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Rivellese F, Nerviani A, Giorli G, Warren L, Jaworska E, Bombardieri M, Lewis MJ, Humby F, Pratt AG, Filer A, Gendi N, Cauli A, Choy E, McInnes I, Durez P, Edwards CJ, Buch MH, Gremese E, Taylor PC, Ng N, Cañete JD, Raizada S, McKay ND, Jadon D, Sainaghi PP, Stratton R, Ehrenstein MR, Ho P, Pereira JP, Dasgupta B, Gorman C, Galloway J, Chinoy H, van der Heijde D, Sasieni P, Barton A, Pitzalis C. Stratification of biological therapies by pathobiology in biologic-naive patients with rheumatoid arthritis (STRAP and STRAP-EU): two parallel, open-label, biopsy-driven, randomised trials. Lancet Rheumatol 2023; 5:e648-e659. [PMID: 38251532 DOI: 10.1016/s2665-9913(23)00241-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Despite highly effective targeted therapies for rheumatoid arthritis, about 40% of patients respond poorly, and predictive biomarkers for treatment choices are lacking. We did a biopsy-driven trial to compare the response to rituximab, etanercept, and tocilizumab in biologic-naive patients with rheumatoid arthritis stratified for synovial B cell status. METHODS STRAP and STRAP-EU were two parallel, open-label, biopsy-driven, stratified, randomised, phase 3 trials done across 26 university centres in the UK and Europe. Biologic-naive patients aged 18 years or older with rheumatoid arthritis based on American College of Rheumatology (ACR)-European League Against Rheumatism classification criteria and an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (DMARDs) were included. Following ultrasound-guided synovial biopsy, patients were classified as B cell poor or B cell rich according to synovial B cell signatures and randomly assigned (1:1:1) to intravenous rituximab (1000 mg at week 0 and week 2), subcutaneous tocilizumab (162 mg per week), or subcutaneous etanercept (50 mg per week). The primary outcome was the 16-week ACR20 response in the B cell-poor, intention-to-treat population (defined as all randomly assigned patients), with data pooled from the two trials, comparing etanercept and tocilizumab (grouped) versus rituximab. Safety was assessed in all patients who received at least one dose of study drug. These trials are registered with the EU Clinical Trials Register, 2014-003529-16 (STRAP) and 2017-004079-30 (STRAP-EU). FINDINGS Between June 8, 2015, and July 4, 2019, 226 patients were randomly assigned to etanercept (n=73), tocilizumab (n=74), and rituximab (n=79). Three patients (one in each group) were excluded after randomisation because they received parenteral steroids in the 4 weeks before recruitment. 168 (75%) of 223 patients in the intention-to-treat population were women and 170 (76%) were White. In the B cell-poor population, ACR20 response at 16 weeks (primary endpoint) showed no significant differences between etanercept and tocilizumab grouped together and rituximab (46 [60%] of 77 patients vs 26 [59%] of 44; odds ratio 1·02 [95% CI 0·47-2·17], p=0·97). No differences were observed for adverse events, including serious adverse events, which occurred in six (6%) of 102 patients in the rituximab group, nine (6%) of 108 patients in the etanercept group, and three (4%) of 73 patients in the tocilizumab group (p=0·53). INTERPRETATION In this biologic-naive population of patients with rheumatoid arthrtitis, the dichotomic classification into synovial B cell poor versus rich did not predict treatment response to B cell depletion with rituximab compared with alternative treatment strategies. However, the lack of response to rituximab in patients with a pauci-immune pathotype and the higher risk of structural damage progression in B cell-rich patients treated with rituximab warrant further investigations into the ability of synovial tissue analyses to inform disease pathogenesis and treatment response. FUNDING UK Medical Research Council and Versus Arthritis.
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Affiliation(s)
- Felice Rivellese
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust and Barts Biomedical Research Centre, National Institute for Health and Care Research (NIHR), London, UK
| | - Alessandra Nerviani
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust and Barts Biomedical Research Centre, National Institute for Health and Care Research (NIHR), London, UK
| | - Giovanni Giorli
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Louise Warren
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Edyta Jaworska
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Michele Bombardieri
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust and Barts Biomedical Research Centre, National Institute for Health and Care Research (NIHR), London, UK
| | - Myles J Lewis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust and Barts Biomedical Research Centre, National Institute for Health and Care Research (NIHR), London, UK
| | - Frances Humby
- Barts Health NHS Trust and Barts Biomedical Research Centre, National Institute for Health and Care Research (NIHR), London, UK; Rheumatology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Directorate of Musculoskeletal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Filer
- Rheumatology Research Group, Institute for Inflammation and Ageing, NIHR Birmingham Biomedical Research Centre and Clinical Research Facility, University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Nagui Gendi
- Basildon University Hospital, Basildon and Thurrock University NHS Hospitals Foundation Trust, Basildon, UK
| | - Alberto Cauli
- Rheumatology Unit, AOU and University of Cagliari, Monserrato, Italy; UOC of Radiology, Ospedale SS Trinità, ATS Cagliari, Italy
| | - Ernest Choy
- CREATE Centre, Cardiff University, Cardiff, UK; Department of Rheumatology, University Hospital of Wales, Cardiff, UK
| | - Iain McInnes
- Glasgow Clinical Research Facility, Glasgow Royal Infirmary, Glasgow, UK
| | - Patrick Durez
- Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium; Department of Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Christopher J Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK
| | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Elisa Gremese
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Nora Ng
- Rheumatology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Juan D Cañete
- Rheumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pí I Sunyer, Barcelona, Spain
| | - Sabrina Raizada
- New Cross Hospital and Cannock Chase Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Neil D McKay
- Edinburgh Rheumatology Research Group and Rheumatic Diseases Unit, NHS Lothian, Edinburgh, UK
| | - Deepak Jadon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Pier Paolo Sainaghi
- Department of Rheumatology, University Eastern Piedmont and Maggiore della Carita Hospital, Novara, Italy
| | - Richard Stratton
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | | | - Pauline Ho
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Joaquim P Pereira
- Rheumatology Department, Hospital De Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-Sea, UK
| | - Claire Gorman
- Department of Rheumatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, UK
| | - James Galloway
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Hector Chinoy
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | | | - Peter Sasieni
- King's Clinical Trials Unit, Kings College London, London, UK
| | - Anne Barton
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust and Barts Biomedical Research Centre, National Institute for Health and Care Research (NIHR), London, UK; IRCCS Humanitas Research Hospital, Milan, Italy.
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Rivellese F, Surace AEA, Goldmann K, Sciacca E, Çubuk C, Giorli G, John CR, Nerviani A, Fossati-Jimack L, Thorborn G, Ahmed M, Prediletto E, Church SE, Hudson BM, Warren SE, McKeigue PM, Humby F, Bombardieri M, Barnes MR, Lewis MJ, Pitzalis C. Rituximab versus tocilizumab in rheumatoid arthritis: synovial biopsy-based biomarker analysis of the phase 4 R4RA randomized trial. Nat Med 2022; 28:1256-1268. [PMID: 35589854 PMCID: PMC9205785 DOI: 10.1038/s41591-022-01789-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/21/2022] [Indexed: 12/29/2022]
Abstract
Patients with rheumatoid arthritis (RA) receive highly targeted biologic therapies without previous knowledge of target expression levels in the diseased tissue. Approximately 40% of patients do not respond to individual biologic therapies and 5-20% are refractory to all. In a biopsy-based, precision-medicine, randomized clinical trial in RA (R4RA; n = 164), patients with low/absent synovial B cell molecular signature had a lower response to rituximab (anti-CD20 monoclonal antibody) compared with that to tocilizumab (anti-IL6R monoclonal antibody) although the exact mechanisms of response/nonresponse remain to be established. Here, in-depth histological/molecular analyses of R4RA synovial biopsies identify humoral immune response gene signatures associated with response to rituximab and tocilizumab, and a stromal/fibroblast signature in patients refractory to all medications. Post-treatment changes in synovial gene expression and cell infiltration highlighted divergent effects of rituximab and tocilizumab relating to differing response/nonresponse mechanisms. Using ten-by-tenfold nested cross-validation, we developed machine learning algorithms predictive of response to rituximab (area under the curve (AUC) = 0.74), tocilizumab (AUC = 0.68) and, notably, multidrug resistance (AUC = 0.69). This study supports the notion that disease endotypes, driven by diverse molecular pathology pathways in the diseased tissue, determine diverse clinical and treatment-response phenotypes. It also highlights the importance of integration of molecular pathology signatures into clinical algorithms to optimize the future use of existing medications and inform the development of new drugs for refractory patients.
