POS1059 ULTRASOUND SYNOVITIS, UNLIKE ENTHESITIS OR CLINICAL JOINT ASSESSMENT, IS ASSOCIATED WITH JOINT DAMAGE PROGRESSION IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

We previously reported that ultrasound assessment of enthesitis (US enthesitis) is not consistent with tenderness of the enthesis (clinical enthesitis) in patients with psoriatic arthritis (PsA). Although US enthesitis reflects inflammatory condition and clinical enthesitis is associated with disease activity and physical function, each of them was not associated with joint destruction by cross-sectional analysis1. It is reported that the utility of US for predicting joint destruction remains unclear among patients with PsA2.

Objectives:

This study is aimed to longitudinally investigate the relationships between enthesitis or synovitis and joint damage progression in patients with PsA.

Methods:

Forty-seven patients with PsA (average age of 56.5 years) underwent US and clinical examination of wrist and finger joints and 14 entheses (the bilateral humeral medial epicondyles and insertions of the triceps, distal quadriceps, proximal/distal patella, Achilles tendons, and plantar fascia). Tender or swollen joint count (TJC/SJC), Gray Scale (GS) and Power Doppler (PD) score of the joints, and US/clinical enthesitis counts were calculated. The relationships between the yearly progression in modified total sharp score (ΔmTSS) at two-time points (baseline and average follow-up of 20.4 months) and US or clinical findings were investigated.

Results:

ΔmTSS was significantly correlated with age (r=0.44, p=0.01), joint GS score (r=0.44, p=0.01), and joint PD score (r=0.38, p=0.03). TJC, SJC, inflammatory marker, and disease activity showed no associations with ΔmTSS. US/clinical enthesitis counts also showed no associations with ΔmTSS (Table 1). The joint PD score, adjusted by age, was significant factor for ΔmTSS by multiple regression analysis (b=0.50, p<0.001).

Conclusion:

The joint PD score or US synovitis, unlike clinical joint assessment, was significant predictive factor for joint damage progression. It is important to assess joints by US as well as clinical examination.

References:

1) Yutaro Yamada et al. Ultrasound assessment, unlike clinical assessment, reflects enthesitis in patients with psoriatic arthritis. Clin Exp Rheumatol. 2020 Apr 17. Online ahead of print.

2) van der Heijde et al. Assessing structural damage progression in psoriatic arthritis and its role as an outcome in research. Arthritis Res Ther. 2020, 22(1): 18.

Table 1.

Univariate analysis of predictive factors for joint damage progression in PsA patients.

mTSS at baselineΔmTSSR valuep valueR valuep valueage0.55<0.0010.440.01PASE0.040.810.120.52PASI-0.250.15-0.010.96DAS28CRP-0.050.750.070.71DAPSA-0.010.94-0.010.97HAQ0.170.27-0.070.73CRP-0.130.380.230.20MMP-30.040.800.290.12biologics use0.190.19-0.110.54Clinical enthesitis counts-0.010.97-0.190.30TJC-0.050.76-0.100.58SJC0.210.180.130.48US enthesitis counts0.120.44-0.130.48joint GS score0.080.600.440.01joint PD score0.080.600.380.03

PsA: psoriatic arthritis, mTSS: modified Total Sharp Score, PASE: Psoriatic Arthritis Screening and Evaluation, PASI: Psoriasis Area Severity Index, DAPSA: Disease Activity in Psoriatic Arthritis, DAS: Disease Activity Score, CRP: C-reactive protein, HAQ: Health Assessment Questionnaire, MMP-3: matrix metalloproteinase 3, TJC: tender joint counts, SJC: swollen joint counts, GS: Gray Scale, PD: Power Doppler

Disclosure of Interests:

Yutaro Yamada: None declared, Kentaro Inui Speakers bureau: Abbvie, Eisai, Eli Lilly, Grant/research support from: Abbvie, Eisai, Chigai, Eli Lilly, Daiichi Sankyo, Mitusbishi Tanabe, Pfizer, UCB, Tadashi Okano Speakers bureau: Abbvie, Koji Mandai: None declared, Kenji Mamoto: None declared, Tatsuya Koike Grant/research support from: Abbvie, Chugai, Chiharu Tateishi: None declared, Daisuke Tsuruta Speakers bureau: Abbvie, Astellas, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Sanofi, Grant/research support from: Abbvie, Eli Lilly, Bristol-Myers Squibb, UCB, Hiroaki Nakamura Grant/research support from: Astellas, Asahi Kasei

Detection of anti-type VII collagen IgE antibodies in epidermolysis bullosa acquisita

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is a rare pemphigoid disease involving autoantibodies to type VII collagen (COL7), a major structural component of anchoring fibrils. IgE autoantibodies to type XVII collagen (BP180) have been identified in bullous pemphigoid (BP), the prototype of pemphigoid diseases. Although the pathogenic relevance of IgG anti-COL7 has been investigated, that of IgE in EBA remains unclear.

OBJECTIVES

To reveal the presence and pathogenic relevance of IgE anti-COL7 in EBA.

METHODS

We examined IgE antibodies in 109 patients with EBA by indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA).

RESULTS

IIF with normal human skin revealed IgE reactivity in the basement membrane zone in 29 (26·6%) cases. To verify whether the IgE antibodies were specific to COL7, we performed IIF with 21 clearly positive cases and the skin of a patient with dystrophic EBA, which does not involve COL7. All cases showed negative results, indicating that IgE antibodies were specific to COL7. In a modified IgG COL7 ELISA for IgE, 16 (14·7%) cases were positive (three and 13 cases were negative and positive on IIF, respectively). We compared anti-COL7 IgG and IgE, and found a weak but significant correlation (r = 0·459, P < 0·001). EBA is clinically divided into a mechanobullous (MB; noninflammatory) type and an inflammatory (INF) type resembling BP. Of the IIF-positive cases, 11 of 30 (37%) had INF and nine of 48 (19%) had MB.

CONCLUSIONS

This study is the first to demonstrate the presence of circulating anti-COL7 IgE in patients with EBA, which may correlate with the clinical phenotype.

Analysis of treatment goal alignment between Japanese psoriasis patients and their paired treating physicians

Background

Appropriate goal‐oriented treatment strategies are important for optimal treatment outcomes and may prevent under‐treatment. As treatment goals vary by patient, a study to examine treatment goals is more meaningful when patients and their physicians are paired. There has not been any study that examines alignment between paired psoriasis patients and physicians in real‐world clinical practice using skin clearance as a treatment goal indicator.

Objectives

To evaluate treatment goal alignment between psoriasis patients and their paired physicians, and to quantitatively identify factors associated with goal misalignment.

Methods

The study was a nationwide multicenter cross‐sectional observational study. Subjects were physician‐reported moderate‐to‐severe psoriasis patients with a history of systemic treatments, directly paired with their treating physicians. Subjects completed surveys independently. Treatment goals included seven categories, and patient–physician pairs were grouped as ‘aligned’ or ‘misaligned’ when the answers were the same or different, respectively.

Results

A total of 425 pairs (mean response rate, 94.7%) of responses were collected from 54 sites (64.8% general practitioners or clinics; 35.2% university or large hospitals). Treatment goal misalignment was found in 67.9% of the patient–physician pairs. The misalignment was mainly ‘patient predominant’ (60.9%) indicating that patients had higher goals (‘complete clearance’) than physicians. In the multivariate logistic regression analyses, patients’ treatment expectation for ‘complete clearance’ [odds ratio (OR): 1.927; 95% confidential interval (CI): 1.232–3.016] and physician rating of ‘level of understanding on treatment options’ being low (OR: 1.552, 95% CI; 1.082–2.227) were significant factors for treatment goal misalignment.

Conclusions

The majority of treatment goal misalignment was found between paired psoriasis patients and their treating physicians in Japan. The most important contributing factors to misalignment were patients’ treatment expectation for ‘complete clearance’ and physicians’ rating of their patients’ ‘level of understanding on treatment options’ being low.

Detection of IgE autoantibodies to BP180 and BP230 and their relationship to clinical features in bullous pemphigoid

BACKGROUND

IgE autoantibodies are considered to be involved in the pathogenesis of bullous pemphigoid (BP), particularly inflammatory and erythematous phenotypes.

OBJECTIVES

To develop reliable enzyme-linked immunosorbent assays (ELISAs) for the detection of IgE autoantibodies to both BP180 and BP230 in BP sera, and to compare the ELISA results with clinical features.

METHODS

We used commercially available IgG ELISAs to develop IgE ELISAs for both BP180 and BP230. To determine the influence of excess amounts of IgG autoantibodies, all normal and BP sera were tested before and after IgG adsorption. The results of the IgE ELISAs were statistically compared with various ELISAs and various clinical parameters, including our own severity scores and BP phenotypes.

RESULTS

IgG adsorption generally showed no changes in sensitivity and specificity for IgE ELISAs, although slight cross-reactivity of anti-IgE secondary antibody to IgG and interference of excess amounts of IgG autoantibodies to IgE reactivity were suggested. IgE autoantibodies to BP180 were found in 21 of 36 BP sera and IgE autoantibodies to BP230 were found in 18 of 36 BP sera. The results of IgG and IgE ELISAs for both BP180 and BP230 were well correlated. IgG and IgE anti-BP180 antibodies correlated with disease activity but IgG and IgE anti-BP230 autoantibodies did not. IgE anti-BP230 autoantibodies correlated with nodular phenotype but not erythematous phenotype.

CONCLUSIONS

The results of this study indicated that IgE autoantibodies to both BP180 and BP230 are frequently detected in BP sera. IgE anti-BP180 autoantibodies seemed to be pathogenic, while an association between IgE autoantibodies and inflammatory BP phenotype was not indicated.

Anti-desmocollin autoantibodies in nonclassical pemphigus

BACKGROUND

Despite the established pathogenic role of anti-desmoglein (Dsg) antibodies in classical pemphigus, the significance of autoantibodies to another desmosomal cadherin, desmocollin (Dsc) is at present unknown. No consistent immunoassay for immunoglobulin (Ig) G autoantibodies to Dscs has been developed.

OBJECTIVES

The aim of this study was to develop reliable assays to detect anti-Dsc autoantibodies.

METHODS

We expressed soluble recombinant proteins (RPs) of human Dsc1-3 in mammalian cells and examined sera of various types of pemphigus, including 79 paraneoplastic pemphigus (PNP) sera, by novel enzyme-linked immunosorbent assays (ELISAs) using the RPs. We also performed ELISAs of Dsc baculoproteins and used the complementary DNA (cDNA) transfection method, and compared the results with those of mammalian ELISAs.

RESULTS

Through mammalian ELISAs, IgG autoantibodies to Dsc1, Dsc2 and Dsc3 were detected in 16.5%, 36.7% and 59.5% of PNP sera, respectively, and considerable numbers of pemphigus herpetiformis (PH) and pemphigus vegetans (PVeg) sera reacted strongly with Dsc1 and Dsc3. Mammalian ELISAs were highly specific and more sensitive than baculoprotein ELISAs or the cDNA transfection method. Several Dsc-positive sera, particularly PH sera, showed no reactivity with Dsgs. The reactivity of PNP serum and PVeg serum with Dscs was not abolished by pre-absorption with Dsg RPs.

CONCLUSIONS

The results of these novel ELISAs indicated that IgG anti-Dsc autoantibodies were frequently detected and potentially pathogenic in nonclassical pemphigus.

Necrotizing fasciitis caused by Cryptococcus neoformans in a patient with pemphigus vegetans

Cryptococcosis occurs most often in immunocompromised people. The cutaneous features of cryptococcosis include papules, pustules, nodules, subcutaneous swelling, abscesses, molluscum contagiosum-like or tumour-like lesions, cellulitis, blisters, ulcers and very rarely, necrotizing fasciitis (NF). NF is a destructive soft-tissue infection that is most typically caused by group A streptococci or by a combination of facultative and anaerobic bacteria. We present the case of a 55-year-old woman with pemphigus vegetans, who developed cryptococcal NF in the legs. She had been treated with immunosuppressants including plasmapheresis and pulse therapy with steroid and cyclophosphamide. Cryptococcal NF localized to the legs is very rare. Because diagnosis and treatment of cryptococcal infection is often delayed, clinicians should be aware of the possibility of cryptococcal infection when antibacterial therapy is not effective in an immunocompromised patient.

Induction of cutaneous delayed hypersensitivity reactions in mice sensitized with intragastrically administered hapten: activation of Langerhans cells in the sensitization and elicitation phases

BACKGROUND

As seen in atopic dermatitis, allergic diseases often produce lesions both in the gastrointestinal tract and the skin, suggesting the involvement of an immunological relationship between the two organs in the pathogenesis.

OBJECTIVES

To study the role of gastric and epidermal Langerhans cells (LCs) in the sensitization and elicitation phases, respectively, of cutaneous delayed-type hypersensitivity (DTH) reactions to intragastrically administered hapten.

METHODS

BALB/c mice, which were subjected to intragastric administration of trinitrochlorobenzene 5 days previously, received an elicitative challenge of the same hapten to the ear skin. Sections of the ear were immunostained for CD4 and CD8. Epidermal sheets of the ear and epithelial sheets of the forestomach were immunostained for I-A and observed under a confocal laser scanning microscope.

RESULTS

Cutaneous DTH reactions were induced in mice, as demonstrated by an increase in ear thickness and a prominent infiltration of CD4+ and CD8+ lymphocytes at 24-36 h after the elicitative challenge. In the elicitation phase, epidermal LCs showed a significant increase in size, indicating in vivo activation, at 24 h. In the sensitization phase, gastric LCs increased in size at 2 h, became round at 6 h, and decreased in number at 24 h, possibly representing the sequential events of LC activation and migration from the epithelium.

CONCLUSIONS

The present study demonstrated that gastric LCs and epidermal LCs were activated in vivo in the sensitization and elicitation phases, respectively, of cutaneous DTH reactions in orally sensitized mice.