Acute Encephalopathy Workup for a Patient With a History of Lupus Cerebritis and Unremarkable Inflammatory Markers: A Case Report

Lupus is a relatively rare disease; however, many of the patients diagnosed with lupus experience an acute confusional state. Despite the prevalence, lupus cerebritis remains a diagnosis of exclusion due to the number of differential diagnoses of the cause of acute confusional state and unreliable clinical markers. This case report highlights the significant duration it takes to work up a broad differential before initiating treatment for lupus. Our case involves a 65-year-old woman with a documented history of lupus, who presented with acute encephalopathy. Following the comprehensive diagnostic investigation, the patient was treated with high-dose steroids that resolved the patient's symptoms. This report considers the option of empiric steroid treatment in the setting of acute encephalopathy in individuals with a history of lupus cerebritis with inconclusive test results.

Moraxella catarrhalis Septic Arthritis Unveils Undiagnosed Systemic Lupus Erythematous in a Pediatric Patient

Septic arthritis is uncommon in pediatric patients, who are less likely to have major risk factors such as underlying joint disease or prosthetic joints. It only rarely affects the elbow and is usually caused by Gram-positive cocci, with Staphylococcus aureus being the most common bacterial organism. We present the case of a 15-year-old previously healthy female who experienced new-onset monoarticular nontraumatic elbow pain and was found to have a synovial effusion growing from Moraxella catarrhalis. The atypical clinical presentation, coupled with the growth of an unusual organism, raised concern for an underlying immunocompromising or inflammatory joint disorder. Further laboratory workup ultimately revealed a diagnosis of systemic lupus erythematosus (SLE), which more commonly presents with arthralgias that are polyarticular, symmetric, and migratory. This case report should encourage clinicians to maintain a high degree of suspicion for underlying joint disease when septic arthritis presents atypically.

Kikuchi-Fujimoto Disease With Systemic Lupus Erythematosus and Systemic Sclerosis Overlap: A Unique Clinical Presentation

Kikuchi-Fujimoto Disease (KFD), or histiocytic necrotizing lymphadenitis (HNL), is a rare self-limiting disorder presenting with fever and swollen lymph nodes. It is characterized by the focal proliferation of reticular cells, the presence of nuclear debris, and histiocytes. In advanced cases, it can present with hepato-splenomegaly and generalized lymphadenopathy. Historically, it has been associated with viral infections, as it frequently was found to be associated with upper respiratory symptoms. Alternative explanations include the immune response of T-cells leading to alteration in CD8-positive T-cell-mediated cell apoptosis. It is also speculated that KFD can be associated with rheumatological autoimmune diseases. We present a case of a 21-year-old African American female with a known diagnosis of systemic lupus erythematosus (SLE)-systemic sclerosis (SS) overlap presented with febrile lymphadenopathy and was diagnosed to have HNL on histological exam of lymph node biopsy.

Bullous Systemic Lupus Erythematosus Successfully Treated With Intravenous Immunoglobulin and Mycophenolate Mofetil

Bullous systemic lupus erythematosus (BSLE) is a rare autoimmune blistering disorder of cutaneous lupus erythematosus (CLE) that typically manifests as an acute vesiculobullous eruption in a patient with systemic lupus erythematosus (SLE). Also, it can rarely present as the initial clinical manifestation of SLE. There is no established US Food and Drug Administration (FDA) therapy for BSLE. We report a case of a 71-year-old Hispanic woman with SLE and lupus nephritis classes III and V who presented to the hospital with a worsening rash with painful, ruptured blisters involving the upper arms, chest, and back. Our patient did not respond to topical or systemic steroids but improved rapidly to combination therapy with intravenous immunoglobulin (IVIg) and mycophenolate mofetil (MMF).

Kikuchi-Fujimoto Disease in a 25-Year-Old Female: A Case Report

BACKGROUND

Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis is a rare benign disease that presents as cervical lymphadenopathy and fever.

CASE PRESENTATION

A 25-year-old South Asian female dentist, recently married, presented to our emergency department due to two weeks of fever, sore throat, swollen neck, and cough. The patient initially presented to a private clinic and was prescribed antibiotics on two visits. On physical examination, her neck was swollen with palpable and tender right posterior and submandibular lymph nodes. Oropharyngeal examination revealed pharyngeal hyperemia without tonsillar enlargement, exudates, or mucocutaneous ulcers. Ultrasound imaging revealed enlarged neck and thoracic and abdominal lymph nodes. CBC showed leukopenia and anemia of chronic disease. B2 microglobulin, lactate dehydrogenase, and kappa light chains were elevated. Anti-ANA, anti-dsDNA, HIV polymerase chain reaction (PCR), Quantiferon-tuberculosis (TB), and rapid plasma reagin were all negative. A lymph node biopsy confirmed the diagnosis of Kikuchi-Fujimoto disease.

CONCLUSION

We believe this is the second case to be reported in the United Arab Emirates (UAE). Kikuchi-Fujimoto disease has a non-specific presentation that overlaps with several conditions including autoimmune, infectious, and malignant. Therefore, a thorough clinical approach and a high grade of clinical suspicion is required to rule out other possible differential diagnosis. Finally, Although Kikuchi-Fujimoto disease is mostly benign, clinicians should be careful as some patients might develop systemic lupus erythematosus (SLE), Still disease, or B cell lymphoma in the future.

Gender Disparities in Hospitalization Outcomes and Healthcare Utilization Among Patients with Systemic Lupus Erythematosus in the United States

Background Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease characterized by various clinical manifestations. Despite efforts to improve outcomes, mortality rates remain high, and certain disparities, including gender, may influence prognosis and mortality rates in SLE. This study aims to examine the gender disparities in outcomes of SLE hospitalizations in the US. Methods We conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) database between 2016 and 2020. The NIS database is the largest publicly available all-payer database for inpatient care in the United States, representing approximately 20% of all hospitalizations nationwide. We selected every other year during the study period and included hospitalizations of adult patients (≥18 years old) with a primary or secondary diagnosis of SLE using International Classification of Diseases, Tenth Revision (ICD-10) codes. The control population consisted of all adult hospitalizations. Multivariate logistic regression was used to estimate the strength of the association between gender and primary and secondary outcomes. The regression models were adjusted for various factors, including age, race, median household income based on patients' zip codes, Charlson comorbidity index score, insurance status, hospital location, region, bed size, and teaching status. To ensure comparability across the years, revised trend weights were applied as the healthcare cost and use project website recommends. Stata version 17 (StataCorp LLC, TX, USA) was used for the statistical analyses, and a two-sided P-value of less than 0.05 was considered statistically significant. Results Among the 42,875 SLE hospitalizations analyzed, women accounted for a significantly higher proportion (86.4%) compared to men (13.6%). The age distribution varied, with the majority of female admissions falling within the 30- to 60-year age range, while most male admissions fell within the 15- to 30-year age category. Racial composition showed a slightly higher percentage of White Americans in the male cohort compared to the female cohort. Notably, more Black females were admitted for SLE compared to Black males. Male SLE patients had a higher burden of comorbidities and were more likely to have Medicare and private insurance, while a higher percentage of women were uninsured. The mortality rate during the index hospitalization was slightly higher for men (1.3%) compared to women (1.1%), but after adjusting for various factors, there was no statistically significant gender disparity in the likelihood of mortality (adjusted odds ratio (aOR): 1.027; 95% confidence interval (CI): 0.570-1.852; P=0.929). Men had longer hospital stays and incurred higher average hospital costs compared to women (mean length of stay (LOS): seven days vs. six days; $79,751 ± $5,954 vs. $70,405 ± $1,618 respectively). Female SLE hospitalizations were associated with a higher likelihood of delirium, psychosis, and seizures while showing lower odds of hematological and renal diseases compared to men. Conclusion While women constitute the majority of SLE hospitalizations, men with SLE tend to have a higher burden of comorbidities and are more likely to have Medicare and private insurance. Additionally, men had longer hospital stays and incurred higher average hospital costs. However, there was no significant gender disparity in the likelihood of mortality after accounting for various factors.

A Rare Case of Antinuclear Antibody (ANA)-Negative Lupus Nephritis

Because most patients with lupus nephritis have a positive antinuclear antibody (ANA), ANA-negative lupus nephritis is a rare complication of systemic lupus erythematosus (SLE). In the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology (EULAR/ACR) classification criteria for SLE, a negative ANA precludes further work-up of SLE. The following case discusses a patient with multiple negative ANA titers but was diagnosed with SLE based on the findings of the kidney biopsy showing lupus nephritis. Though ANA was negative, anti-double-stranded DNA (anti-dsDNA) and anti-Sjogren's syndrome-A (anti-SS-A) antibodies were high. This case highlights the nuances of SLE and further illustrates the challenges in making a diagnosis of SLE when serology alone is relied on for screening.

Treatment Using Both Voclosporin and Belimumab in Four Patients With Lupus Nephritis

Nearly 50% of patients with systemic lupus erythematosus (SLE) will develop lupus nephritis (LN). Current treatment regimens for LN are suboptimal as the majority of patients fail to achieve complete renal response after several months of treatment and there are high rates of relapse. We report outcomes in four LN patients who were treated with both voclosporin and belimumab. These patients had no serious infections, and we were able to taper glucocorticoids and reduce proteinuria.

Pleural and Pericardial Effusion With COVID-19 and Systemic Lupus Erythematosus and Its Recurrence: A Case Study

As a chronic autoimmune disease, systemic lupus erythematosus (SLE) primarily affects young women and does not discriminate against any particular organs. In December 2019, coronavirus disease 2019 (COVID-19) spread worldwide, with many speculations of cardiac involvement in the pathogenesis of infection. Moreover, in cases where cardiac symptoms were described, they consisted solely of chest pain or a general deterioration in health if the patient presented with pleural effusion or pericardial effusion. Our patient, a 25-year-old Hispanic woman, initially complained of chest pain, cough, and shortness of breath. After being admitted, she noticed growing dyspnea and mild discomfort on the right side of her chest. The patient had both SLE and COVID-19 and had developed pleural and pericardial effusions. After two days in culture, nothing had grown from the fluid samples. In addition, measures of brain natriuretic peptide and total creatine kinase fell within the normal range. Considering the investigational findings, pericardiocentesis was performed. After the procedure, the patient's condition improved, and she was discharged. The patient continued taking CellCept® 1,500 mg and Plaquenil 200 mg and started taking colchicine. Her daily prednisone dose was increased to 40 milligrams. She felt well initially; however, after two weeks of follow-up, the pericardial effusion recurred, and pericardiocentesis was performed again. The patient was discharged in stable condition after a two-day hospital stay. After treatment of both initial and recurrent effusions, the patient's cardiac symptoms were resolved, and blood pressure became stable. We hypothesize that there may be other unreported cases of COVID-19-related viral pericarditis, pericardial effusion, and pericardial tamponade that could be caused by a combination of COVID-19 and a pre-existing condition, mainly autoimmune disorders. Due to the lack of clarity surrounding typical COVID-19 manifestations, it is crucial to record all cases of this unique illness and analyze any increased incidence of pericarditis, pericardial effusion, and pericardial tamponade in the public.

The Lupus Attack: A Case Report and Literature Review of Myocardial Infarction and Antiphospholipid Syndrome

Acute myocardial infarction in a young patient is a nebulous entity, but in the absence of traditional cardiovascular risk factors, particular attention must be paid to thrombotic disorders and hypercoagulable states. A 28-year-old male presented with worsening substernal chest pain for 36 hours. He was recently diagnosed with systemic lupus erythematosus (SLE) with active class II lupus nephritis. With an initial electrocardiogram revealing ischemic changes, and an elevated troponin I, a concern was raised for myocardial infarction. Transthoracic echocardiography revealed a severely reduced ejection fraction of 25%, and a subsequent emergent left heart catheterization revealed a complete, massive thrombotic occlusion of the proximal left anterior descending artery, requiring aspiration thrombectomy. After extensive workup for hypercoagulable states, he was found to have elevated anticardiolipin IgG and IgM antibodies on two occasions, twelve weeks apart. The patient was managed with triple anticoagulation with aspirin, clopidogrel, and warfarin for one month, followed by dual anticoagulation with clopidogrel and warfarin with a targetted international normalized ratio (INR) of 2.0 - 3.0. The management of acute coronary syndrome caused by antiphospholipid syndrome (APS) is highly individualized and driven by clinician gestalt owing to the lack of a standardized consensus. While systemic thrombolysis, primary percutaneous coronary intervention (PCI), and coronary artery bypass grafting all have their utility, only a very small handful of case reports exist on the benefits of each. This particular case serves to showcase an instance where a patient was successfully managed with PCI with dual antiplatelet therapy. Further prospective randomized controlled trials are necessary to determine the optimal management of this rarely encountered patient population.

Potential for Antigen-Specific Tolerizing Immunotherapy in Systematic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic complex systemic autoimmune disease characterized by multiple autoantibodies and clinical manifestations, with the potential to affect nearly every organ. SLE treatments, including corticosteroids and immunosuppressive drugs, have greatly increased survival rates, but there is no curative therapy and SLE management is limited by drug complications and toxicities. There is an obvious clinical need for safe, effective SLE treatments. A promising treatment avenue is to restore immunological tolerance to reduce inflammatory clinical manifestations of SLE. Indeed, recent clinical trials of low-dose IL-2 supplementation in SLE patients showed that in vivo expansion of regulatory T cells (Treg cells) is associated with dramatic but transient improvement in SLE disease markers and clinical manifestations. However, the Treg cells that expanded were short-lived and unstable. Alternatively, antigen-specific tolerance (ASIT) approaches that establish long-lived immunological tolerance could be deployed in the context of SLE. In this review, we discuss the potential benefits and challenges of nanoparticle ASIT approaches to induce prolonged immunological tolerance in SLE.

A Review of the Efficacy of Influenza Vaccination in Autoimmune Disease Patients

Patients suffering from autoimmune diseases appear to be at greater risk for developing infections with the influenza virus compared to healthy controls due to their immunosuppressive treatment, suggesting the importance of vaccination. Within this literature review, we highlight the importance, efficacy, and safety of influenza vaccination in individuals with autoimmune diseases, including systemic lupus erythematosus (SLE), Sjogren syndrome (SS), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) in both vaccinated and unvaccinated individuals. Overall, vaccination is generally well tolerated by SLE patients and the literature recommends the inactivated influenza vaccine to SLE patients according to the recommendations and schedules for the general population and annually against seasonal influenza viruses. While the data are still unclear in patients with SS, there does seem to be a general consensus to vaccinate these individuals to prevent harmful risks of influenza disease. In patients with RA and IBD, vaccination efficacy with the inactivated influenza vaccine should be determined on a case-by-case basis, taking patient therapy into account. In light of the current pandemic and global coronavirus disease 2019 (COVID-19) crisis, it is crucial to emphasize the safety and immunogenicity of influenza vaccination in vulnerable individuals suffering from autoimmune diseases. Public health measures are recommended to protect these individuals with vaccinations, keeping in mind the possibility of the multiple COVID-19 vaccines that are currently available.

Thrombotic Thrombocytopenic Purpura After Live Liver Donation: Villain or Scapegoat?

Living donor liver transplantation is a complex surgery, where the donor’s safety is of paramount importance. Despite all precautions, donor morbidity may be inevitable, and long-term follow-up data attest to this fact. However, being a “past donor” all ailments are intuitively attributed to the donation process, which may not always be the case. We present the case of a 47-year-old lady, who developed thrombotic thrombocytopenic purpura secondary to systemic lupus erythematosus 18 months following her liver donation, when she detected to be anti-nuclear antibody (ANA) positive. She developed neurological signs and was managed successfully with therapeutic plasma exchange and steroids. She was discharged home on immunosuppression and remains well on follow-up. We present the medical and social issues that were addressed in the case and highlight the need for a more stringent follow-up protocol in those who are ANA positive. This would also help detect morbidities that may be unrelated to the donation process.

A Lean Lady With Acanthosis Nigricans and Uncontrolled Diabetes Mellitus

A 47-year-old Asian Indian woman presented with uncontrolled hyperglycaemia and osmotic symptoms despite multiple oral antidiabetic medications and insulin. She had a history of recurrent oral ulcers, profound weight loss, and intermittent fever for one and a half years before the presentation. She had severe acanthosis nigricans, although her body mass index (BMI) was 14.6 kg/m².

Her blood glucose remained uncontrolled despite very large dosages of intravenous insulin (more than 12,000 units daily). Evaluation for possible underlying collagen vascular diseases and malignancies were negative. Her serum insulin levels were high. She tested negative for anti-insulin antibodies but positive for anti-insulin-receptor antibodies. She improved with a pulse dose of intravenous methylprednisolone but relapsed within one month. A second pulse dose was given following which a complete remission of diabetes and regression of acanthosis was observed.

Type B insulin resistance, a rare cause of severe insulin resistance, may respond favourably to immunosuppressive therapy with high-dose methylprednisolone.

Impact of hydroxychloroquine on the gestational outcomes of pregnant women with immune system problems that necessitate the use of the drug

AIM

To evaluate the impact of hydroxychloroquine (HCQ) on the perinatal outcomes of pregnancies with immune system disorders that necessitate the use of the drug.

METHODS

This cohort consisted of 202 pregnancies with poor obstetric history and immune system problems. Patients enrolled in special antenatal care program were administered low-dose low-molecular-weight heparin, low-dose salicylic acid and low-dose corticosteroid (prophylaxis protocol) as soon as their pregnancies were confirmed. Pregnancies with systemic lupus erythematosis, Sjogren syndrome and rheumatoid arthritis were additionally administered HCQ 200 mg daily as a part of their routine treatment. Pregnancies using HCQ were included in the study group (n = 39) while the remainders were included in control group (n = 163). We compared the groups in terms of the presence of miscarriage, fetal growth restriction (FGR), preeclampsia and preterm birth, as well as gestational week at birth, birthweight and "APGAR score of <7" at 10th minute.

RESULTS

Miscarriage rates were 28.2% and 28.2% while preterm birth rates were 16.6% and 28.2% in the control and study groups, respectively (P = 0.215). Preeclampsia and HCQ-related side effects were not detected in the groups. There were also no significant differences between the groups in terms of FGR, gestational day at birth, birthweight and the presence of "APGAR score <7" at 10th minute (P = 0.462, P = 0.064, P = 0.273 and P = 0.627, respectively).

CONCLUSION

Low-dose low-molecular-weight heparin, low-dose salicylic acid and low-dose corticosteroid prophylaxis together with HCQ seem to be promising in pregnancies with immune system disorders. HCQ seems to be a safe and effective drug in low dosages.

Spectrum of Morphologic Features of Lupus Nephritis According to Nephrology/Renal Pathology Society (ISN/RPS) Classification

Introduction

Lupus nephritis is one of the most important secondary glomerulopathy and a significant cause of chronic renal failure. Early diagnosis is key to improved prognosis. The International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification stratifies renal biopsy evaluation in different classes that correlates with clinical renal outcome. In the current study, we aimed to evaluate the proportion of patients in each class of lupus nephritis in our population.

Methods

We evaluated renal biopsies of 128 patients that fulfilled the clinical and serologic criteria of lupus nephritis. The histologic classification was done according to the ISN/RPS classification, and immunofluorescence studies were performed. Active and chronic lesions were assessed on renal biopsy, and association of different histopatholgic parameters with lupus classes was done.

Results

The mean age was 28.85±12.24 years. Most of the patients were from age group ≤25 years (48.4%). Active lesions were seen in 66 (51.6%) patients, with endocapillary hypercellularity being the most common active lesion type, i.e. 81.8%. Chronic lesions were noted in 42 (32.8%) patients, with glomerular sclerosis being the most common chronic lesion type, i.e. 69%. Majority of the patients belonged to class IV (46.9%). Females were more likely to present at advanced lupus stage compared to males, and older patients (>50 years) had a higher chance to present at a late stage (class IV and higher). Active lesions were significantly found more frequently in classes III and IV, while chronic lesions were more likely to present in classes III to V.

Conclusion

We found that a significant proportion of patients of lupus nephritis in our population presents at an advanced stage as more than 60% patients were of class IV or higher. This signifies lack of appropriate clinical surveillance of patients and assessment of renal functions early in disease course. This also necessitates revision of our locoregional protocols to manage lupus nephritis patients and a need to perform a renal biopsy early in disease course.

Organising pneumonia in Rhupus syndrome

Interstitial lung disease (ILD) is seen in 17% of patients with Rhupus syndrome. Organising pneumonia (OP), a subtype of connective tissue disease-associated ILD, is rare but associated with good outcomes. Here, we present a patient with Rhupus who developed OP.

Immunomodulatory drugs in pregnancy and lactation

Pregnancy presents challenges for women with autoimmune diseases. It is associated with significant physiological, hormonal and immunomodulatory changes which are complex and vary according to the stage of pregnancy

Pregnancy planning and counselling should be offered

Autoimmune diseases such as rheumatoid arthritis tend to improve in pregnancy while systemic lupus erythematosus may increase in activity

During pregnancy the chosen regimen should control or prevent underlying disease activity and minimise risk to the fetus. Ideally, women should be on a stable regimen before conception

Poorly controlled disease is associated with poor outcomes for both mother and fetus, such as higher risks of pre-eclampsia, early delivery and growth restriction of the fetus

Postpartum, there is a sudden fall in hormone concentrations, and a switch to a pro-inflammatory state. This increases the risk of relapse of many autoimmune diseases in particular rheumatoid arthritis, Crohn’s disease and autoimmune hepatitis

Many drugs are compatible with breastfeeding, but there are limited data on many of the new drugs

Sodium 4-phenylbutyrate treatment protects against renal injury in NZBWF1 mice

Systemic lupus erythematosus (SLE) is an autoimmune disease predominantly affecting women and often leading to lupus nephritis and kidney damage. Endoplasmic reticulum (ER) stress has been implicated in several forms of kidney disease, but whether ER stress contributes to renal injury in SLE is unknown. To investigate this, a small molecule chaperone, sodium 4-phenylbutyrate (4-PBA), was administered to the New Zealand Black x New Zealand White F₁ hybrid (NZBWF1) mouse model of SLE. In a prevention study, treatment with 4-PBA from 20 weeks of age (prior to the development of renal injury) delayed the onset of albuminuria and significantly reduced additional indices of renal injury compared with vehicle-treated NZBWF1 mice at 36 weeks of age, including collagen deposition, tubular casts, renal cell apoptosis, and blood urea nitrogen (BUN) concentration. To test whether ER stress contributes to the progression of renal injury once albuminuria has developed, mice were monitored for the onset of albuminuria (3+ or ≥300 mg/dl by dipstick measurement of 24-h urine sample) and once established, were either killed (onset group), or underwent 4-PBA or vehicle treatment for 4 weeks. Treatment with 4-PBA blocked the worsening of glomerular injury, reduced the number of dilated or cast-filled tubules, and reduced the number of apoptotic cells compared with vehicle-treated mice. BUN and left ventricle to bodyweight ratio (LV:BW) were also reduced by 4-PBA treatment. Renal expression of the endogenous chaperones, protein disulphide isomerase (PDI), and 78 kDa glucose-regulated protein (GRP78, also known as binding Ig protein (BiP)), were increased in 4-PBA-treated mice. Together, these results suggest a therapeutic potential for agents like 4-PBA in combating renal injury in SLE.

Intravascular Images of Coronary Stenosis with Multiple Channels in a Patient with Antiphospholipid Syndrome: The Optical Coherence Tomography Findings

Intravascular images of coronary stenosis by antiphospholipid syndrome (APS) would be beneficial to understand the mechanism of this disease. A 59-year-old woman with APS/systemic lupus erythematosis (SLE) underwent emergent coronary angiography which revealed stenosis with micro channels in the proximal left anterior descending artery. According to optical coherence tomography (OCT), the central lumen was surrounded by a thick septum with a homogenous and high intensity. Multiple small channels existed near the vessel wall with diffuse intimal hyperplasia. White thrombi were floating distal to the stenosis. Intravascular images obtained by optical coherence tomography (OCT) revealed the microstructure of complex coronary stenosis, which had ambiguous findings on angiography and intravascular ultrasound (IVUS) in an acute coronary syndrome (ACS) patient with APS/SLE.

Structural basis of the broadly neutralizing anti-interferon-α antibody rontalizumab

Interferons-alpha (IFN-α) are the expressed gene products comprising thirteen type I interferons with protein pairwise sequence similarities in the 77-96% range. Three other widely expressed human type I interferons, IFN-β, IFN-κ and IFN-ω have sequences 29-33%, 29-32% and 56-60% similar to the IFN-αs, respectively. Type I interferons act on immune cells by producing subtly different immune-modulatory effects upon binding to the extracellular domains of a heterodimeric cell-surface receptor composed of IFNAR1 and IFNAR2, most notably anti-viral effects. IFN-α has been used to treat infection by hepatitis-virus type C (HCV) and a correlation between hyperactivity of IFN-α-induced signaling and systemic lupus erythematosis (SLE), or lupus, has been noted. Anti-IFN-α antibodies including rontalizumab have been under clinical study for the treatment of lupus. To better understand the rontalizumab mechanism of action and specificity, we determined the X-ray crystal structure of the Fab fragment of rontalizumab bound to human IFN-α2 at 3Å resolution and find substantial overlap of the antibody and IFNA2 epitopes on IFN-α2.

Primary Adrenal Insufficiency (Addison's Disease) Associated with Systemic Lupus Erythematosus: A Rare Occurrence

Coexistence of Addison's disease and systemic lupus erythematosus (SLE) is a rare occurrence with only few reported cases in the literature. We describe a 29-year-old woman who presented to us with clinical features of acute Addisonian crisis and SLE. Laboratory investigations were confirmatory of Addison's disease in a background of SLE. The patient made remarkable improvement on administration of steroids as replacement therapy for adrenal insufficiency and treatment of SLE. Clinicians need to have a high-index of suspicion of this possible coexistence in order to avoid the associated deleterious hemodynamic and metabolic consequences.

The immunological basis of villitis of unknown etiology - review

Villitis of unknown etiology (VUE) represents a common placental inflammatory lesion, primarily, but not exclusively, identifiable T lymphocytes at term. Despite considerable evidence to contest that this simply represents a benign pathological finding, VUE remains a significantly undervalued diagnosis. Given its association with adverse pregnancy outcomes; including fetal growth restriction, preterm birth, and recurrent pregnancy loss, an increased awareness amongst clinician obstetricians is certainly warranted. The underlying immunopathogenesis of VUE remains uncertain. Despite initial theories that this represents an infectious placental lesion of undiagnosed pathogenic source, a more complex sequence of events involving the "breakdown" of maternal-fetal tolerance is emerging. Characterization of a unique inflammatory phenomenon in which both maternal and fetal T lymphocytes and Höfbauer cells interact has captivated particular research interest and has generated analogies to both the problems of allograft rejection and graft-versus-host disease (GvHD). Within the context of VUE, this review evaluates how disruption of the multidimensional immunological mechanisms underlying feto-maternal tolerance may permit abnormal lymphocyte infiltration into placental villi. We shall review the existing evidence for these events in VUE and outline areas of certain future interest.

Rescue and worsening of congenital heart block-associated electrocardiographic abnormalities in two transgenic mice

INTRODUCTION

Congenital heart block (CHB) is a passively acquired autoimmune disease considered to be due to the transfer of maternal autoantibodies, anti-SSA/Ro -SSB/La, to the fetus resulting in atrioventricular (AV) block and sinus bradycardia. We previously established a murine model for CHB where pups born to immunized wild-type (WT) mothers exhibited electrocardiographic abnormalities similar to those seen in CHB and demonstrated inhibition of L-type Ca channels (LTCCs) by maternal antibodies. Here, we hypothesize that overexpression of LTCC should rescue, whereas knockout of LTCC should worsen the electrocardiographic abnormalities in mice.

METHODS AND RESULTS

Transgenic (TG) mice were immunized with SSA/Ro and SSB/La antigens. Pups born to immunized WT mothers had significantly greater sinus bradycardia and AV block compared to pups from nonimmunized WT. TG pups overexpressing LTCC had significantly less sinus bradycardia and AV block compared to their non-TG littermates and to pups born to immunized WT mothers. All LTCC knockout pups born to immunized mothers had sinus bradycardia, advanced degree of AV block, and decreased fetal parity. No sinus bradycardia or AV block were manifested in pups from control nonimmunized WT mothers. IgG from mothers with CHB children, but not normal IgG, completely inhibited intracellular Ca transient ([Ca](i)T) amplitude.

CONCLUSIONS

Cardiac-specific overexpression of LTCC significantly reduced the incidence of AV block and sinus bradycardia in pups exposed to anti-SSA/Ro -SSB/La autoantibodies, whereas exposure of LTCC knockout pups to these autoantibodies significantly worsened the electrocardiographic abnormalities. These findings support the hypothesis that maternal antibodies inhibit LTCC and [Ca](i)T thus contributing to the development of CHB. Altogether, the results are relevant to the development of novel therapies for CHB.

B cells as a therapeutic target in autoimmune disease

Depleting B cells with anti-CD20 monoclonal antibodies emerges as a new therapeutic strategy in autoimmune diseases. Preliminary clinical studies suggest therapeutic benefits in patients with classic autoantibody-mediated syndromes, such as autoimmune cytopenias. Treatment responses in rheumatoid arthritis have opened the discussion about whether mechanisms beyond the removal of potentially pathogenic antibodies are effective in B-cell depletion. B cells may modulate T-cell activity through capturing and presenting antigens or may participate in the neogenesis of lymphoid microstructures that amplify and deviate immune responses. Studies exploring which mechanisms are functional in which subset of patients hold the promise of providing new and rational treatment approaches for autoimmune syndromes.