Freeze-dried amniotic membrane graft with a spongy layer in bilateral peripheral ulcerative keratitis: a case report

BACKGROUND

Peripheral ulcerative keratitis (PUK) is a group of inflammatory corneal ulcers with stromal thinning and peripheral localization. Amniotic membranes (AM) are used for their anti-inflammatory and healing properties. A freeze-drying process now allows maintaining the AM viable for a long time at room temperature without altering its physical, biological, and morphologic characteristics. The effectiveness of spongy freeze-dried amniotic membrane (FD-AM) graft with multimodal imaging in the management of severe corneal thinning PUK has not been reported.

CASE PRESENTATION

A 67-year-old Caribbean man histologically diagnosed with ulcerative colitis, was referred to our tertiary eye care center for a deep nasal juxtalimbal ulcer of the left eye. He was treated with topical steroids and antibiotics, methylprednisolone pulses, and oral prednisone. Due to continuous stromal thinning with 100 μm of residual corneal thickness, the decision was made to perform surgery. Conjunctival resection, inlay and overlay spongy FD-AM (Visio Amtrix® S, Tissue Bank of France, FR) were performed to preserve globe integrity. Despite tapering off oral steroids, PUK developed in the fellow eye on the 2 months follow-up. Treatment with human monoclonal antibody against tumor necrosis factor-alpha was initiated to control the active underlying inflammation. Six months following surgery, the ulcer was healed and corneal thickness in front of the former ulceration was measured at 525 μm on anterior segment-optical coherence tomography. Confocal microscopy confirmed the integration of the amniotic membrane between the corneal epithelium and the anterior stroma.

CONCLUSION

Transplantation of FD-AM with a spongy layer was associated with restoration of normal corneal thickness in the PUK area. It seems to be a safe, effective, and easily accessible solution for the surgical management of PUK with impending perforation.

Iloprost Duration for Digital Ulcers in Systemic Sclerosis: French Retrospective Study at Two Centers and Literature Review

Objective

Ischemic digital ulcers (DUs) are frequent and severe complications of systemic sclerosis (SSc). Treatment options for SSc-related digital vasculopathy are based on aggressive vasodilation, with the objective to improve blood flow in ischemic areas. Intravenous prostanoids are recommended to treat active DUs. However, the level of evidence for the duration of 5 days is low. Therefore, the aim of this study was to determine whether prolonging the infusion beyond 5 days increases the rate of healing of active DUs in SSc.

Methods

This is an observational longitudinal retrospective bicenter study from 2000 to 2017. The objective was to compare the healing rate and time (defined by a healing of at least 50% of DUs) between two durations of iloprost administration: 5 days or less, or more than 5 days.

Results

Forty-one patients, with a mean age of 47 ± 15 years at diagnosis and 32 (78%) females have been included. Systemic sclerosis was diffuse in 10 (24%) cases and 13 (32%) had an interstitial lung disease. A total of 243 iloprost infusions for DUs were performed: 140 infusions for 5 days or less, and 103 infusions for more than 5 days (prolonged duration). Patients with active DUs which received >5 days of iloprost had higher modified Rodnan skin scale at the time of iloprost infusion (median 33 vs. 15; p < 0.05), more interstitial lung disease (44 vs. 27%; p < 0.05), more anti-topoisomerase I antibody positivity (59 vs. 44%; p < 0.05), and received more previous cyclophosphamide therapy (48 vs. 19%; p < 0.05). While the number of active DUs before iloprost infusion was not significantly different among those who received ≤5 days and >5 days of iloprost, the time to healing after iloprost infusion significantly decreased in SSc patients who received >5 days iloprost infusion: 48 [7–392] vs. 91 [9–365] days (p < 0.05). The proportion of SSc patients with healed DUs tended to increase in patients with >5 days iloprost infusion (log rank = 0.06). The number of patients with complete DU healing at day 90 was significantly increased in SSc who received >5 days of iloprost: 53 (51%) vs. 52 (37%) (p < 0.05). In addition, the time to healing was not significantly associated with the use of calcium channel blockers, endothelin receptor antagonists or a combination of PDE-5 inhibitors.

Conclusion

Prolonging duration of iloprost >5 days could improve the healing rate and the time to healing of SSc-related DUs. Prospective randomized studies are needed to confirm these data and define the optimal duration of iloprost therapy.

SAT0226 MINOR SALIVARY GLAND BIOPSY TO DIAGNOSE LYMPHOMA IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME

Background:

Non-Hodgkin B-cell lymphoma (NHL), especially mucosa-associated lymphoid tissue (MALT) lymphoma, is one of the main complications of primary Sjögren’s syndrome (pSS). Frequent extranodal lymphoproliferation makes its diagnosis challenging and obtaining a biopsy difficult. Since pSS-associated lymphomas are very frequently MALT lymphomas with salivary gland involvement, we hypothesized that minor salivary gland biopsy (MSGB) could be useful for NHL diagnosis in this context.

Objectives:

To evaluate the potential contribution of MSGB for the diagnosis of pSS-associated MALT lymphoma by comparing patients diagnosed with NHL based on MSGB or another tissue.

Methods:

All pSS patients (ACR/EULAR 2016 classification criteria), from the Paris National Referral Centers for Rare Systemic Autoimmune Diseases, diagnosed with NHL between January 2010 and October 2019, were included. Each patient’s clinical, biological, radiological and therapeutic information was collected retrospectively at NHL diagnosis and 1-year later. Only patients with MSGB available were analyzed; they were divided into 2 groups according to MSGB results for NHL: MSGB+and MSGB–.

Results:

Among 36 pSS patients diagnosed with NHL during the study period, 25 had an MSGB available at the time of NHL diagnosis. Among them, 13 MSGBs contained NHL (MSGB+). MSGB was the only site enabling NHL diagnosis for 10/13 (77%); pSS and NHL were diagnosed simultaneously in 4/13 (31%). MSBGs were NHL–for lymphomas diagnosed based on other tissue samples for 12 (48%) patients (MSGB–). The clinical, biological, histological and radiological characteristics of both groups are reported in Table 1. No major differences were found between groups for median ESSDAI at NHL diagnosis and the frequency of salivary gland hypermetabolism on PET-CT. MALT-type NHL was found in 24/25 (96%) patients including 13/13 (100%) of those MSGB+and 11/12 (92%) of those MSGB–. Six of the 13 (46%) MSGB+patients received no treatment, while all MSGB–patients were treated. Between diagnosis and 1 year of follow-up, ESSDAI scores without the NHL item did not differ (6.5 [3.5–9.5]) for the 6 untreated patients, but had significantly decreased for the 19 treated patients (3.5 [2.0–5.8]) (p=0.02).

Table 1.

Comparison of the pSS patients’ characteristics according to MSGB+vs. MSGB–for NHL

CharacteristicMSGB+, n=13MSGB–, n=12Female/male (ratio)12/1 (12)11/1 (11)Age at NHL diagnosis, yr60 (52–72)58 (49.5–69.8)pSS duration at NHL diagnosis, yr2.(0–9)3.5 (0.8–11)ESSDAI score without NHL item9 (6–16)10.(3.5–19.8)Cryoglobulinemia+9 (69)3/9 (33)Rheumatoid factor+9/11 (82)8/8 (100)Anti-SSA antibody+10 (77)7 (58)Anemia (Hb<12g/dL)2 (15)6/11 (55)Gammaglobulins, g/L12.4 (10.8–16.9)16.1 (12.3–20.0)Histology MALT-type lymphoma13 (100)11 (92) Diffuse-large B-cell lymphoma0 (0)1 (8)[18F]FDG-PET–CT, SUV max >4.7 Parotid or submandibular gland6/12 (50)3/10 (30) Lymph nodes1/12 (8)3/10 (30)

Results are presented as number (%) or median (IQR).

Conclusion:

Our results showed that, when MALT lymphoma is suspected, MSGB contributed to diagnosing NHL, either at initial assessment or during pSS evolution, enabling MALT lymphoma diagnosis in at least a third of NHL patients and >50% when MSGB was obtained systematically. Thus, MSGB might avoid the need for a more invasive procedure. Moreover, our findings suggest MSGB should be obtained at pSS diagnosis, and repeatedly during follow-up, when NHL, especially MALT, is suspected.

Disclosure of Interests:

Simon Parreau: None declared, Raphaèle Seror Consultant of: BMS UCB Pfizer Roche, Benjamin Terrier: None declared, Barbara Burroni: None declared, Céline Jamart: None declared, Alexis Régent: None declared, Gaetane Nocturne: None declared, Luc Mouthon: None declared, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Véronique LE GUERN Grant/research support from: UCB for GR2 study (to our institution)

Severe Attack of Henoch-Schönlein Purpura With Neurological Involvement During Adalimumab Treatment for Crohn's Disease

Tumour necrosis factor-α [TNF-α] inhibitors have revolutionised the management of chronic inflammatory conditions. A number of cutaneous adverse events have been reported with TNF inhibition, including vasculitis. Most reactions are mild and rarely warrant treatment withdrawal. Here we describe a patient with Crohn's disease treated with adalimumab in whom severe multivisceral Henoch-Schönlein purpura developed, including neurological involvement, requiring definitive TNF blocker withdrawal.

Cancer : maladie chronique ou chroniques d’une maladie ?

Considérer le cancer comme maladie chronique produit dans le discours qui la concerne des changements radicaux affectant l’approche clinique. Le concept psychanalytique de discours, tel qu’organisant les places dans le champ social, permet d’en éclairer le repérage. Mais « chronique » en tant que forme narrative linéarisée complexifie les temporalités en jeu. Temporalité chronologique du processus morbide et du traitement, temporalité freudienne rétroactive de l’après-coup, temporalité logique lacanienne de l’instant de voir, du temps pour comprendre et du moment de conclure. Un détour par les rites et leur fonction d’inscription corporelle singulière et collective introduit la temporalité du rythme comme mise en forme et en mouvement du sujet.

Effect of acute environmental hypoxia on protein metabolism in human skeletal muscle

Hypoxia-induced muscle wasting has been observed in several environmental and pathological conditions. However, the molecular mechanisms behind this loss of muscle mass are far from being completely elucidated, certainly in vivo. When studying the regulation of muscle mass by environmental hypoxia, many confounding factors have to be taken into account, such as decreased protein ingestion, sleep deprivation or reduced physical activity, which make difficult to know whether hypoxia per se causes a reduction in muscle mass.

AIM

We hypothesized that acute exposure to normobaric hypoxia (11% O2 ) would repress the activation of the mTOR pathway usually observed after a meal and would activate the proteolytic pathways in skeletal muscle.

METHODS

Fifteen subjects were exposed passively for 4 h to normoxic and hypoxic conditions in a random order after consumption of a light breakfast. A muscle biopsy and a blood sample were taken before, after 1 and 4 h of exposure.

RESULTS

After 4 h, plasma insulin concentration and the phosphorylation state of PKB and S6K1 in skeletal muscle were higher in hypoxia than in normoxia (P < 0.05). At the same time, Redd1 mRNA level was upregulated (P < 0.05), whilst MAFbx mRNA decreased (P < 0.05) in hypoxia compared with normoxia. Proteasome, cathepsin L and calpain activities were not altered by environmental hypoxia.

CONCLUSION

Contrary to our hypothesis and despite an increase in the mRNA level of Redd1, an inhibitor of the mTORC1 pathway, short-term acute environmental hypoxia induced a higher response of PKB and S6K1 to a meal, which may be due to increased plasma insulin concentration.