POS0013 SJÖGREN-LIKE SYNDROME, MULTIPLE AUTOIMMUNE DISEASES, THYMOMA AND GENETIC VARIANTS IN AIRE

Background

The autoimmune regulator gene AIRE is the main controlling factor for developing central immunotolerance. Variants in AIRE lead to autoimmunity and underly the autoimmune polyendocrine syndrome type 1 (APS-1 or APECED), defined by the clinical triad chronic mucocutaneous candiasis hypoparathyroidism and adrenal insufficiency.(1, 2) Manifold additional manifestation have been described, including Sjögren-like disease lacking the typical serology.(3) Furthermore, serological abnormalities, e.g. antibodies against IL-22, IL-17F and IFNώ are a hallmark of the disease. Due to the diversity in clinical manifestations and the genetic variants in AIRE, diagnosis is often delayed.

Objectives

Case report of a patient with 2 new variants in AIRE with diverse rheumatological and autoimmune disorders as well as thymoma.

Methods

Case report.

Results

The 38-year-old male patient was transferred to our clinic for immunoglobuline therapy, from his treating neurologist. His medical history included diabetes mellitus type 1, diagnosed in 1996, followed by Grave’s disease in 2000, culminating in a thyroidectomy in 2017. In 2009 he underwent a thymectomy for a thymoma. He had been treated with a series of immunosuppressive therapies including prednisolone, rituximab and mycophenolate, as well as plasmapheresis and immunopheresis for his atypical, seronegative myasthenia gravis. Due to the limited effect of the previous therapeutic regimen a trial with intravenous immunoglobulin had been initiated inducing clinical stabilization.

We diagnosed Sjogren-like syndrome based on sicca symptoms and a suspicious submandibular salivary gland in sonography, without typical serology. Family history was negative for autoimmune diseases. The clinical findings pointed towards immunodysregulation, prompting cytokine examination, lymphocyte phenotyping and genetic testing. Cytokines (IFNγ, IL-2, IL-4, IL-10, IL-17) under immunosuppression with 20 mg prednisolone and 2 g of mycophenolate were all low/below detection threshold. Flow cytometry showed no abnormalities except for a low CD20 (after Rituximab) and a slightly elevated T-reg count. Genetic testing revealed heterozygous variants in exon three (c.354C>G) and eight (c.927C>G) of AIRE. The patient´s mother showed the same genotype - indicating that the variants in the patient are in cis - but is asymptomatic. (Figure 1)

Figure 1.

Electropherograms of the heterozygous patient, his heterozygous, asymptomatic mother and his asymptomatic father, who has a wildtype of AIRE.

Conclusion

To our knowledge this is the first report of a patient with thymoma and genetic variant(s) in the AIRE gene displaying several autoimmune diseases. Although clinical similarities between thymoma patients and APECED / APS1 are known (4), a genetic link between these 2 diseases has not yet been described. As rheumatic autoimmunity can be induced by either, rheumatologists should be aware of these potentially underlying causes.

An additional point of interest is the lack of autoimmunity in the mother with the same genetic variants, which suggests an additional environmental trigger (e.g. smoking, viral infection) in the patient.

References

[1]Aaltonen J, Björses P, Perheentupa J, Horelli–Kuitunen N, Palotie A, Peltonen L, et al. An autoimmune disease, APECED, caused by mutations in a novel gene featuring two PHD-type zinc-finger domains. Nature Genetics. 1997;17(4):399-403.

[2]Ahonen P, Myllärniemi S, Sipilä I, Perheentupa J. Clinical variation of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in a series of 68 patients. N Engl J Med. 1990;322(26):1829-36.

[3]Ferre EM, Rose SR, Rosenzweig SD, Burbelo PD, Romito KR, Niemela JE, et al. Redefined clinical features and diagnostic criteria in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. JCI Insight. 2016;1(13).

[4]Wolff AS, Kärner J, Owe JF, Oftedal BE, Gilhus NE, Erichsen MM, et al. Clinical and serologic parallels to APS-I in patients with thymomas and autoantigen transcripts in their tumors. J Immunol. 2014;193(8):3880-90.

Disclosure of Interests

None declared

Additional heterologous versus homologous booster vaccination in immunosuppressed patients without SARS-CoV-2 antibody seroconversion after primary mRNA vaccination: a randomised controlled trial

OBJECTIVES

SARS-CoV-2-induced COVID-19 has led to exponentially rising mortality, particularly in immunosuppressed patients, who inadequately respond to conventional COVID-19 vaccination.

METHODS

In this blinded randomised clinical trial, we compare the efficacy and safety of an additional booster vaccination with a vector versus mRNA vaccine in non-seroconverted patients. We assigned 60 patients under rituximab treatment, who did not seroconvert after their primary mRNA vaccination with either BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna), to receive a third dose, either using the same mRNA or the vector vaccine ChAdOx1 nCoV-19 (Oxford-AstraZeneca). Patients were stratified according to the presence of peripheral B cells. The primary efficacy endpoint was the difference in the SARS-CoV-2 antibody seroconversion rate between vector (heterologous) and mRNA (homologous) vaccinated patients by week 4. Key secondary endpoints included the overall seroconversion and cellular immune response; safety was assessed at week 1 and week 4.

RESULTS

Seroconversion rates at week 4 were comparable between vector (6/27 patients, 22%) and mRNA (9/28, 32%) vaccines (p=0.6). Overall, 27% of patients seroconverted; specific T cell responses were observed in 20/20 (100%) vector versus 13/16 (81%) mRNA vaccinated patients. Newly induced humoral and/or cellular responses occurred in 9/11 (82%) patients. 3/37 (8%) of patients without and 12/18 (67%) of the patients with detectable peripheral B cells seroconverted. No serious adverse events, related to immunisation, were observed.

CONCLUSIONS

This enhanced humoral and/or cellular immune response supports an additional booster vaccination in non-seroconverted patients irrespective of a heterologous or homologous vaccination regimen.

HFE hemochromatosis screening in patients with severe hip osteoarthritis: A prospective cross-sectional study

OBJECTIVE

Despite the high frequency of HFE gene mutations in Western Europe, widespread screening for HFE hemochromatosis is not recommended due to its variable phenotype. Joint pain and a premature osteoarthritis-like disease including the hip joints are the most frequent manifestation in patients with HFE hemochromatosis and iron overload. Therefore, screening of patients with severe osteoarthritis of the hip could identify patients with HFE hemochromatosis.

METHODS

In this prospective cross-sectional study, 940 patients aged <70 years with end-stage osteoarthritis of the hip undergoing elective joint replacement surgery were screened for HFE hemochromatosis and compared to age- and sex-matched controls.

RESULTS

No greater prevalence of C282Y homozygosity mutation or elevated serum ferritin or transferrin saturation levels was found in the study cohort with severe osteoarthritis of the hip than in controls from the general population.

CONCLUSION

Our screening approach could not identify an increased prevalence of HFE gene mutations and iron overload in younger patients with severe osteoarthritis of the hip.

Relations of vitamin D status, gender and type 2 diabetes in middle-aged Caucasians

Vitamin D (Vit D) deficiency may be linked to the development of obesity-associated complications such as insulin resistance and type 2 diabetes. We therefore evaluated the relationship of Vit D serum concentrations with metabolic parameters and type 2 diabetes in middle-aged Caucasian men and women. One thousand six hundred and thirty-one Caucasians (832 males, 58.8 ± 9.7 years; 799 females, 59.7 ± 10.7 years) were evaluated in a cross-sectional study. Vit D status was assessed by measuring the serum concentration of 25-hydroxyvitamin D3 [25(OH)D3]. Type 2 diabetes prevalence was ascertained by medical history, fasting plasma glucose concentrations, oral glucose tolerance testing and/or glycosylated hemoglobin. Men displayed higher crude or seasonally adjusted 25(OH)D3 serum concentrations than women (24.64 ± 10.98 vs. 22.88 ± 11.6 ng/ml; P < 0.001). Strong associations between body mass index (BMI) and 25(OH)D3 were observed in both genders (P < 0.001). Seasonally adjusted levels of 25(OH)D3 revealed stronger associations with type 2 diabetes in women than men (P < 0.001). However, adjustment for BMI and other confounding variables revealed an independent inverse association of 25(OH)D3 with diabetes only in women (P < 0.001), whereas the association was abrogated in men. Using a 15 ng/ml 25(OH)D3 cutoff for binary comparison, adjusted odds ratios for having newly diagnosed or known type 2 diabetes more than doubled (2.95 [95 % CI 1.37-4.89] and 3.26 [1.59-6.68], respectively), in women below the cutoff. We conclude that in women, but not in men, low 25(OH)D3 serum levels are independently associated with type 2 diabetes. These findings suggest sex-specific effects of Vit D in the pathogenesis of type 2 diabetes.

Gender- and site-specific differences of colorectal neoplasia relate to vitamin D

BACKGROUND

The effect of vitamin D on colorectal adenomas may vary with regard to gender, localisation and histological type of the lesion.

AIM

To define the role of vitamin D and gender in a Caucasian cohort of subjects undergoing screening colonoscopy after consideration of established risk factors.

METHODS

One thousand five hundred and thirty-two subjects (813 males, 58.8 ± 9.7 years; 719 females, 59.7 ± 10.7 years) were allocated to tertiles of 25-hydroxyvitamin D3 [25(OH)D3 ] serum concentrations. The number, localisation, size and histology of the detected colonic lesions were recorded.

RESULTS

Among men, no association was found between vitamin D and the total number, size and histological stage of adenomas at any site. In female subjects, less women with adenomas were found in the highest vitamin D tertile (N = 42/239; 17.2%) as compared to the low vitamin D group (N = 60/240; 25.0%; P = 0.035). In particular, the number of women with adenomas in the proximal colon was significantly lower in the highest tertile (N = 21/239, 8.8%) compared to the low vitamin D group (N = 41/240; 17.1%; P = 0.007). The rates at other sites were not different. The inverse association of vitamin D serum concentrations with the presence of adenomas in the proximal colon was maintained after adjustment for potential confounders. In 80 women on vitamin D supplementation, the rate of adenomas was lower compared to those not on supplementation (3/80; 3.8%; vs. 90/719; 12.5%; P = 0.016).

CONCLUSIONS

A potential preventive effect of vitamin D on colorectal adenomas was found in the proximal colon in women. This observation is supported by further decrease of lesions in the proximal colon of women on vitamin D supplementation.

HFE-related hemochromatosis: an update for the rheumatologist

Hereditary hemochromatosis is a frequent disease in Caucasian populations. It leads to progressive iron overload in a variety of organs. The most common cause is the C282Y homozygous mutation in the HFE gene. The classical triad of skin hyperpigmentation, diabetes, and liver cirrhosis is nowadays rare but musculoskeletal symptoms are common in HFE-related hemochromatosis. Typically the second and third metacarpophalangeal joints, and the wrist, hip, and ankle joints are affected. Clinical symptoms include osteoarthritis-like symptoms, pseudogout attacks, and synovitis sometimes resembling rheumatoid arthritis. Radiographs show degenerative changes with joint space narrowing, osteophytes, and subchondral cysts. Chondrocalcinosis in the wrist and knee joints is seen in up to 50 % of patients. Although most other organ manifestations regress during phlebotomy, musculoskeletal symptoms often persist or even become worse. Importantly, patients are at an increased risk of severe large-joint arthritis necessitating joint replacement surgery. Therefore, future research should focus on the pathogenesis and treatment options for HH arthropathy.

VCAM-1 serum levels are associated with arthropathy in hereditary haemochromatosis

OBJECTIVES

The aim of this study was to assess the role of vascular adhesion molecule 1 (VCAM-1) in patients with hereditary haemochromatosis (HH) with or without arthropathy.

METHODS

Sera from a large cross-sectional cohort of unselected HH patients (n=147) were obtained and compared to an age-matched and sex-matched control group. Serum levels of VCAM-1 were measured by ELISA and were correlated with clinical measures.

RESULTS

VCAM-1 serum levels were elevated in HH patients as compared to matched controls (mean 913±456 vs 654±451 ng/ml, p<0.0001). Within the HH patient group, VCAM-1 levels were much higher in patients with arthropathy and joint replacement surgery. VCAM-1 levels correlated well with radiographic measures of HH arthropathy (r=0.36, p<0.0001). Multivariate regression analysis confirmed a highly significant association of VCAM-1 serum levels and the presence of HH arthropathy, independent from diabetes, body mass index and age.

CONCLUSIONS

VCAM-1 serum levels emerge as a biomarker for haemochromatosis arthropathy.

Premature osteoarthritis as presenting sign of type II collagenopathy: a case report and literature review

OBJECTIVES

Osteoarthritis (OA) is a frequent, chronic, and often disabling disease. Early-onset OA should prompt rheumatologists to search for underlying causes. We describe the clinical presentation and diagnosis of a patient with severe premature OA.

METHODS

We report a patient with severe polyarticular OA starting in young adulthood due to a heterozygous mutation in the COL2A1 gene. We discuss the clinical features, diagnosis, and known mutations of previously reported cases identified through a PubMed literature review.

RESULTS

A 43-year-old Caucasian woman of normal stature presented with a 24-year history of symmetrical polyarticular OA involving both large and small joints. At the time of presentation, the patient already underwent 6 joint replacement surgeries. Family history was unremarkable. Clinical, serologic, radiographic, and histologic studies did not reveal any specific cause for this unusual clinical presentation. Genetic analysis revealed a heterozygous COL2A1 mutation (R519C) consistent with the clinical phenotype. Reviewing the literature, we discuss the clinical spectrum of type II collagenopathies emphasizing premature OA as the sole clinical manifestation.

CONCLUSIONS

Unusual clinical presentations of OA should prompt investigations to search for an underlying cause. Type II collagenopathy should be considered in young adults with severe symmetrical OA even in the absence of other clinical features. A correct diagnosis allows classification and genetic counseling of the patient.