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Affiliation(s)
- Felice Rivellese
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anna E A Surace
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katriona Goldmann
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Elisabetta Sciacca
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Cankut Çubuk
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Giovanni Giorli
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christopher R John
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alessandra Nerviani
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Liliane Fossati-Jimack
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgina Thorborn
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Manzoor Ahmed
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Edoardo Prediletto
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | | | - Paul M McKeigue
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Frances Humby
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michele Bombardieri
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael R Barnes
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Myles J Lewis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Rivellese F, Cubuk C, Surace A, Goldmann K, Sciacca E, Giorli G, Nerviani A, Fossati-Jimack L, Thorborn G, Bombardieri M, Barnes M, Lewis M, Pitzalis C. OP0085 CELL LINEAGE-SPECIFIC TRANSCRIPT DECONVOLUTION OF SYNOVIAL BIOPSIES FROM THE R4RA TRIAL IDENTIFIES CELL POPULATIONS ASSOCIATED WITH RESPONSE TO RITUXIMAB AND TOCILIZUMAB. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundThe R4RA trial, the first biopsy-based randomised trial in TNF-i inadequate responder patients with Rheumatoid Arthritis, showed that molecular stratification of RA synovial tissue was associated with clinical response, demonstrating that, in patients with low/absent B-cell lineage signature in synovial-tissue, tocilizumab is superior to rituximab1.ObjectivesHere, we aimed to perform cell-transcript deconvolution of pre-and post-treatment synovial biopsies from the R4RA trial.MethodsA total of 164 patients underwent pre-treatment synovial biopsy (US-guided or arthroscopic) prior to randomization 1:1 to rituximab (83) or tocilizumab (81). 65 patients had a repeat biopsy at 16 weeks when clinical response was assessed using Clinical Disease Activity Index (CDAI) 50% improvement. RNA extracted from a minimum of 6 synovial samples/patient underwent RNA-sequencing and the abundance of tissue-infiltrating immune and stromal cell populations was estimated using the Microenvironment Cell Populations-counter (MCP-counter) method (Figure 1a).ResultsAt baseline, while synovial semiquantitative immunohistochemistry scores did not differ between CDAI50% responders and non-responders, both for rituximab and tocilizumab, MCP-counter analysis showed significantly higher CD8 T-cells in responders to rituximab and higher macrophage-monocytes and myeloid dendritic cells (mDC) in responders to tocilizumab (Figure 1b). Moreover, when patients were classified according to MCP-counter scores, B-cell poor patients (MCP-counter B cell score <median value) showed significantly higher response rates to tocilizumab, while no difference was found in B-cell rich patients (Figure 1c). In contrast, macrophage and myeloid dendritic cell (mDC) rich individuals showed higher responses to tocilizumab (Figure 1d). Combined scores for lymphoid and myeloid cells demonstrated that patients poor in B-cells but rich in macrophages/mDC had a significantly higher response to tocilizumab (77% responders to tocilizumab vs 14% responders to rituximab, p=0.017, OR 16.48, 95%CI 1.29-1000.5) (Figure 1e). By analysing disease activity over time from baseline to week 16, we found a statistically significant interaction effect between treatments and time in B-cell poor (p=0.003), T-cell poor (p=0.022), mDC rich (p=0.029) and B-cell poor/Macrophages-mDC rich patients (p=0.006) (Figure 1f-g-h). Finally, by applying MCP-counter on matched pre-and post-treatment biopsies, rituximab-treated patients showed a significant reduction of B-cells, T-cells and monocyte/macrophages, while tocilizumab-treated patients showed a significant reduction of monocyte/macrophages, T-cells, but also neutrophils, myeloid dendritic cells and, interestingly, an increase in fibroblast signature (Figure 1i).ConclusionIn silico deconvolution of the synovial tissue identify pre-treatment lymphoid cell lineages associated with response to rituximab and myeloid cells for tocilizumab. The longitudinal analysis of matched pre- and post-treatment synovial biopsies indicated that both medications have an effect on synovial immune cells, but tocilizumab can also affect stromal cells.References[1]Humby et al. Rituximab versus tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis (R4RA): 16-week outcomes of a stratified, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial Lancet. 2021 Jan 23;397(10271):305-317. doi: 10.1016/S0140-6736(20)32341-2.AcknowledgementsWe would like to thank all patients and the R4RA recruiting centres and principal investigators http://www.r4ra-nihr.whri.qmul.ac.uk/recruiting_centres.php We would also like to acknowledge the UK National Institute of Health Research for funding the R4RA trial (grant reference: 11/100/76) and Versus Arthritis for providing infrastructure support through the Experimental Arthritis Treatment Centre (grant number: 20022).Disclosure of InterestsNone declared.
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Surace A, Sciacca E, Goldmann K, Rivellese F, Cubuk C, Giorli G, Fossati-Jimack L, Ahmed M, Prediletto E, Bombardieri M, Lewis M, Pitzalis C. OP0077 SYNOVIAL RNA-SEQ ANALYSIS OF THE R4RA TRIAL IDENTIFIES SIGNATURES OF TREATMENT RESISTANCE AND REFRACTORY STATE IN RHEUMATOID ARTHRITIS. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundAlthough up to 5-20% of rheumatoid arthritis (RA) patients do not respond to all current medications including biologic therapies, relatively little is known about the underlying pathogenic mechanisms driving non-response. In the first biopsy-driven randomized clinical trial in RA (R4RA)1, patients, in whom synthetic-DMARDs and at least one anti-TNF drug were not effective, were randomised 1:1 to rituximab (RTX) or tocilizumab (TOC) with a balanced stratification based on their synovial B-cell rich/poor signature, and response was assessed at 16 weeks. Non-responders were subsequently allowed to switch to the alternative drug with 48-week follow-up.ObjectivesInvestigate mechanisms of response and non-response to RTX and TOC through deep molecular (RNA-Sequencing) profiling of synovial tissue.MethodsRNA-Seq from baseline synovial tissue biopsies of patients who received RTX (n=88) or TOC (n=94) at any point in the trial was analysed for differentially expressed genes and associated modules between responders and non-responders. Response was defined as 50% improvement in clinical disease activity index (CDAI) score. Patients who had received both drugs during the trial were subdivided into RTX only responders (pro-RTX, n=9), TOC only responders (pro-TOC, n=12) and refractory patients (no response to both RTX & TOC, n=32) and analysed for differential gene expression and performed gene module analysis.Results6625 genes were significantly differentially expressed between RTX responders compared to non-responders, with a predominance of antigen presentation as well as T- and B-cell genes being associated with response, while non-response was linked to fibroblast associated genes. Comparison between TOC responders and non-responders identified fewer (85) differentially expressed genes, however lymphocyte and immunoglobulin genes were also high in the synovial tissue of TOC responders similar to RTX responders, while non-responder genes and modules also included a fibroblast signature.The cross-over study design enabled comparison of rituximab-specific responders (pro-RTX), tocilizumab-specific responders (pro-TOC) and refractory patients (non-responders to both RTX & TOC, n=32) in a 3-way analysis (see Figure 1). This identified 1980 genes upregulated both in pro-RTX and pro-TOC patients, 175 genes exclusive to the pro-RTX group and 306 to the pro-TOC group, while 1277 genes were exclusive to the refractory group. While leukocyte modules and genes dominated RTX & TOC response, the refractory state was strongly associated with fibroblast genes and modules. We confirmed the observed expansion of fibroblasts from the RNA-Seq data by immunohistochemistry showing the presence of DKK3+ sublining fibroblasts in refractory rather than responder patients.ConclusionWe provide novel insights into the cellular and molecular pathways underpinning multi-biologic resistance that define a refractory RA phenotype, characterised by a stromal/fibroblast signature.References[1]Humby, F., et al. Lancet (2021)AcknowledgementsWe would like to thank all patients and the R4RA recruiting centres and principal investigators http://www.r4ra-nihr.whri.qmul.ac.uk/recruiting_centres.php We would also like to acknowledge the UK National Institute of Health Research for funding the R4RA trial (grant reference: 11/100/76) and Versus Arthritis for providing infrastructure support through the Experimental Arthritis Treatment Centre (grant number: 20022).Disclosure of InterestsNone declared.
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Humby F, Durez P, Buch MH, Lewis MJ, Rizvi H, Rivellese F, Nerviani A, Giorli G, Mahto A, Montecucco C, Lauwerys B, Ng N, Ho P, Bombardieri M, Romão VC, Verschueren P, Kelly S, Sainaghi PP, Gendi N, Dasgupta B, Cauli A, Reynolds P, Cañete JD, Moots R, Taylor PC, Edwards CJ, Isaacs J, Sasieni P, Choy E, Pitzalis C. Rituximab versus tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis (R4RA): 16-week outcomes of a stratified, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial. Lancet 2021; 397:305-317. [PMID: 33485455 PMCID: PMC7829614 DOI: 10.1016/s0140-6736(20)32341-2] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although targeted biological treatments have transformed the outlook for patients with rheumatoid arthritis, 40% of patients show poor clinical response, which is mechanistically still unexplained. Because more than 50% of patients with rheumatoid arthritis have low or absent CD20 B cells-the target for rituximab-in the main disease tissue (joint synovium), we hypothesised that, in these patients, the IL-6 receptor inhibitor tocilizumab would be more effective. The aim of this trial was to compare the effect of tocilizumab with rituximab in patients with rheumatoid arthritis who had an inadequate response to anti-tumour necrosis factor (TNF) stratified for synovial B-cell status. METHODS This study was a 48-week, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial (rituximab vs tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis; R4RA) done in 19 centres across five European countries (the UK, Belgium, Italy, Portugal, and Spain). Patients aged 18 years or older who fulfilled the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for rheumatoid arthritis and were eligible for treatment with rituximab therapy according to UK National Institute for Health and Care Excellence guidelines were eligible for inclusion in the trial. To inform balanced stratification, following a baseline synovial biopsy, patients were classified histologically as B-cell poor or rich. Patients were then randomly assigned (1:1) centrally in block sizes of six and four to receive two 1000 mg rituximab infusions at an interval of 2 weeks (rituximab group) or 8 mg/kg tocilizumab infusions at 4-week intervals (tocilizumab group). To enhance the accuracy of the stratification of B-cell poor and B-cell rich patients, baseline synovial biopsies from all participants were subjected to RNA sequencing and reclassified by B-cell molecular signature. The study was powered to test the superiority of tocilizumab over rituximab in the B-cell poor population at 16 weeks. The primary endpoint was defined as a 50% improvement in Clinical Disease Activity Index (CDAI50%) from baseline. The trial is registered on the ISRCTN database, ISRCTN97443826, and EudraCT, 2012-002535-28. FINDINGS Between Feb 28, 2013, and Jan 17, 2019, 164 patients were classified histologically and were randomly assigned to the rituximab group (83 [51%]) or the tocilizumab group (81 [49%]). In patients histologically classified as B-cell poor, there was no statistically significant difference in CDAI50% between the rituximab group (17 [45%] of 38 patients) and the tocilizumab group (23 [56%] of 41 patients; difference 11% [95% CI -11 to 33], p=0·31). However, in the synovial biopsies classified as B-cell poor with RNA sequencing the tocilizumab group had a significantly higher response rate compared with the rituximab group for CDAI50% (rituximab group 12 [36%] of 33 patients vs tocilizumab group 20 [63%] of 32 patients; difference 26% [2 to 50], p=0·035). Occurrence of adverse events (rituximab group 76 [70%] of 108 patients vs tocilizumab group 94 [80%] of 117 patients; difference 10% [-1 to 21) and serious adverse events (rituximab group 8 [7%] of 108 vs tocilizumab group 12 [10%] of 117; difference 3% [-5 to 10]) were not significantly different between treatment groups. INTERPRETATION The results suggest that RNA sequencing-based stratification of rheumatoid arthritis synovial tissue showed stronger associations with clinical responses compared with histopathological classification. Additionally, for patients with low or absent B-cell lineage expression signature in synovial tissue tocilizumab is more effective than rituximab. Replication of the results and validation of the RNA sequencing-based classification in independent cohorts is required before making treatment recommendations for clinical practice. FUNDING Efficacy and Mechanism Evaluation programme from the UK National Institute for Health Research.
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Affiliation(s)
- Frances Humby
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK; Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Patrick Durez
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
| | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal & Dermatological Sciences, The University of Manchester, Manchester, UK; National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, Manchester, UK
| | - Myles J Lewis
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK; Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Hasan Rizvi
- Institute of Health Sciences Education, Queen Mary University of London, London, UK; Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | - Felice Rivellese
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK; Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Alessandra Nerviani
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK; Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Giovanni Giorli
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK
| | - Arti Mahto
- Department of Rheumatology, Kings College Hospital NHS Foundation Trust, London, UK
| | - Carlomaurizio Montecucco
- Department of Rheumatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Bernard Lauwerys
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
| | - Nora Ng
- Rheumatology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Pauline Ho
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michele Bombardieri
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK; Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Vasco C Romão
- Rheumatology Department, Hospital De Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Patrick Verschueren
- Skeletal Biology and Engineering Research Centre, Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium; Division of Rheumatology, University Hospital Leuven, Leuven, Belgium
| | - Stephen Kelly
- Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Pier Paolo Sainaghi
- Department of Rheumatology, University of Eastern Piedmont and Maggiore della Carita Hospital, Novara, Italy
| | - Nagui Gendi
- Rheumatology Department, Basildon Hospital, Basildon, UK
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid & South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-Sea, UK
| | - Alberto Cauli
- Rheumatology Unit, Department of Medicine and Public Health, Azienda Ospedaliero-Universitaria and University of Cagliari, Monserrato, Italy
| | - Piero Reynolds
- Department of Rheumatology, Homerton University Hospital, London, UK
| | - Juan D Cañete
- Rheumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pí I Sunyer, Barcelona, Spain
| | - Robert Moots
- Academic Rheumatology Unit, Aintree University Hospital, Liverpool, UK; Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Christopher J Edwards
- NIHR Clinical Research Facility, University Hospital Southampton, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK
| | - John Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Musculoskeletal Unit, Newcastle upon Tyne hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Peter Sasieni
- King's Clinical Trials Unit, Kings College London, London, UK
| | - Ernest Choy
- CREATE Centre, Cardiff University, Cardiff, UK; Department of Rheumatology, University Hospital of Wales, Cardiff, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK; Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust, London, UK.
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6
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Rivellese F, Rossi FW, Giorli G, Napolitano F, de Paulis A, Pitzalis C. Persistence of Mast Cell-Positive Synovitis in Early Rheumatoid Arthritis Following Treatment With Conventional Synthetic Disease Modifying Anti-Rheumatic Drugs. Front Pharmacol 2020; 11:1051. [PMID: 32760275 PMCID: PMC7371927 DOI: 10.3389/fphar.2020.01051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/29/2020] [Indexed: 11/13/2022] Open
Abstract
Mast cells (MCs) are immune cells infiltrating the synovial membrane and implicated in the pathogenesis of Rheumatoid Arthritis (RA). Their infiltration in the synovia of early RA patients has been shown to be associated with systemic inflammation, disease activity and autoantibody positivity. Here, we analyzed their presence in matched synovial samples obtained by ultrasound-guided synovial biopsies pre- and post-treatment with conventional synthetic Disease Modifying Anti-Rheumatic Drugs (csDMARDs) (n=20). Upon IHC staining, patients were classified as MC+ve/-ve based on the presence/absence of CD117+ synovial MCs. At baseline, MC+ve patients had significantly higher synovial inflammation, inflammatory markers, disease activity and a higher prevalence of lympho-myeloid aggregates. Synovial biopsies after 6 months of treatment with csDMARDs showed a significant reduction of synovitis scores, but only a partial reduction of MC numbers. Accordingly, 45% of patients (9/20) were MC+ve after treatment, in association with significantly higher degree of synovitis and higher proportion lympho-myeloid aggregates. Finally, significantly lower patients with MC+ve synovitis at 6 months reached Low Disease Activity (LDA), while the association of MCs with disease activity was independent from lymphoid aggregates, after adjustment for BMI and age. Overall, this study confirms the relevance of MCs as part of the inflammatory infiltrate in the synovia of RA patients, warranting further investigations in larger cohorts to clarify their role in disease progression and response to treatment and their relevance as prognostic markers and potential therapeutic targets.
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Affiliation(s)
- Felice Rivellese
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Francesca W. Rossi
- Department of Translational Medical Sciences (DiSMeT) and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Giovanni Giorli
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Filomena Napolitano
- Department of Translational Medical Sciences (DiSMeT) and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences (DiSMeT) and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Costantino Pitzalis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Buonfrate D, Bisanzio D, Giorli G, Odermatt P, Fürst T, Greenaway C, French M, Reithinger R, Gobbi F, Montresor A, Bisoffi Z. The Global Prevalence of Strongyloides stercoralis Infection. Pathogens 2020; 9:pathogens9060468. [PMID: 32545787 PMCID: PMC7349647 DOI: 10.3390/pathogens9060468] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 12/18/2022] Open
Abstract
Strongyloidiasis is a common neglected tropical disease in tropical and sub-tropical climatic zones. At the worldwide level, there is high uncertainty about the strongyloidiasis burden. This uncertainty represents an important knowledge gap since it affects the planning of interventions to reduce the burden of strongyloidiasis in endemic countries. This study aimed to estimate the global strongyloidiasis prevalence. A literature review was performed to obtain prevalence data from endemic countries at a worldwide level from 1990 to 2016. For each study, the true population prevalence was calculated by accounting for the specificity and the sensitivity of testing and age of tested individuals. Prediction of strongyloidiasis prevalence for each country was performed using a spatiotemporal statistical modeling approach. The country prevalence obtained from the model was used to estimate the number of infected people per country. We estimate the global prevalence of strongyloidiasis in 2017 to be 8.1% (95% CI: 4.2-12.4%), corresponding to 613.9 (95% CI: 313.1-910.1) million people infected. The South-East Asia, African, and Western Pacific Regions accounted for 76.1% of the global infections. Our results could be used to identify those countries in which strongyloidiasis prevalence is highest and where mass drug administration (MDA) should be deployed for its prevention and control.
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Affiliation(s)
- Dora Buonfrate
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024 Verona, Italy; (F.G.); (Z.B.)
- Correspondence:
| | - Donal Bisanzio
- RTI International, Washington, DC 20005, USA; (D.B.); (M.F.); (R.R.)
- Epidemiology and Public Health Division, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Giovanni Giorli
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London E1 4NS, UK;
| | - Peter Odermatt
- Swiss Tropical and Public Health Institute, CH-4051 Basel, Switzerland; (P.O.); (T.F.)
- University of Basel, CH-4051 Basel, Switzerland
| | - Thomas Fürst
- Swiss Tropical and Public Health Institute, CH-4051 Basel, Switzerland; (P.O.); (T.F.)
- University of Basel, CH-4051 Basel, Switzerland
| | - Christina Greenaway
- Division of Infectious Diseases and Clinical Epidemiology, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, QC H3A 2B2, Canada;
| | - Michael French
- RTI International, Washington, DC 20005, USA; (D.B.); (M.F.); (R.R.)
| | | | - Federico Gobbi
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024 Verona, Italy; (F.G.); (Z.B.)
| | - Antonio Montresor
- Department of Control of Neglected Tropical Diseases, World Health Organization, 1211 Geneva, Switzerland;
| | - Zeno Bisoffi
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024 Verona, Italy; (F.G.); (Z.B.)
- Department of Diagnostics and Public Health, University of Verona, 37129 Verona, Italy
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Rivellese F, Humby F, Lliso Ribera G, Nerviani A, Sciacca E, Giorli G, Hands R, Fossati-Jimack L, Thorborn G, Lewis M, Pitzalis C. OP0217 INVOLVEMENT OF LARGE JOINTS AT DISEASE PRESENTATION IS ASSOCIATED WITH DIVERSE HISTOPATHOLOGICAL FEATURES AND CLINICAL OUTCOMES IN EARLY RHEUMATOID ARTHRITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:The involvement of large joints at disease presentation in early Rheumatoid Arthritis (RA) has been associated with severe disease activity. At the same time, the clinical heterogeneity of RA is known to be mirrored by heterogeneity of synovial inflammation, with specific histological patterns (pathotypes) associated with treatment response and disease progression. However, it is not known whether joint size is associated with specific pathotypes.Objectives:To analyse histopathological features of synovial biopsies from joints of different sizes and establish the relationship with clinical outcomes in patients with early RA.Methods:167 patients with early (<1 year) treatment-naïve RA, fulfilling the 2010 RA criteria and recruited at Barts Health NHS Trust, underwent US-guided synovial biopsy of the most inflamed joint, either large (knee), medium (e.g. wrist, ankle, elbow) or small (MCPs, MTPs), before starting treatment with csDMARDS with a treat to target approach. Upon SQ scoring (0-4) of immune cell infiltration, tissues were classified into lympho-myeloid, diffuse-myeloid and pauci-immune pathotypes. Synovial samples from 111 patients underwent RNA-seq.Results:The majority of synovial biopsies were performed on medium and small joints (60.6% and 19.4%) as compared to 21.3% in large joints (Table 1). At baseline, patients who underwent large joint biopsy showed significantly higher levels of inflammation (CRP 27.9±32.4 large, 20.7±26.9 medium, 10.4±9.8 small, p=0.007) and higher HAQ (1.8 ± 0.7 large, 1.4 ± 0.8 medium, 1.2 ±0.9 small, p=0.012), with no differences in DAS28. Significantly higher inflammatory scores and higher proportion of lympho-myeloid pathotype were observed in large joints (Table 1 and Figure 1). 6 months after treat-to-target treatment with csDMARDs, large joints patients had significantly higher HAQ and lower response (RR for low disease activity in large vs medium joints 0.5, 95%CI 0.2-0.9, p=0.03). Finally, differentially expressed genes by RNA-seq showed segregation according to joint size (Figure 2), with upregulation of genes of the Homeobox transcription factors family in large joints.Table 1.EULAR 2010 RA (n=167)Large joints#33 (19.4%)Medium joints#100 (60.6%)Small Joints#34 (20%)P*Clinical featuresESR mm/h,mean (SD)48.2 (31.5)39.6 (30.8)29.2 (17.3)nsCRP mg/L,mean (SD)27.9 (32.4)20.7 (26.9)10.4 (9.8)0.007DAS28, mean (SD)6 (1.2)5.7 (1.4)5.7 (1.5)nsHAQ, mean (SD)1.8 (0.7)1.4 (0.8)1.2 (0.9)0.012ACPA-positive, %70.9%77.3%83.9%nsRF-positive,%71.9%74.2%80.6%nsHistologyInflammatory score,median IQR)5 (3)4 (4)2 (2.75)<0.001Pathotype,%Ungraded6.1%7.8%2.9%0.014Fibroid6.1%24.3%32.3%Myeloid30.3%28.1%47.1%Lympho-myeloid57.6%39.8%17.6%Clinical outcomes at 6 monthsDAS28 6m,mean (SD)4.2 (1.8)3.4 (1.9)3.7 (1.5)nsHAQ 6m,mean (SD)1.2 (0.8)0.8 (0.8)0.8 (0.8)0.012DAS28 6m <3.2,%23.3%48.8%37.9%0.04#Large joints: knees; Medium joints: wrists, ankle, elbows; Small joints: MCPs, MTPs, PIPs; * Chi-squared or Kruskal–Wallis as appropriate;Conclusion:Synovial biopsy of large joints as the most inflamed joints at disease presentation identified patients with early RA with specific histopathological features and clinical outcomes. Together with clustering of differentially expressed genes according to joint size, this suggests that the involvement of different joint compartments in early RA contributes to disease heterogeneity with potential physiopathological and clinical implications.References:[1]Humby et al Ann Rheum Dis. 2019 Jun;78(6):761-772[2]Lewis et al Cell Rep. 2019 Aug 27;28(9):2455-2470.e5[3]Linn-Rasker SP et al Ann Rheum Dis. 2007 May;66(5):646-50Acknowledgments:PEAChttp://www.peac-mrc.mds.qmul.ac.ukMRC grant 36661 & ARUK Grant 20022F. Rivellese NIHR Fellowship TRF-2018-11-ST2-002Disclosure of Interests:None declared
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Nerviani A, Di Cicco M, Mahto A, Lliso-Ribera G, Rivellese F, Thorborn G, Hands R, Bellan M, Mauro D, Boutet MA, Giorli G, Lewis M, Kelly S, Bombardieri M, Humby F, Pitzalis C. A Pauci-Immune Synovial Pathotype Predicts Inadequate Response to TNFα-Blockade in Rheumatoid Arthritis Patients. Front Immunol 2020; 11:845. [PMID: 32431716 PMCID: PMC7214807 DOI: 10.3389/fimmu.2020.00845] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/14/2020] [Indexed: 01/17/2023] Open
Abstract
Objectives: To assess whether the histopathological features of the synovium before starting treatment with the TNFi certolizumab-pegol could predict clinical outcome and examine the modulation of histopathology by treatment. Methods: Thirty-seven RA patients fulfilling UK NICE guidelines for biologic therapy were enrolled at Barts Health NHS trust and underwent synovial sampling of an actively inflamed joint using ultrasound-guided needle biopsy before commencing certolizumab-pegol and after 12-weeks. At 12-weeks, patients were categorized as responders if they had a DAS28 fall >1.2. A minimum of 6 samples was collected for histological analysis. Based on H&E and immunohistochemistry (IHC) staining for CD3 (T cells), CD20 (B cells), CD138 (plasma cells), and CD68 (macrophages) patients were categorized into three distinct synovial pathotypes (lympho-myeloid, diffuse-myeloid, and pauci-immune). Results: At baseline, as per inclusion criteria, DAS28 mean was 6.4 ± 0.9. 94.6% of the synovial tissue was retrieved from the wrist or a metacarpophalangeal joint. Histological pathotypes were distributed as follows: 58% lympho-myeloid, 19.4% diffuse-myeloid, and 22.6% pauci-immune. Patients with a pauci-immune pathotype had lower levels of CRP but higher VAS fatigue compared to lympho- and diffuse-myeloid. Based on DAS28 fall >1.2, 67.6% of patients were deemed as responders and 32.4% as non-responders. However, by categorizing patients according to the baseline synovial pathotype, we demonstrated that a significantly higher number of patients with a lympho-myeloid and diffuse-myeloid pathotype in comparison with pauci-immune pathotype [83.3% (15/18), 83.3 % (5/6) vs. 28.6% (2/7), p = 0.022) achieved clinical response to certolizumab-pegol. Furthermore, we observed a significantly higher level of post-treatment tender joint count and VAS scores for pain, fatigue and global health in pauci-immune in comparison with lympho- and diffuse-myeloid patients but no differences in the number of swollen joints, ESR and CRP. Finally, we confirmed a significant fall in the number of CD68+ sublining macrophages post-treatment in responders and a correlation between the reduction in the CD20+ B-cells score and the improvement in the DAS28 at 12-weeks. Conclusions: The analysis of the synovial histopathology may be a helpful tool to identify among clinically indistinguishable patients those with lower probability of response to TNFα-blockade.
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Affiliation(s)
- Alessandra Nerviani
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Maria Di Cicco
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Arti Mahto
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Gloria Lliso-Ribera
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Felice Rivellese
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Georgina Thorborn
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rebecca Hands
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mattia Bellan
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Daniele Mauro
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Marie-Astrid Boutet
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Giovanni Giorli
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Myles Lewis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Stephen Kelly
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michele Bombardieri
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Frances Humby
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Costantino Pitzalis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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10
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Rivellese F, Humby F, Bugatti S, Fossati‐Jimack L, Rizvi H, Lucchesi D, Lliso‐Ribera G, Nerviani A, Hands RE, Giorli G, Frias B, Thorborn G, Jaworska E, John C, Goldmann K, Lewis MJ, Manzo A, Bombardieri M, Pitzalis C. B Cell Synovitis and Clinical Phenotypes in Rheumatoid Arthritis: Relationship to Disease Stages and Drug Exposure. Arthritis Rheumatol 2020; 72:714-725. [PMID: 31785084 PMCID: PMC7217046 DOI: 10.1002/art.41184] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To define the relationship of synovial B cells to clinical phenotypes at different stages of disease evolution and drug exposure in rheumatoid arthritis (RA). METHODS Synovial biopsy specimens and demographic and clinical data were collected from 2 RA cohorts (n = 329), one of patients with untreated early RA (n = 165) and one of patients with established RA with an inadequate response to tumor necrosis factor inhibitors (TNFi-IR; n = 164). Synovial tissue was subjected to hematoxylin and eosin and immunohistochemical staining and semiquantitative assessment for the degree of synovitis (on a scale of 0-9) and of CD20+ B cell infiltrate (on a scale of 0-4). B cell scores were validated by digital image analysis and B cell lineage-specific transcript analysis (RNA-Seq) in the early RA (n = 91) and TNFi-IR (n = 127) cohorts. Semiquantitative CD20 scores were used to classify patients as B cell rich (≥2) or B cell poor (<2). RESULTS Semiquantitative B cell scores correlated with digital image analysis quantitative measurements and B cell lineage-specific transcripts. B cell-rich synovitis was present in 35% of patients in the early RA cohort and 47.7% of patients in the TNFi-IR cohort (P = 0.025). B cell-rich patients showed higher levels of disease activity and seropositivity for rheumatoid factor and anti-citrullinated protein antibody in early RA but not in established RA, while significantly higher histologic synovitis scores in B cell-rich patients were demonstrated in both cohorts. CONCLUSION We describe a robust semiquantitative histologic B cell score that closely replicates the quantification of B cells by digital or molecular analyses. Our findings indicate an ongoing B cell-rich synovitis, which does not seem to be captured by standard clinimetric assessment, in a larger proportion of patients with established RA than early RA.
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Affiliation(s)
- F. Rivellese
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - F. Humby
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - S. Bugatti
- IRCCSPoliclinico San Matteo Foundation and University of PaviaPaviaItaly
| | - L. Fossati‐Jimack
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | | | - D. Lucchesi
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - G. Lliso‐Ribera
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - A. Nerviani
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - R. E. Hands
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - G. Giorli
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - B. Frias
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - G. Thorborn
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - E. Jaworska
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - C. John
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - K. Goldmann
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - M. J. Lewis
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - A. Manzo
- IRCCSPoliclinico San Matteo Foundation and University of PaviaPaviaItaly
| | - M. Bombardieri
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - C. Pitzalis
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
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Giorli G, Rouette J, Yin H, Lapi F, Simonetti M, Cricelli C, Pollak M, Azoulay L. Prediagnostic use of low-dose aspirin and risk of incident metastasis and all-cause mortality among patients with colorectal cancer. Br J Clin Pharmacol 2020; 86:2266-2273. [PMID: 32352592 DOI: 10.1111/bcp.14329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 12/24/2022] Open
Abstract
AIMS Previous studies suggest that the use of low-dose aspirin before a colorectal cancer (CRC) diagnosis may be associated with a decreased risk of CRC progression. Data supporting this association, however, have been inconsistent. We evaluate whether the use of prediagnostic low-dose aspirin is associated with a lower risk of metastases and all-cause mortality in CRC patients. METHODS Using a large Italian population-based primary care database, we identified a cohort of 7478 patients newly diagnosed with nonmetastatic CRC between 2000 and 2013. Use of prediagnostic low-dose aspirin was compared with no use of low-dose aspirin. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of incident metastasis and of all-cause mortality associated with prediagnostic low-dose aspirin use, both overall and by duration of use. RESULTS There were 314 incident metastatic events and 2189 deaths during a mean follow-up time of 4.4 and 4.7 years, respectively. Overall prediagnostic use of low-dose aspirin was not associated with a decreased risk of incident metastasis (HR 0.88; 95% CI 0.63-1.22) or all-cause mortality (HR 1.09; 95% CI 0.96-1.22) in CRC patients. Cumulative duration of aspirin use was not associated with a decreased risk of incident metastasis (P-trend = .22) or all-cause mortality (P-trend = .38). These findings remained consistent in sensitivity analyses. CONCLUSION In this real-world, population-based study, the prediagnostic use of low-dose aspirin was not associated with a decreased risk of incident metastasis or all-cause mortality in CRC patients.
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Affiliation(s)
- Giovanni Giorli
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.,Department of Statistics and Quantitative Methods, Unit of Biostatistics and Epidemiology, University of Milano-Bicocca, Milan, Italy.,Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Julie Rouette
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Hui Yin
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care - SIMG, Florence, Italy
| | - Monica Simonetti
- Health Search, Italian College of General Practitioners and Primary Care - SIMG, Florence, Italy
| | - Claudio Cricelli
- Health Search, Italian College of General Practitioners and Primary Care - SIMG, Florence, Italy
| | - Michael Pollak
- Segal Cancer Center, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
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Navarro M, Camprubí D, Requena-Méndez A, Buonfrate D, Giorli G, Kamgno J, Gardon J, Boussinesq M, Muñoz J, Krolewiecki A. Safety of high-dose ivermectin: a systematic review and meta-analysis. J Antimicrob Chemother 2020; 75:827-834. [PMID: 31960060 DOI: 10.1093/jac/dkz524] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/17/2019] [Accepted: 11/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ivermectin is a key anthelmintic for the control of neglected tropical diseases. The main indications for population-level control with ivermectin through mass drug administration are onchocerciasis and lymphatic filariasis; however, there is interest in using higher, fixed-dose regimens for the control of scabies, soil-transmitted helminths and malaria. Safety data for these higher-dose regimens are needed. METHODS A systematic literature review and meta-analysis on the safety and doses of ivermectin was conducted. Eligible studies reported patient-level data and, for the meta-analysis, clinical trials reporting data on doses ≥200 and ≥400 μg/kg were included. Incidence ratios were used to compare adverse events by severity and organ system affected. RESULTS The systematic search identified six studies for inclusion, revealing no differences in the number of individuals experiencing adverse events. A descriptive analysis of these clinical trials for a variety of indications showed no difference in the severity of the adverse events between standard (up to 400 μg/kg) and higher doses of ivermectin. Organ system involvement only showed an increase in ocular events in the higher-dose group in one trial for the treatment of onchocerciasis, all of them transient and mild to moderate in intensity. CONCLUSIONS Although within this review the safety of high-dose ivermectin appears to be comparable to standard doses, there are not enough data to support a recommendation for its use in higher-than-approved doses. Ocular adverse events, despite being transient, are of concern in onchocerciasis patients. These data can inform programme managers and guide operational research activities as new approaches for the use of ivermectin are evaluated.
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Affiliation(s)
- Miriam Navarro
- Department of Public Health, Science History and Gynecology, Universidad Miguel Hernández de Elche, Alicante, Spain
| | - Daniel Camprubí
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Ana Requena-Méndez
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Dora Buonfrate
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Giovanni Giorli
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Joseph Kamgno
- Centre de Recherche sur les Filarioses et autres Maladies tropicales, Yaounde, Cameroon
| | - Jacques Gardon
- Institut de Recherche pour le Développement, Montpellier, France
| | | | - Jose Muñoz
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Alejandro Krolewiecki
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Instituto de Investigaciones de Enfermedades Tropicales Universidad Nacional de Salta/CONICET, Orán, Argentina
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Humby FC, Lewis M, Durez P, Buch MH, Bombardieri M, Rizvi H, Rivellese F, Fossati L, Hands R, Giorli G, John C, Mahto A, Kelly S, Nerviani A, Montecucco C, Lauwerys B, Ng N, Thornborn G, Romao VC, Ho P, Verschueren P, Sainaghi PP, Bellan M, Bugatti S, Pratt AG, Holyroyd C, Congia M, Thompson C, Gendi N, Dasgupta B, Cauli A, Reynolds P, Cañete J, Moots RJ, Taylor PC, Edwards C, Isaacs J, Sasieni P, Fonseca JE, Choy E, Pitzalis C. O07 Randomised, open labelled clinical trial to investigate synovial mechanisms determining response: resistance to rituximab versus tocilizumab in RA patients failing TNF inhibitor therapy. Rheumatology (Oxford) 2020. [DOI: 10.1093/rheumatology/keaa110.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Biologic therapies have transformed the outlook for RA but the significant health economic impact of these therapies has highlighted the need to define predictive markers of response. Rituximab (RTX) is licensed for use following failure of csDMARDs and TNF inhibitor (TNFi) therapy. However, in this increasing therapeutically resistant cohort only 30% of patients achieve an ACR50 response. The observation in early RA that 50% of patients show low/absence of synovial B-cells prompted us to test the hypothesis that in these patients a biologic agent targeting alternative pathways maybe more effective. We report results from the first pathobiology-driven randomised controlled trial (RCT) in RA (R4RA) evaluating whether patient stratification according to the synovial B-cell rich/poor status enriches for response/non response to RTX.
Methods
R4RA is a phase IV open-label RCT conducted in 19 European centres recruiting patients failing or intolerant to csDMARD therapy and at least one TNFi. Synovial tissue was obtained at trial entry and used to classify patients as B-cell rich or poor using both histological and RNA-seq classification criteria. Patients were randomised to receive RTX or tocilizumab (TCZ). The study was powered to test in the B cell poor population superiority of TCZ over RTX at 16 weeks. The primary and co-primary end-points were defined respectively as Clinical Disease Activity Index (CDAI) ≥50% improvement from baseline and Major Treatment response (MTR)= CDAI improvement ≥ 50% and CDAI ≤10.1.
Results
The trial recruited to target (n = 164) with a power of 89.5%. In the B cell poor cohort a numerically higher number of patients achieved the primary endpoint and a significantly higher number of patients achieved co-primary endpoint (MTR). Classification of patients as B cell poor/rich according to RNA-seq criteria enhanced the difference between TCZ and RTX, with a significantly higher number of TCZ treated patients reaching both CDAI 50% improvement and CDAI MTR in the B-cell poor group.
Conclusion
In a RA B cell poor population failing csDMARDs and TNFi therapy, TCZ is more effective than RTX. This first biopsy-driven RCT suggests clinical utility for integrating molecular pathology profiling into treatment algorithms to allocate targeted therapies.
Disclosures
F. Humby: Honoraria; Roche, Pfizer. Grants/research support; Pfizer. P. Durez: BMS,Bristol-Myers Squibb, Celltrion, Eli Lilly, Hospira, Mundipharma, Pfizer, Samsung, Sanofi, UCB. M. Buch: Consultancies; Pfizer, Roche, UCB, AbbVie, Eli Lilly, Sandoz, and Sanofi. Grants/research support; Pfizer, Roche, UCB, AbbVie, Eli Lilly, Sandoz, and Sanofi. M. Lewis: None. M. Bombardieri: None. H. Rizvi: None. S. Kelly: None. L. Fossati: None. R. Hands: None. G. Giorli: None. A. Mahto: None. C. Montecucco: None. B. Lauwerys: None. V.C. Romao: None. A.G. Pratt: Member of speakers’ bureau; Eli Lilly and Janssen-Cilag Ltd. Grants/research support; Pfizer. S. Bugatti: None. N. Ng: None. F. Rivellese: None. P. Ho: None. M. Bellan: None. P. Sainaghi: None. P. Verschueren: None. N. Gendi: None. B. Dasgupta: Abbvie, BMS, GSK, Roche, Roche Chugai, Sanofi, Sanofi Aventis, Sanofi-Aventis. A. Cauli: BMS, Celgene, Lilly, Lilly MSD, MSD, Novartis, Pfizer, Sanofi, Sigma Wesseumen, UCB. C. John: None. A. Nerviani: None. G. Thornborn: None. D. Holroyd: None. M. Congia: None. C. Thompson: None. P. Reynolds: None. J. Cañete: None. R. J. Moots: Biogen, Bristol-Myers Squibb, Chugai,
Novartis, Pfizer Inc, Roche, Sandoz, UCB. P.C. Taylor: AbbVie, Biogen, Celgene, Eli Lilly and Company, Fresenius, Fresenius SE & Co, Galapagos, Gilead. GlaxoSmithKline, Janssen, Lilly, Nordic Pharma, Pfizer, Pfizer Inc, Roche, Sanofi, UCB. C. Edwards: Abbvie, Biogen, BMS, Fresenius, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB. J. Isaacs: None. P. Sasieni: None. J. E. Fonesca: None. E. Choy: AbbVie, Abbvie, Roche, Chugai, Amgen, Eli Lilly, Janssen, Novartis, Regeneron, R-Pharm and Sanofi, Amgen, Amgen, Roche, Chugai, Bristol-Myers Squibb, Eli-Lilly Janssen, Pfizer, Regeneron, Sanofi and UCB., AstraZeneca, Bio-Cancer, Bio-Cancer, Biogen, Novartis, Sanofi, Roche, Pfizer and UCB ,Biogen, BMS, Boehringer Ingelheim, Celgene, Chugai Pharma, Eli Lilly, Ferring Pharmaceuticals, GSK, Hospira, Janssen, Jazz Pharmaceuticals, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, Regeneron, Roche, R-Pharm, Sanofi, SynAct Pharma, Tonix, Union Chimique Belge. C. Pitzalis: None. NIHR have funded the study.
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Affiliation(s)
- Frances C Humby
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Myles Lewis
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Patrick Durez
- Pôle de Recherche en Rhumatologie, Institut de Recherche Expérimentale et Clinique, UCL Saint-Luc
| | - Maya H Buch
- University of Leeds & NIHR Leeds Biomedical Research Centre, UNITED KINGDOM
| | - Michele Bombardieri
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Hasan Rizvi
- Barts Health NHS Trust, London, UNITED KINGDOM
| | - Felice Rivellese
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Liliane Fossati
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Rebecca Hands
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Giovanni Giorli
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Chris John
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | - Arti Mahto
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | | | - Alessandra Nerviani
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | | | - Bernard Lauwerys
- Faculty of Medicine, Catholic University of Louvain, London, BELGIUM
| | - Nora Ng
- Guys and St Thomas NHS Trust, London, UNITED KINGDOM
| | - Georgina Thornborn
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
| | | | - Pauline Ho
- University of Manchester, UNITED KINGDOM
| | - Patrick Verschueren
- Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, BELGIUM
| | | | | | | | | | | | | | | | - Nagui Gendi
- Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UNITED KINGDOM
| | | | | | | | - Juan Cañete
- Rheumatology Department, Hospital Clínic and IDIBAPS
| | - Robert J Moots
- Institute of Ageing and Chronic Disease, University of Liverpool, UNITED KINGDOM
| | | | | | - John Isaacs
- Newcastle University, Newcastle, UNITED KINGDOM
| | | | - João Eurico Fonseca
- Rheumatology and Bone Diseases Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa; Centro Académico de Medicina de Lisboa; Lisbon, PORTUGAL
| | | | - Costantino Pitzalis
- Queen Mary University of London, UNITED KINGDOM, Queen Mary University of London, UNITED KINGDOM
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Tamarozzi F, Martello E, Giorli G, Fittipaldo A, Staffolani S, Montresor A, Bisoffi Z, Buonfrate D. Morbidity Associated with Chronic Strongyloides stercoralis Infection: A Systematic Review and Meta-Analysis. Am J Trop Med Hyg 2020; 100:1305-1311. [PMID: 30963990 DOI: 10.4269/ajtmh.18-0895] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Strongyloides stercoralis, a worldwide-distributed soil-transmitted helminth, causes chronic infection which may be life threatening. Limitations of diagnostic tests and nonspecificity of symptoms have hampered the estimation of the global morbidity due to strongyloidiasis. This work aimed at assessing S. stercoralis-associated morbidity through a systematic review and meta-analysis of the available literature. MEDLINE, Embase, CENTRAL, LILACS, and trial registries (WHO portal) were searched. The study quality was assessed using the Newcastle-Ottawa scale. Odds ratios (ORs) of the association between symptoms and infection status and frequency of infection-associated symptoms were calculated. Six articles from five countries, including 6,014 individuals, were included in the meta-analysis-three were of low quality, one of high quality, and two of very high quality. Abdominal pain (OR 1.74 [CI 1.07-2.94]), diarrhea (OR 1.66 [CI 1.09-2.55]), and urticaria (OR 1.73 [CI 1.22-2.44]) were associated with infection. In 17 eligible studies, these symptoms were reported by a large proportion of the individuals with strongyloidiasis-abdominal pain by 53.1% individuals, diarrhea by 41.6%, and urticaria by 27.8%. After removing the low-quality studies, urticaria remained the only symptom significantly associated with S. stercoralis infection (OR 1.42 [CI 1.24-1.61]). Limitations of evidence included the low number and quality of studies. Our findings especially highlight the appalling knowledge gap about clinical manifestations of this common yet neglected soil-transmitted helminthiasis. Further studies focusing on morbidity and risk factors for dissemination and mortality due to strongyloidiasis are absolutely needed to quantify the burden of S. stercoralis infection and inform public health policies.
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Affiliation(s)
| | - Elisa Martello
- Department of Veterinary Sciences, University of Turin, Turin, Italy
| | | | | | | | | | - Zeno Bisoffi
- Università degli Studi di Verona, Verona, Italy.,IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
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15
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Buonfrate D, Gobbi F, Marchese V, Postiglione C, Badona Monteiro G, Giorli G, Napoletano G, Bisoffi Z. Extended screening for infectious diseases among newly-arrived asylum seekers from Africa and Asia, Verona province, Italy, April 2014 to June 2015. ACTA ACUST UNITED AC 2019; 23. [PMID: 29692316 PMCID: PMC5915973 DOI: 10.2807/1560-7917.es.2018.23.16.17-00527] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Management of health issues presented by newly-arrived migrants is often limited to communicable diseases even though other health issues may be more prevalent. We report the results of infectious disease screening proposed to 462 recently-arrived asylum seekers over 14 years of age in Verona province between April 2014 and June 2015. Methods: Screening for latent tuberculosis (TB) was performed via tuberculin skin test (TST) and/or QuantiFERON-TB Gold in-tube assay and/or chest X-ray. An ELISA was used to screen for syphilis. Stool microscopy was used to screen for helminthic infections, and serology was also used for strongyloidiasis and schistosomiasis. Screening for the latter also included urine filtration and microscopy. Results: Most individuals came from sub-Saharan Africa (77.5%), with others coming from Asia (21.0%) and North Africa (1.5%). The prevalence of viral diseases/markers of human immunodeficiency virus (HIV) infection was 1.3%, HCV infection was 0.85% and hepatitis B virus surface antigen was 11.6%. Serological tests for syphilis were positive in 3.7% of individuals. Of 125 individuals screened for TB via the TST, 44.8% were positive and of 118 screened via the assay, 44.0% were positive. Of 458 individuals tested for strongyloidiasis, 91 (19.9%) were positive, and 76 of 358 (21.2%) individuals from sub-Saharan Africa were positive for schistosomiasis. Conclusions: The screening of viral diseases is questionable because of low prevalence and/or long-term, expensive treatments. For opposing reasons, helminthic infections are probably worth to be targeted by screening strategies in asylum seekers of selected countries of origin.
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Affiliation(s)
- Dora Buonfrate
- Centre for Tropical Diseases (CTD), Sacro Cuore Hospital, Negrar, Verona, Italy
| | - Federico Gobbi
- Centre for Tropical Diseases (CTD), Sacro Cuore Hospital, Negrar, Verona, Italy
| | - Valentina Marchese
- University Department of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.,Centre for Tropical Diseases (CTD), Sacro Cuore Hospital, Negrar, Verona, Italy
| | - Chiara Postiglione
- Prevention Department, Unità Locale Socio Sanitaria (ULSS) 9, Verona, Italy
| | | | - Giovanni Giorli
- Centre for Tropical Diseases (CTD), Sacro Cuore Hospital, Negrar, Verona, Italy
| | | | - Zeno Bisoffi
- Centre for Tropical Diseases (CTD), Sacro Cuore Hospital, Negrar, Verona, Italy
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16
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Angheben A, Buonfrate D, Cruciani M, Jackson Y, Alonso-Padilla J, Gascon J, Gobbi F, Giorli G, Anselmi M, Bisoffi Z. Rapid immunochromatographic tests for the diagnosis of chronic Chagas disease in at-risk populations: A systematic review and meta-analysis. PLoS Negl Trop Dis 2019; 13:e0007271. [PMID: 31150377 PMCID: PMC6561601 DOI: 10.1371/journal.pntd.0007271] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 06/12/2019] [Accepted: 02/28/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Despite of a high disease burden, mainly in Latin America, Chagas disease (CD) is underdiagnosed and undertreated. Rapid diagnostic tests (RDTs) might improve the access to diagnosis. The aim of this study is to review the accuracy of commercially available RDTs used in field conditions for the diagnosis of chronic CD in populations at risk, in endemic and non-endemic countries. METHODS/PRINCIPAL FINDINGS We undertook a comprehensive search of the following databases: PubMed, SCOPUS, LILACS (last up-date on the 01st July, 2017), without language or date limits. Non-electronic sources have been also searched. This review included clinical studies with cohort recruitment of individuals at risk of T. cruzi exposure, without age limits; adequate reference standards for the diagnosis of CD. We excluded case-control studies and those testing RDTs during acute CD. Data on test accuracies were pooled through a bivariate random-effects model. Only one index test was evaluated separately. Geographical area, commercial brand, disease prevalence, study size, and risk of bias were explored as possible source of heterogeneity. Values of sensitivity and specificity were computed to obtain summary positive/negative likelihood ratios, and summary diagnostic odds ratio. Ten studies were included on six different immunochromatographic RDTs. The pooled sensitivity and specificity of the RDTs resulted 96.6% (95% CI 91.3-98.7%) and 99.3% (95% CI 98.4-99.7%), respectively. Test accuracy was particularly good in endemic areas (98.07%/99.03% of sensitivity/specificity, respectively). One test (Stat-Pak) showed an overall sensitivity of 97% (95% CI 87.6-99.3) and specificity of 99.4% (95% CI 98.6-99.8). CONCLUSIONS/SIGNIFICANCE RDTs demonstrated to be sufficiently accurate to recommend their use for screening in endemic areas, even as stand-alone tests. This approach might increase the accessibility to the diagnosis. However, an additional confirmatory test in case of positive result remains a prudent approach.
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Affiliation(s)
- Andrea Angheben
- Department of Infectious – Tropical Diseases and Microbiology, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar, Verona, Italy
| | - Dora Buonfrate
- Department of Infectious – Tropical Diseases and Microbiology, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar, Verona, Italy
| | - Mario Cruciani
- Infectious Diseases Unit, Azienda ULSS 9 Scaligera, Verona, Italy
| | - Yves Jackson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- Institute of Global Health, Geneva University, Geneva, Switzerland
| | | | - Joaquim Gascon
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Federico Gobbi
- Department of Infectious – Tropical Diseases and Microbiology, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar, Verona, Italy
| | - Giovanni Giorli
- Department of Infectious – Tropical Diseases and Microbiology, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar, Verona, Italy
| | - Mariella Anselmi
- Centro de Epidemiologia Comunitaria y Medicina Tropical (CECOMET), Esmeraldas, Ecuador
| | - Zeno Bisoffi
- Department of Infectious – Tropical Diseases and Microbiology, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar, Verona, Italy
- Diagnostic and Public Health Department, University of Verona, Verona, Italy
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17
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Beltrame A, Ragusa A, Perandin F, Formenti F, Fenollar F, Edouard S, Laroche M, Zavarise G, Doro F, Giorli G, Raoult D, Bisoffi Z. Tropheryma whipplei intestinal colonization in Italian and migrant population: a retrospective observational study. Future Microbiol 2019; 14:283-292. [PMID: 30855186 DOI: 10.2217/fmb-2018-0347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To obtain the first molecular epidemiological survey of Tropheryma whipplei intestinal colonization in Italy. Materials & methods: Retrospective, observational study to assess the prevalence of T. whipplei, the causative agent of Whipple's disease, in stool samples (real-time PCR) of patients attending the Center for Tropical Diseases (Italy) and risk factors associated. RESULTS Overall prevalence was 6.9% (85/1240). The younger age group showed a significantly higher rate than older age group (12.7 vs 5.9%, p = 0.002). The prevalence was 4.9% for Italians and 9.3% for migrants (p = 0.003). Among the latter, children less than 10 years had higher prevalence than older ones (17.3 vs 7.3%, p = 0.003). The young age, male gender and Giardia duodenalis and Entamoeba histolytica coinfection were risk factors. CONCLUSION Our study confirms an increased risk of acquiring T. whipplei infection during childhood, under poor sanitary conditions.
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Affiliation(s)
- Anna Beltrame
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Andrea Ragusa
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesca Perandin
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Fabio Formenti
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Florence Fenollar
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Sophie Edouard
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Maureen Laroche
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Giorgio Zavarise
- Paediatrics Department, IRCSS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesco Doro
- Paediatrics Department, IRCSS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Giovanni Giorli
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Didier Raoult
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Zeno Bisoffi
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy.,Department of Diagnostic & Public Health, University of Verona, P.le L. A. Scuro 10, 37134 Verona, Italy
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18
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Formenti F, La Marca G, Perandin F, Pajola B, Romano M, Santucci B, Silva R, Giorli G, Bisoffi Z, Buonfrate D. A diagnostic study comparing conventional and real-time PCR for Strongyloides stercoralis on urine and on faecal samples. Acta Trop 2019; 190:284-287. [PMID: 30521805 DOI: 10.1016/j.actatropica.2018.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/27/2018] [Accepted: 12/02/2018] [Indexed: 12/16/2022]
Abstract
Strongyloides stercoralis is a soil-transmitted helminth with a wide distribution in tropical and subtropical areas. The diagnosis of S. stercoralisinfection can be challenging, due to the low sensitivity of microscopic examination of stool samples and coproculture. In the last decade, different in-house molecular biology techniques for S. stercoralis have been implemented. They demonstrated good accuracy, although sensitivity does not seem sufficiently high yet. Recently, a novel PCR technique has been evaluated for the detection of S. stercoralis DNA in urine. Aim of this work was to compare the sensitivity of the real-time PCR (qPCR) on feces routinely used at the Centre for Tropical Disease (CTD) of Negrar, Verona, Italy, with that of the novel based PCR on urine. As secondary objective, we evaluated a Urine Conditioning Buffer ® (Zymoresearch) with the aim of improving nucleic acid stability in urine during sample storage/transport at ambient temperatures. Patients attending the CTD and resulting positive at routine screening with serology for S. stercoralis were invited, previous written consent, to supply stool and urine samples for molecular biology. A convenience sample of 30 patients was included. The sensitivity of qPCR on feces resulted 63%, and that of based PCR on urine was 17%. In all the samples treated with the Urine Conditioning Buffer ® there was no detectable DNA. In conclusion, the sensitivity of the novel technique resulted low, and needs further implementation before being considered as a valid alternative to the validated method.
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Affiliation(s)
- Fabio Formenti
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy.
| | - Giulia La Marca
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
| | - Francesca Perandin
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
| | - Barbara Pajola
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
| | - Miryam Romano
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Beatrice Santucci
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
| | - Ronaldo Silva
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
| | - Giovanni Giorli
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
| | - Zeno Bisoffi
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy; Department of Diagnostics and Public Health, University of Verona, Italy
| | - Dora Buonfrate
- Centre for Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, 37024, Italy
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Piubelli C, Soleymanpoor H, Giorli G, Formenti F, Buonfrate D, Bisoffi Z, Perandin F. Blastocystis prevalence and subtypes in autochthonous and immigrant patients in a referral centre for parasitic infections in Italy. PLoS One 2019; 14:e0210171. [PMID: 30615638 PMCID: PMC6322732 DOI: 10.1371/journal.pone.0210171] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 12/18/2018] [Indexed: 11/19/2022] Open
Abstract
In this study we characterized the presence and subtype (ST1-ST4) of Blastocystis in patients attended at a referral center for tropical diseases in Northern Italy. We also, evaluated the organism's association with other intestinal parasites. Parasite screening was performed on 756 patients, from different geographical origins (namely, Italians, Africans, South Americans, Asian and non-Italian Europeans) in which Italians represented the largest group. Blastocystis was seen to be the most prevalent parasite in the study. Subtype 3 and 1 were the most frequently found in the Italians and Africans. Our data confirmed previous studies performed in Italy, in which ST3 proved to be the most prevalent subtype, but we highlighted also a high frequency of mixed subtypes, which were probably underestimated in former analyses. Interestingly, the mixed subtypes group was the most prevalent in all the analysed geographical areas. About half of our cases showed other co-infecting parasites and the most frequent was Dientamoeba fragilis. Our study confirms that, in Blastocystis infection, multiple subtypes and co-infecting parasites are very frequently present, in particular Dientamoeba fragilis.
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Affiliation(s)
- Chiara Piubelli
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
- * E-mail:
| | - Hossein Soleymanpoor
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
- Institute of Infectious Diseases and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Giovanni Giorli
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
| | - Fabio Formenti
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
| | - Dora Buonfrate
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
| | - Zeno Bisoffi
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
| | - Francesca Perandin
- Department of Infectious and Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar (Vr), Italy
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Staffolani S, Buonfrate D, Angheben A, Gobbi F, Giorli G, Guerriero M, Bisoffi Z, Barchiesi F. Acute histoplasmosis in immunocompetent travelers: a systematic review of literature. BMC Infect Dis 2018; 18:673. [PMID: 30563472 PMCID: PMC6299618 DOI: 10.1186/s12879-018-3476-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 10/31/2018] [Indexed: 11/15/2022] Open
Abstract
Background Histoplasmosis is a fungal infection highly endemic in the American continent. The disease can be severe in immunocompromised subjects. In immunocompetent subjects the clinical manifestations are variable. Aim of this work was to review the cases of acute histoplasmosis in immunocompetent travelers reported in literature. Methods A systematic review of literature was conducted. Electronic search was performed in Pubmed and LILACS. Two reviewers independently extracted data on demographic, clinical and radiological features, and treatment. Cases were classified according to Wheat’s definitions. Results Seventy-one studies were included in the analysis, comprising a total of 814 patients. Twenty-one patients diagnosed at the Centre of Tropical Diseases, Negrar (VR), Italy were also included. The most common travel destination was Central America (168 people, 29.8%); the most common way of exposure to histoplasma was the exploration of caves and/or contact with bat guano (349 people, 60.9%). The multivariate logistic regression model showed association between the development of disseminated histoplasmosis (DH) and activities that involved the exploration of caves and/or the contact with bats’ guano (adjusted OR: 34.20 95% CI: 5.29 to 220.93) or other outdoor activities (adjusted OR: 4.61 95% CI: 1.09 to 19.56). No significant difference in the attack rate between countries of destination was observed (p-value: 0.8906, Kruskal-Wallis test). Conclusions Histoplasmosis often causes no or mild symptoms in immunocompetent individuals, although a severe syndrome may occur. The infection can mimic other diseases, and the epidemiological risk of exposure is an important clue to raise the index of suspicion. Electronic supplementary material The online version of this article (10.1186/s12879-018-3476-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Silvia Staffolani
- Centro per le Malattie Tropicali, IRCCS Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Sacro Cuore - Don Calabria, Via Don Sempreboni 5, 37024, Verona, Negrar, Italy. .,SOD Malattie Infettive emergenti e degli immunodepressi, Azienda Ospedaliero Universitaria, Ospedali Riuniti di Ancona, Via Conca Torrette, Ancona, Italy.
| | - Dora Buonfrate
- Centro per le Malattie Tropicali, IRCCS Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Sacro Cuore - Don Calabria, Via Don Sempreboni 5, 37024, Verona, Negrar, Italy
| | - Andrea Angheben
- Centro per le Malattie Tropicali, IRCCS Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Sacro Cuore - Don Calabria, Via Don Sempreboni 5, 37024, Verona, Negrar, Italy
| | - Federico Gobbi
- Centro per le Malattie Tropicali, IRCCS Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Sacro Cuore - Don Calabria, Via Don Sempreboni 5, 37024, Verona, Negrar, Italy
| | - Giovanni Giorli
- Centro per le Malattie Tropicali, IRCCS Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Sacro Cuore - Don Calabria, Via Don Sempreboni 5, 37024, Verona, Negrar, Italy
| | - Massimo Guerriero
- Computer Sciences, Dipartimento di Economia Aziendale, Università degli Studi di Verona, Strada le Grazie, Verona, Italy
| | - Zeno Bisoffi
- Centro per le Malattie Tropicali, IRCCS Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Sacro Cuore - Don Calabria, Via Don Sempreboni 5, 37024, Verona, Negrar, Italy.,Sezione di Malattie Infettive e Tropicali, Dipartimento di Diagnostica e Sanità Pubblica, Università di Verona, Strada le Grazie, Verona, Italy
| | - