.46, 0-38.5), and significantly lower than in benign pSS patients from the two cohorts (n=203, mean 31.48, 0-140.8; p=0.0022). Metachronous samples from one patient, at the stage of NHL activity and then at NHL remission, showed a decrease in TSLP from 128.04 pg/mL to undetectable levels. Finally, TSLP levels were increased also in the Greek cohort (mean 54.9, 26.72-78.95), and significantly higher than the two Italian cohorts (p=0.0085 and p<0.0001, vs cohort 1 and 2, respectively).

Conclusion:

Serum TSLP levels are increased in pSS, as herein confirmed in independent cohorts. TSLP might be important in the disease pathophysiology and mirrors the course of pSS-related B-cell lymphoproliferation itself. It may thus represent a novel important biomarker.

References:

[1]Gandolfo S. et al, Clin Exp Rheumatol. 2019 May-Jun;37 Suppl 118(3):55-64.

Disclosure of Interests:

Saviana Gandolfo: None declared, Cinzia Fabro: None declared, Serena Colafrancesco: None declared, Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Francesco Ferro: None declared, Elena Bartoloni Bocci: None declared, Efstathia Kapsogeorgou: None declared, Andreas Goules: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Roberta Priori: None declared, Alessia Alunno: None declared, Guido Valesini: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer, Roberto Gerli: None declared, Chiara Baldini: None declared, Athanasios Tzioufas: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis

FRI0565 PREVALENCE AND SIGNIFICANCE OF ANTIBODIES AGAINST CITRULLINATED ALPHA-ENOLASE (ANTI-CEP1) IN CONNECTIVE TISSUE DISEASES

Background:

Anti-cyclic citrullinated peptide (anti-CCP) auto-antibodies represent the current gold standard for the diagnosis of rheumatoid arthritis (RA). However, growing evidence suggests that a variety of other citrullinated self-proteins may act as autoantigens and lead to the production of autoantibodies (1). Furthermore, autoantibodies believed to be RA-specific have been detected also in patients with connective tissue diseases (CTDs). We recently demonstrated that antibodies against citrullinated alpha-enolase (anti-CEP1) are a biomarker of erosive disease and RA-associated interstitial lung disease (2).

Objectives:

The purpose of this study was to investigate the prevalence and possible prognostic value of anti-CEP-1 in patients with CTDs.

Methods:

Two hundred and twelve consecutive patients with CTDs (51 systemic lupus erythematosus (SLE), 85 primary Sjogren’s syndrome (pSS) and 76 systemic sclerosis (SSc)) were studied and compared to 97 sex and age matched normal controls (NC) and 267 patients with RA. Anti-CEP1 IgG were detected in serum samples with a commercial ELISA kit (Euroimmun).

Results:

The overall prevalence of anti-CEP1 in CTDs was 7% (15/212 patients). In detail, these antibodies were detectable in 4 out of 85 pSS (5%), 5 out of 51 SLE (10%) and 6/76 SSc (8%). The prevalence and the titer of anti-CEP1 in CTDs was significantly higher compared to NC and significantly lower compared to RA. Anti-CEP1 positive patients did not display a specific clinical and serological picture. Unlike in RA, anti-CEP1 did not correlate with CTD-associated ILD.

Conclusion:

This is the first study assessing anti-CEP1 in a large cohort of patients with CTDs. We demonstrated that the association of these autoantibodies with ILD is specific for RA since it is not observed in SLE, pSS and SSc. Furthermore, although being significantly more prevalent and at higher titer compared to NC, anti-CEP1 do not allow to discriminate different patient subsets displaying peculiar clinical or serological phenotypes. Based on our results, the application of anti-CEP1 in CTDs is not advisable, however larger studies may possibly identify correlations not evident in our cohort.

References:

[1] Bonifacio AF, Alunno A, La Paglia GMC, Valentini E, Leone MC, Bartoloni E, Gerli R. Novel autoantibodies in rheumatoid arthritis. Reumatismo 2019;71(1):1-12

[2] Alunno A, Bistoni O, Pratesi F, La Paglia GMC, Puxeddu I, Migliorini P, Gerli R. Anti-citrullinated alpha enolase antibodies, interstitial lung disease and bone erosion in rheumatoid arthritis. Rheumatology (Oxford). 2018;57(5):850-855

Disclosure of Interests:

Alessia Alunno: None declared, Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Onelia Bistoni: None declared, Matteo Antonucci: None declared, Elena Bartoloni Bocci: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer, Roberto Gerli: None declared

THU0073 THE ANTI-ANGIOGENIC ROLE OF TOFACITINIB DURING EXPERIMENTAL MODEL OF ARTHRITIS

Background:

During rheumatoid arthritis (RA), a chronic autoimmune disease, the loop existing between inflammation and angiogenesis, characterised by new vessels formation associated with the increased recruitment of inflammatory cells, via the abnormal neo-angiogenesis in the synovial tissues, is considered an early important pathogenic mechanism.

Tofacitinib, a potent and selective JAK inhibitor, showed a good profile of safety and efficacy in RA patients, slowing the radiographic progression of the disease. In the last years, many works confirmed that some pro-angiogenic genes are targets of STATs family, and among them, vascular endothelial growth factors (VEGF), a potent pro-angiogenic molecule, may promote the new vessels formation via JAK/STAT pathways.

Objectives:

The aim of this work was to investigate the inhibiting role of tofacitinib, on the angiogenic mechanisms occurring during experimental model of arthritis.

Methods:

Healthy control (HC) ECs were stimulated with VEGF and/or tofacitinib and assessed for tube formation and migration, by matrigel and Boyden chamber assay. Furthermore, after ethical approval the experimental model of arthritis was obtained, stimulating 32 mice with collagen (CIA) and 32 mice with PBS (control). At day-19, CIA and controls mice were divided in 16 mice receiving vehicle and 16 mice receiving tofacitinib. At day-35, the mice were scarified and the thickness of paw joints, the synovial vessels and the serum levels of VEGF and Ang-2 were evaluated

Results:

In vitro, after tofacitinib-treatment, HC-ECs lose their ability to form vessels and to migrate.In vivo, tofacitinib significantly prevented the increase of paw thickness induced by the collagen administration and reduced the vessel density in synovial tissues of joints, when compared to CIA that did not received tofacitinib. Furthermore, the serum levels of VEGF and Ang-2 were higher in CIA mice, than in control mice. The administration of tofacitinib was able to prevent the VEGF and Ang-2 accumulation in CIA mice.

Conclusion:

During the last decade, the biological analogies between solid tumors and synovial pannus, and the encouraging results of anti-angiogenic treatments in oncology, lead to increasing interest for angiogenesis as a possible therapeutic target in RA. The present study demonstrated the anti-angiogenic efficacy of tofacitinib, opening a new perspective application for this molecule and improving our therapeutic skill to control the clinical evolution of RA.

References:

[1]Leblond A et al. Autoimmun Rev 2017;16:594-601.

[2]Fleischmann R et al. N Engl J Med 2012;367:495-507.

[3]Marrelli A, Autoimmun Rev 2011;10:595-8.

Disclosure of Interests:

Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Paola Di Benedetto Grant/research support from: Paola Di Benedetto received grant from Dompè outside this work., Piero Ruscitti Grant/research support from: Piero Ruscitti received grant from Pfizer outside this work., Speakers bureau: Piero Ruscitti received speaker honoraria BMS, MSD, Ely Lilly, SOBI outside this work, Onorina Berardicurti: None declared, Vasiliki Liakouli Grant/research support from: Vasiliki Liakouli received grant from Pfizer outside this work., Speakers bureau: Vasiliki Liakouli received speaker honoraria from Sanofi Genzyme outside this work., Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Noemi Panzera: None declared, Nicolò Grazia: None declared, Mauro Di Vito Nolfi: None declared, Barbara Di Francesco: None declared, Antonio Maurizi: None declared, Nadia Rucci: None declared, Anna Teti: None declared, Francesca Zazzeroni: None declared, Edoardo Alesse: None declared, Roberto Giacomelli Grant/research support from: Roberto Giacomelli received research grant from Pfizer.

This study was supported by an unconditioned Research grant from Pfizer., Speakers bureau: Roberto Giacomelli received speaker honoraria from Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI and Pfizer outside this work.

FRI0006 ASSESSING PRO-INFLAMMATORY PROPERTIES OF H-FERRITIN BY EX VIVO AND IN VITRO OBSERVATIONS

Background:

The concept of ‘hyperferritinemic syndrome’ has recently been proposed, suggesting high levels of ferritin as pathogenic pro-inflammatory mediator [1] Ferritin is an intracellular iron storage protein, comprising 24 subunits, heavy (H) and light (L) based on molecular weight. The H-/L subunits ratio may be different in tissues, since the ferritin enriched in L subunits (L-ferritin) and the ferritin enriched in H subunits (H-ferritin) may be observed in different tissues, according to pathophysiologic status [1].

Objectives:

We aimed to assess the presence of H- and L-ferritin as well as of CD68/H-ferritin and CD68/L-ferritin in bone marrow (BM) biopsies of adult macrophage activation syndrome (MAS) patients. In the same patients, we matched the findings of BM biopsies with sera to identify the main represented subunits of ferritin. Furthermore, we evaluated effects of ferritin, L-ferritin, and H-ferritin on human monocytes, assessing pro- and anti-inflammatory cytokines, and expression of NLRP3 inflammasome. Finally, we checked the ability of monocytes, which were treated with ferritin, to stimulate or not the proliferation of peripheral blood mononuclear cells (PBMCs).

Methods:

Immunofluorescence analysis was performed to investigate the tissue presence of L- and H-ferritin in BM biopsies as well as of CD68/H-ferritin and CD68/L-ferritin. Liquid chromatography mass spectrometry (LC-MS/MS) based proteomics was performed to identify L- and H-ferritin in sera proteins. Human monocytes were cultured with M-CSF for 7 days and, after that, treated with ferritin, H-ferritin, and L-ferritin at 10nM, for 120 and 240 minutes. After stimulation, IL-1β, IL-6, IL-10, IL-12, IFN-γ, TGF-β, TNF, and VEGF were assessed by RT-PCR and, in case of positive finding, evaluated by western blot. NLRP3 inflammasome was also assessed. Finally, the proliferation of PBMCs when co-cultured with ferritin-treated monocytes was tested by a specific proliferation assay.

Results:

Immunofluorescence showed an increased H-ferritin expression in the BMs of MAS patients, whereas L-ferritin did not. Conversely, LC-MS/MS identified that the L-ferritin was the dominant form, after stringent probability matching.In vitro, H-Ferritin induced a significant increased expression of IL-1β, IL-6, IL-12, and TNF after 240 minutes. Ferritin also induced a significant increased expression of IL-1β, IL-6, IL-12, and TNF after 240 minutes. Effects on pro-inflammatory cytokines were more marked with H-ferritin than ferritin. Conversely, no significant effects were retrieved analysing IFN-γ, IL-10, TGF-β, and VEGF after 240 minutes, after ferritin and H-ferritin stimulation. Furthermore, both ferritin and H-ferritin induced a direct effect on NLRP3 inflammasome. Finally, monocytes, which were treated with H-ferritin, stimulated the proliferation of co-cultured PBMCs.

Conclusion:

In our work, results showed the presence of H-ferritin and CD68/H-ferritin cells in BM biopsies of MAS patients, by immunofluorescence. Conversely, LC-MS/MS identified L-ferritin in sera proteins of those patients. Furthermore, pro-inflammatory effects of ferritin and, particularly, of H-ferritin on human monocytes were observedin vitro, increasing pro-inflammatory cytokines and NLRP3 inflammosome. Finally, H-ferritin-treated monocytes stimulated the proliferation of co-cultured PBMCs.

References:

[1]Rosario C, et al. BMC Med 2013; 11:185.

Disclosure of Interests:

Piero Ruscitti Grant/research support from: Pfizer, Speakers bureau: BMS, MSD, Ely Lilly, SOBI, Paola Di Benedetto Grant/research support from: Paola Di Benedetto received grant from Dompè outside this work., Onorina Berardicurti: None declared, Noemi Panzera: None declared, Federica Sensini: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

AB0369 EFFICACY AND SAFETY OF RITUXIMAB ORIGINATOR AND BIOSIMILAR IN PRIMARY SJÖGREN’S SYNDROME IN A REAL-LIFE SETTING

Background:

Over the last 2 decades rituximab (RTX) has been widely used, albeit off-label, in primary Sjögren’s syndrome (pSS). Several studies reported that B-lymphocyte depletion with RTX is effective in this disease not only by reducing disease activity but also by affecting the inflammation and the lymphoid organization that occur in target tissues. With the recent release of several RTX biosimilars (bRTX) on the market, the demonstration of their interchangeability with RTX originator (oRTX) is required.

Objectives:

To compare efficacy and safety of oRTX and bRTX in pSS patients in a real-life setting.

Methods:

Clinical records of pSS patients referring to a tertiary rheumatology clinic were retrospectively evaluated. Patients having received at least 2 courses of either oRTX or bRTX (1000 mg IV infusion, repeated after 2 weeks -1 course- and the course repeated after 24 weeks) with complete data at baseline and after 3, 6, 9 and 12 months of treatment were enrolled. Disease activity was assessed with the EULAR SS disease activity index (ESSDAI) and its clinical version without the biological domain (ClinESSDAI). Patient-reported symptoms were assessed with the EULAR SS Patient Reported Index (ESSPRI).

Results:

Seven patients that received oRTX and 7 patients that received bRTX were enrolled. Baseline clinical features, including ESSDAI and ESSPRI were similar in the 2 treatment groups. Both compounds significantly reduced ESSDAI and ESSPRI as early as 3 months and no difference between the groups was observed at any time point (Figure 1). Of interest, ESSDAI slowly decreased until month 6 when the most pronounced reduction was observed. Conversely, ESSPRI dropped to its lowest values already at month 3. With regard to safety, at 12 months of follow-up no adverse event was observed in any of the treatment groups.

Conclusion:

At 12 months of follow-up, oRTX and bRTX display similar efficacy and safety profiles. The improvement of patient reported outcomes is faster than the improvement of disease activity with both compounds. Our data support interchangeability of oRTX and bRTX in pSS.

References:

[1]Carubbi F et al. Arthritis Res Ther. 2013;15(5):R172

[2]Carubbi F et al. Lupus. 2014;23(13):1337-49

Figure 1 ESSDAI and ESSPRI values at every time point in the 2 treatment groups. Asterisks indicate p values <0.05 compared to the other treatment group at the same time point

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Alessia Alunno: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Viktoriya Pavlych: None declared, claudia di muzio: None declared, Roberto Gerli: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

FRI0158 CLINICAL AND IMAGING FEATURES OF ARTICULAR MANIFESTATIONS IN PRIMARY SJÖGREN’S SYNDROME: SIMILARITIES AND DIFFERENCES ACCORDING TO THE TIME OF ONSET

Background:

Articular manifestations (AMs) are observed in a large proportion of patients with primary Sjögren’s syndrome (pSS) and can occur at the time of pSS diagnosis or during the disease course. Although in the majority of cases AMs are mild and self-limiting, some patients may experience chronic polyarthritis requiring treatment with DMARDs. However to date no specific discriminating biomarkers have been identified. Magnetic resonance imaging (MRI) can help assessing the extent of articular involvement and guide the treatment.

Objectives:

To describe clinical and serological features of patients with pSS developing articular involvement along with the MRI findings of affected joints.

Methods:

Clinical records were retrospectively evaluated and MRI was performed to evaluate AMs. Disease activity was assessed with the EULAR SS disease activity index (ESSDAI) and its clinical version without the biological domain (ClinESSDAI). Patient-reported symptoms were assessed with the EULAR SS Patient Reported Index (ESSPRI). MRI features were described according to the OMERACT rheumatoid arthritis (RA) MRI scoring system. Values are displayed as mean ± standard error of the mean or number and percentages. Patients were tested for autoantibodies such as anti-cyclic citrullinated peptide, anti-citrullinated α enolase and anti-carbamylated proteins with commercially available ELISA kits.

Results:

45 pSS patients were included. 29 patients (64%) displayed AMs at pSS onset while 15 (36%) at a later stage (6.7±1 years after pSS diagnosis). Besides AMs, at the time of pSS diagnosis the two cohorts were comparable with regard to other ESSDAI domains. Interestingly, all patients with anti-SSA and anti-/SSB had AMs at the time of pSS diagnosis (p=0.05) while those developing AMs in the disease course were more likely single positive for anti-SSA (p=0.04). When comparing the clinical and serological features of both groups of patients at the time of overt AMs (Tables 1-2), patients that displayed AMs in the course of the disease have a significantly higher ESSPRI compared to patients that display AMs at pSS onset. With regard to MRI, 80% of patients with AM displayed signs of synovitis, 59% bone erosions, 59% joint space narrowing and 50% bone marrow oedema. To note, 60% of patients displaying AMs at pSS onset show bone marrow oedema while this is present in only 27% of patients developing AMs at a later stage (p<0.05). Anti-cyclic citrullinated peptide, anti-citrullinated α enolase, anti-carbamylated proteins were undetectable in all patients.

Conclusion:

Our results confirm the relevance of AMs in pSS, particularly because of the high prevalence of RA-like MRI features. MRI assessment in patients with pSS is advisable to identify more severe AMs in the spectrum of pSS disease and guide the therapeutic approach.

Table 1.

Clinical and serological features at the time of overt AMs. Categoric variables

All AMs (N=44)AMs at pSS onset (n=29)AMs in the course of disease (N=15)N%N%N%p valueESSDAI domainsConstitutional37310000.54Lymphadenopathy15347248530.09Glandular9205174270.46Articular441002910015100naCutaneous614274270.15Pulmonary614517170.65Renal000000naMuscular000000naPNS6144142131CNS1200170.34Hematological10238282130.45Biological511134270.04Morning stiffness441002910015100naSmall joints2966175912800.31Large joints3727171Both122710342130.17Table 2.

Clinical and serological features at the time of overt AMs. Continuous variables

All AMs (N=44)AMs at pSS onset (n=29)AMs in the course of disease (N=15)p valueMEAN±SEMMEAN±SEMMEAN±SEMYears from pSS diagnosis2.3±0.606.7±1naVAS pain8.4±0.37.7±0.49.7±0.150.001VAS dryness7±0.45.6±0.57.5±0.60.02VAS fatigue6.3±0.46.3±0.58.5±0.70.02ESSPRI7.2±0.36.5±0.48.6±0.40.001ESSDAI18±1.616.8±1.820.2±30.32ClinESSDAI17.5±1.616.4±1.819.6±30.35N of involved joints5.5±46.3±0.84±0.50.06

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Alessia Alunno: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Elena Bartoloni Bocci: None declared, Alessandro Conforti: None declared, Ilenia Di Cola: None declared, Roberto Gerli: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

AB0674 CLINICAL AND IMAGING FEATURES IN SPONDYLOARTHRITIS PATIENTS WITH AND WITHOUT HLA-B27 AND HLA-B51

Background:

Despite being commonly expressed in the general population, the human leucocyte antigen (HLA)-B27 allele strongly increases the susceptibility to develop spondyloarthritis (SpA). Likewise, the association between the HLA-B51 allele and the development of Behçet’s disease is well documented. However, the exact mechanisms responsible for their pathologic role are still a matter of debate. Moreover, anecdotal reports show an association between HLA-B51 and the clinical spectrum of SpA.

Objectives:

To investigate the clinical and imaging findings of SpA patients according to the absence or presence of HLA-B27 or HLA-B51.

Methods:

We retrospectively analyzed 236 patients with axial or peripheral SpA, according to the ASAS criteria, referring to two tertiary Rheumatology Clinics between 2017 and 2019. All patients had been tested for HLA-B alleles. Patients with HLA-B51 haplotype and fulfilling the criteria for Behçet’s disease were excluded.

Results:

Table 1 shows demographic and clinical features of patients, according with the HLA-B haplotype (neither HLA-B27 nor -B51, double negative; positive for HLA-B27 only, positive for HLA-B51 only). Inflammatory low back pain and sacroiliitis, assessed by X-ray or magnetic resonance imaging (MRI), were more prevalent in double negative and HLA-B27 patients, compared to HLA-B51 patients. In this regard, the presence of HLA-B51 was negatively associated with axial manifestations at onset (OR 0.347, 95% CI 0.200-0.604, p<0.0001) and in the course of the disease (low back pain: OR 0.395, 95% CI 0.225-0.689 p<0.0001; sacroiliitis on imaging: OR 0.342 CI 0.189-0.619 p<0.0005). When considering extra-articular manifestation, aphtous lesions were more prevalent in patients with HLA-B51 (p< 0.0001), inflammatory bowel diseases in the double negative group (p=0.0006), and increased C-reactive protein in double negative and HLA-B27 patients (p=0.02).

Table 1.All (236 patients)Double-negative (101 patients)HLA-B27 (53 patients)HLA-B51 (82 patients)p valueFemale (%)167 (71)73 (72)28 (53)66 (60)0.0024 (cumulative)Age, years (mean±SD)53.7±13.356.4±12.7#48.2±14.4$54±12.7#<0.01 vs HLA-B27$< 0.05 vs HLA-B51Age at diagnosis, years (mean±SD)48±14.550.3±13*40.8±15.5§50.2±14.3*<0.001 vs HLA-B27§<0.001 vs HLA-B51Time from symptoms to diagnosis, years (mean±SD)3.8±5.73.6±4.83.2±3.74.4±7.5nsType of onset:0.0031 (cumulative)-Axial (%)129 (55)67 (66)31 (59)31 (38)-Peripheral (%)63 (27)19 (19)12 (23)32 (39)-Axial and peripheral (%)44 (19)15 (15)10 (19)19 (23)

Conclusion:

The presence of HLA-B51 identifies a subgroup of SpA patients with peculiar features compared to double-negative or HLA-B27 SpA patients. HLA-B51-related SpA may be an additional condition to be included in the SpA spectrum.

References:

[1]Bodis G, et al. Role of Human Leukocyte Antigens (HLA) in Autoimmune Diseases. Rheumatol Ther 2018;5:5–20.

[2]Rudwaleit M, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009;68:777–83.

[3]Rudwaleit M, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011;70:25–31.

[4]Maksymowych WP, et al. MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group. Ann Rheum Dis. 2019;78:1550-1558.

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Alessia Alunno: None declared, Alessandro Conforti: None declared, Angelo Francesco Bonifacio: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Roberto Gerli: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

Evaluation of the influence of social, demographic, environmental, work-related factors and/or lifestyle habits on Raynaud's phenomenon: a case-control study

Raynaud's phenomenon (RP) is a clinical disorder characterized by recurrent, reversible episodes of digital vasospasm. RP can be classified as primary (pRP) or secondary, depending on whether it occurs as a benign condition (not disease-associated) or is associated with other diseases, mainly of the connective tissues. In both cases, it can be triggered by environmental factors, as indicated by the increased incidence of pRP episodes following exposure to cold, vibration injury or chemicals. The purpose of this prospective case-control study was to assess, in an Italian cohort of 132 pRP patients, the association of the phenomenon with demographic, lifestyle habits, environmental and work-related factors. Compared to healthy controls, pRP was found to be inversely associated with the use of contact lenses (OR = 0.4; p = 0.004) and of chlorous-based disinfectants (OR = 0.3; p < 0.001) and directly associated with the presence of prosthesis implants (OR = 5.3; p = 0.001) and the use of hydrogen peroxide-based compounds (OR = 2.6; p = 0.002), suggesting that the latter should be avoided in RP affected patients. Multivariate and multivariable analysis confirmed the associations. Further investigations are needed to understand the mechanism(s) underlying these findings.

Histopathology of salivary glands

Salivary gland (SG) biopsy is a technique broadly applied for the diagnosis of primary Sjögren's syndrome (pSS), lymphoma accompanying SS, sarcoidosis, amyloidosis, and IgG4-related disease The most peculiar feature of pSS on biopsy is focal lymphocytic sialadenitis. In the past, several histological scores have been reported in the literature to describe glandular involvement during pSS. However, the variability among centres in reporting glandular scores is one of the rationales behind the development of standardised consensus guidance. SGs as well as lacrimal glands are involved in up to 50% of patients with IgG4-related disease with 3 histopathological hallmarks such as dense lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. SGs can be also affected by amyloidosis with MSG biopsy being more sensitive than that of rectal mucosa or subcutaneous fat. SG involvement is a rare manifestation during sarcoidosis, and the presence of non-caseating granulomas needs to be differentiated from granulomas of other etiology. This review article provides an overview of normal and pathological SGs in the context of rheumatic diseases, identifying key elements in the tissue as diagnostic and prognostic biomarkers, useful in the current clinical practice.

H-ferritin and proinflammatory cytokines are increased in the bone marrow of patients affected by macrophage activation syndrome

Macrophage activation syndrome (MAS) is hyperinflammatory life-threatening syndrome, associated typically with high levels of serum ferritin. This is an iron storage protein including heavy (H) and light (L) subunits, categorized on their molecular weight. The H-/L subunits ratio may be different in tissues, depending on the specific tissue and pathophysiological status. In this study, we analysed the bone marrow (BM) biopsies of adult MAS patients to assess the presence of: (i) H-ferritin and L-ferritin; (ii) CD68⁺ /H-ferritin⁺ and CD68⁺ /L-ferritin⁺ ; and (iii) interleukin (IL)-1β, tumour necrosis factor (TNF) and interferon (IFN)-γ. We also explored possible correlations of these results with clinical data. H-ferritin, IL-1β, TNF and IFN-γ were increased significantly in MAS. Furthermore, an increased number of CD68⁺ /H-ferritin⁺ cells and an infiltrate of cells co-expressing H-ferritin and IL-12, suggesting an infiltrate of M1 macrophages, were observed. H-ferritin levels and CD68⁺ /H-ferritin⁺ cells were correlated with haematological involvement of the disease, serum ferritin and C-reactive protein. L-ferritin and CD68⁺ /L-ferritin⁺ cells did not correlate with these parameters. In conclusion, during MAS, H-ferritin, CD68⁺ /H-ferritin⁺ cells and proinflammatory cytokines were increased significantly in the BM inflammatory infiltrate, pointing out a possible vicious pathogenic loop. To date, H-ferritin and CD68⁺ /H-ferritin⁺ were associated significantly with haematological involvement of the disease, suggesting biomarkers assessing severity of clinical picture.

Interleukin-9 over-expression and T helper 9 polarization in systemic sclerosis patients

T helper 9 (Th9) cells and interleukin (IL)-9 are involved in the pathogenesis of several autoimmune diseases. The exact role of IL-9 and Th9 cells in patients with systemic sclerosis (SSc) have not yet been studied adequately. IL-9, IL-9R, transcription factor PU.1 (PU.1), IL-4, thymic stromal lymphopoietin (TSLP) and transforming growth factor (TGF)-β expression were assessed in skin and kidney biopsies of SSc patients and healthy controls (HC) by immunohistochemistry (IHC). The cellular source of IL-9 was also analysed by confocal microscopy analysis. Peripheral IL-9-producing cells were also studied by flow cytometry. The functional relevance of IL-9 increased expression in SSc was also investigated. Our results demonstrated a strong expression of IL-9, IL-9R, IL-4, TSLP and TGF-β in skin tissues of patients with both limited and diffuse SSc. IL-9 expression was observed mainly in the context of skin infiltrating mononuclear cells and keratinizing squamous epithelium. IL-9 over-expression was also observed in renal biopsies of patients with SSc. IL-9 producing cells in the skin were identified as Th9 cells. Similarly, Th9 cells were expanded and were the major source of IL-9 among SSc peripheral blood mononuclear cells (PBMC), their percentage being correlated directly with the modified Rodnan skin score. Infiltrating mononuclear cells, mast cells and neutrophils expressed IL-9R. In in-vitro studies stimulation with rIL-9 significantly induced NET (neutrophil extracellular traps) release by dying cells (NETosis) in neutrophils, expansion of mast cells and increase of anti-systemic scleroderma 70 (Scl70) production by B cells. Our findings suggest that Th9 cells and IL-9 could be implicated in the pathogenesis of SSc.

Interleukin-9 and T helper type 9 cells in rheumatic diseases

Interleukin (IL)-9 is a 28-30 kDa monomeric glycosylated polypeptide belonging to the IL-7/IL-9 family of proteins that bind to a composite receptor consisting of the private receptor IL-9R and the IL-2 receptor, gamma (IL-2RG), a common gamma subunit shared by the receptors of many different cytokines. The IL-9R is expressed widely and IL-9 impacts a number of effector cells, such as effector T cells, B cells, innate lymphoid cells, mast cells, polymorphonuclear cells, epithelial cells and smooth muscle cells, playing an important role in regulating inflammatory immunity. The critical role of IL-9 in promoting cellular and humoral immune responses makes it an important focus of potential therapeutic interventions. Recently, a defined subset of T helper type cells, Th9 cells, has been identified by the potent production of IL-9. The involvement of the Th9 cell subset has been described in many types of inflammatory diseases, namely atopic diseases, helminth infections, experimental autoimmune encephalomyelitis and ulcerative colitis. In this review, we summarize the IL-9 biological activities, highlighting roles for IL-9 and Th9 cells in rheumatoid and psoriatic arthritis, systemic vasculitis, systemic lupus erythematosus and systemic sclerosis.

Interleukin (IL)-9/IL-9R axis drives γδ T cells activation in psoriatic arthritis patients

Cytokines such as tumour necrosis factor (TNF)-α, interleukin (IL)-12, interferon (IFN)-γ, IL-23 and, more recently, IL-9, have been implicated in the initiation/maintenance of inflammation in psoriasis and psoriatic arthritis (PsA). In the present study we aimed to characterize the role of γδ T cells in peripheral blood and synovial fluid of PsA patients and to investigate their response to in-vitro stimulation with antigen or cytokines (IL-9 and IL-23). γδ T cells isolated from peripheral blood mononuclear cells and synovial fluid were analysed by flow cytometry to evaluate the phenotype and cytokine production. IL-23R and IL-9R gene expression were also evaluated by reverse transcription-polymerase chain reaction (RT-PCR). Peripheral blood mononuclear cells (PBMC), sorted γδ T cells and γδ cell lines were also stimulated in vitro with isopentenyl pyrophosphate (IPP), recombinant IL-9 or recombinant IL-23. Our results show an expansion of γδ T cells with a predominant effector memory phenotype in peripheral blood and synovium of untreated PsA patients, which reverses significantly after treatment with anti-TNF-α or anti-IL-12/IL-23R monoclonal antibodies (mAbs). Moreover, in PsA patients γδ T cells activation is driven prevalently by IL-9/IL-9R interaction, and not only by IL-23/IL-23R. Together these findings indicate γδ T cells and IL-9 as new players in the pathogenesis of PsA.

H-ferritin and CD68(+) /H-ferritin(+) monocytes/macrophages are increased in the skin of adult-onset Still's disease patients and correlate with the multi-visceral involvement of the disease

Adult-onset Still's disease (AOSD) patients may show an evanescent salmon-pink erythema appearing during febrile attacks and reducing without fever. Some patients may experience this eruption for many weeks. During AOSD, exceptionally high serum levels of ferritin may be observed; it is an iron storage protein composed of 24 subunits, heavy (H) subunits and light (L) subunits. The ferritin enriched in L subunits (L-ferritin) and the ferritin enriched in H subunits (H-ferritin) may be observed in different tissues. In this work, we aimed to investigate the skin expression of both H-and L-ferritin and the number of macrophages expressing these molecules from AOSD patients with persistent cutaneous lesions. We observed an increased expression of H-ferritin in the skin, associated with an infiltrate in the biopsies obtained from persistent cutaneous lesions of AOSD patients. Furthermore, a positive correlation between H-ferritin skin levels as well as the number of CD68(+) /H-ferritin(+) cells and the multi-visceral involvement of the disease was observed. Our data showed an increased expression of H-ferritin in the skin of AOSD patients, associated with a strong infiltrate of CD68(+) /H-ferritin(+) cells. Furthermore, a correlation between the levels of H-ferritin as well as of the number of CD68(+) /H-ferritin(+) cells and the multi-visceral involvement of the disease was observed.

Familial autoimmunity as a risk factor for systemic lupus erythematosus and vice versa: a case-control study

The objective of this multicentric case-control study was to investigate if a history of autoimmune disease (AD) in first-degree relatives (FDR) is a risk factor for systemic lupus erythematosus (SLE) and to evaluate the risk of AD among FDR of SLE patients. Cases were Italian SLE patients consecutively enrolled. Controls were orthopaedic inpatients without any autoimmune diseases.The strength of the association between family history of AD and SLE was measured as an odds ratio (OR) calculated from the coefficient of an unconditional regression model. To calculate the risk of AD among FDR of SLE patients, the extended generalized estimating equation technique was used. In total, 154 SLE cases and 140 controls were enrolled. A family history of AD was reported by 22.7% of SLE patients and by 5.7% of the controls. The risk of SLE increased with the number of FDR with AD (one FDR affected, OR 4.1; two or more, OR 11.3). The probability of having AD was higher among FDR of SLE cases in comparison to FDR of controls (RR 4.6; 95%CI 1.9-11.1). A female SLE patient conferred an increased risk of AD to her FDR; this risk is doubled in females (OR 10.3; 95% CI 3.1-34.4).

γ/δ T Cells are not Involved in the Natural and Antibody-Dependent Cytotoxicity of Peripheral blood Mononuclear Cells in Inflammatory Bowel Disease

In a previous study, we showed an imbalance in the cytotoxic phenotype of circulating PBMC of IBD patients, possibly related to an alteration in the cytotoxic activity, which might play a role in the immunopathogenesis of IBD. γ/δ T cells, which are increased in the PBMC of IBD patients, represent a minor population of peripheral lymphocytes displaying cytolytic potential and showing both MHC and non-MHC cytotoxicity. This study was performed in order to verify their role in the cytotoxic activity of PBMC from IBD patients and correlate this activity to UC and CD, respectively. We observed a decreased NK cytotoxicity of PBMC in both UC and CD patients and this findings was unrelated to γ/δ T lymphocytes. In fact, both total and γ/δ-depleted PBMC of IBD patients, showed comparable lytic activity. On the contrary, the ADCC lytic activity was within normal range in our patients, ad was not modified by removal of γ/δ cells. The increase of Vδ1+ T cells, previously observed in our patients, seems to be unrelated to this functional impairment, because of a low cytotoxic activity displayed by this subset. Alternatively, the expanded Vδ1+ T cells could be involved in the pathogenesis of the autoimmune phenomena observed in IBD, by a mechanism different from cytotoxicity, such as autoantibodies production and/or loss of tolerance.

Interleukin (IL)-17-producing pathogenic T lymphocytes co-express CD20 and are depleted by rituximab in primary Sjögren's syndrome: a pilot study

Compelling evidence suggests that interleukin (IL)-17 and IL-17-producing cells play a pivotal role in the pathogenesis of primary Sjögren's syndrome (pSS). We investigated phenotypical and functional effects of the anti-CD20 antibody rituximab (RTX) on circulating and glandular IL-17-producing T cells in pSS. RTX is able to deplete glandular IL-17(+) CD3(+) CD4(-) CD8(-) double-negative (DN) and CD4(+) Th17 cells as well as circulating IL-17(+) DN T cells. A fraction of glandular and circulating IL-17(+) DN cells and CD4(+) T helper type 17 (Th17) cells co-expresses CD20 on the cell surface explaining, at least in part, such depletive capacity of RTX. The exposure to RTX does not rescue the in-vitro corticosteroid resistance of IL-17(+) DN T cells. Our results support further the therapeutic role in pSS of RTX that, despite its B cell specificity, appears able to also hamper IL-17-producing T cells in this disease.

The CD68(+)/H-ferritin(+) cells colonize the lymph nodes of the patients with adult onset Still's disease and are associated with increased extracellular level of H-ferritin in the same tissue: correlation with disease severity and implication for pathogenesis

In this work, we aimed to evaluate the levels of ferritin enriched in H subunits (H-ferritin) and ferritin enriched in L subunits (L-ferritin) and the cells expressing these two molecules in the lymph node (LN) biopsies obtained from adult-onset Still's disease (AOSD) patients, and the possible correlation among these data and the severity of the disease. Ten patients with AOSD underwent LN biopsy. All the samples were stained by immunofluorescence. A statistical analysis was performed to estimate the possible correlation among both H-ferritin and L-ferritin tissue expression and the clinical picture of the disease. Furthermore, the same analysis was performed to evaluate the possible correlation among the number of CD68(+)/H-ferritin(+) or CD68(+)/L-ferritin(+) cells and the clinical picture. Immunofluorescence analysis demonstrated an increased tissue H-ferritin expression in the LNs of AOSD patients. This increased expression correlated with the severity of the disease. An increased number of CD68 macrophages expressing H-ferritin was observed in the LN samples of our patients. Furthermore, we observed that the number of CD68(+)/H-ferritin(+) cells correlated significantly with the severity of the clinical picture. Our data showed an imbalance between the levels of H- and L-ferritin in LNs of AOSD patients and the evidence of an increased number of CD68(+)/H-ferritin(+) cells in the same organs. Furthermore, a correlation among both the tissue H-ferritin levels and the CD68(+)/H-ferritin(+) cells and the clinical picture was observed.

Interleukin-36α axis is modulated in patients with primary Sjögren's syndrome

The aim of this study was to investigate the expression of the interleukin (IL)-36 axis in patients with primary Sjögren's syndrome (pSS). Blood and minor labial salivary glands (MSG) biopsies were obtained from 35 pSS and 20 non-Sjögren's syndrome patients (nSS) patients. Serum IL-36α was assayed by enzyme-linked immunosorbent assay (ELISA). IL-36α, IL-36R, IL-36RA, IL-38, IL-22, IL-17, IL-23p19 and expression in MSGs was assessed by reverse transcription-polymerase chain reaction (RT-PCR), and tissue IL-36α and IL-38 expression was also investigated by immunohistochemistry (IHC). αβ and γδ T cells and CD68(+) cells isolated from MSGs were also studied by flow cytometry and confocal microscopy analysis. IL-36α was over-expressed significantly in the serum and in the salivary glands of pSS. Salivary gland IL-36α expression was correlated with the expression levels of IL-17, IL-22 and IL-23p19. IL-38, that acts as inhibitor of IL-36α, was also up-regulated in pSS. αβ(+) CD3(+) T cells and CD68(+) cells were the major source of IL-36α in minor salivary glands of pSS. γδ T cells were not significantly expanded in the salivary glands of pSS but produced more IL-17, as their percentage correlated with the focus score. Higher expression of IL-36α and IL-36R was also demonstrated in γδ T cells isolated from pSS compared to controls. In this study we demonstrate that a significant increase in circulating and tissue levels of IL-36α occurs in pSS patients.

Cardiovascular disease risk burden in primary Sjögren's syndrome: results of a population-based multicentre cohort study

OBJECTIVE

Systemic autoimmune diseases, in particular systemic lupus erythematosus and rheumatoid arthritis, are characterized by a high risk of premature cardiovascular (CV) events. Disease-related characteristics and traditional CV disease risk factors may contribute to atherosclerotic damage. However, there are limited data on the risk of overt CV events in primary Sjögren's syndrome (pSS).

METHODS

We retrospectively analysed a cohort of patients with 1343 pSS. Disease-related clinical and laboratory data, traditional CV disease risk factors and overt CV events were recorded. Prevalence of traditional CV disease risk factors and of major CV events was compared between a subgroup of 788 female patients with pSS aged from 35 to 74 years and 4774 age-matched healthy women.

RESULTS

Hypertension and hypercholesterolaemia were more prevalent, whereas smoking, obesity and diabetes mellitus were less prevalent, in women with pSS than in control subjects. Cerebrovascular events (2.5% vs. 1.4%, P = 0.005) and myocardial infarction (MI) (1.0% vs. 0.4%, P = 0.002) were more common in patients with pSS. In the whole population, central nervous system involvement (odds ratio (OR) 5.6, 95% confidence interval (CI) 1.35-23.7, P = 0.02) and use of immunosuppressive therapy (OR 1.9, 95% CI 1.04-3.70, P = 0.04) were associated with a higher risk of CV events. Patients with leucopenia had a higher risk of angina (P = 0.01).

CONCLUSIONS

pSS is associated with an increased risk of cerebrovascular events and MI. Disease-related clinical and immunological markers may have a role in promoting CV events.

Interleukin (IL)-22 receptor 1 is over-expressed in primary Sjogren's syndrome and Sjögren-associated non-Hodgkin lymphomas and is regulated by IL-18

The aim of this study was to elucidate more clearly the role of interleukin (IL)-18 in modulating the IL-22 pathway in primary Sjögren's syndrome (pSS) patients and in pSS-associated lymphomas. Minor salivary glands (MSGs) from patients with pSS and non-specific chronic sialoadenitis (nSCS), parotid glands biopsies from non-Hodgkin lymphomas (NHL) developed in pSS patients, were evaluated for IL-18, IL-22, IL-22 receptor 1 (IL-22R1), IL-22 binding protein (IL-22BP) and signal transducer and activator of transcription-3 (STAT-3) expression. MSGs IL-22R1-expressing cells were characterized by confocal microscopy and flow cytometry in pSS, nSCS and healthy controls . The effect of recombinant IL-18 and IL-22 on peripheral blood mononuclear cells (PBMCs) from pSS and nSCS was studied by flow cytometry and reverse transcription-polymerase chain reaction (RT-PCR). MSGs of pSS and NHL were characterized by an imbalance between IL-22 and IL-22BP protein expression, with IL-18 and IL-22BP being expressed in a mutually exclusive manner and IL-18 and IL-22R1 being correlated directly. Aberrant expression of IL-22R1, induced by IL-18, was observed only among tissue and circulating myeloid cells of pSS patients and macrophages of NHL tissues of pSS patients, but not nSCS. IL-22R1 expression on PBMC of pSS was functional, as its stimulation with recombinant IL-22 significantly up-regulated the expression of STAT-3, IL-17 and IL-22. An IL-18-dependent aberrant expression of IL-22R1 on cells of haematopoietic origin seems to be a specific immunological signature of patients with pSS and pSS-associated lymphomas.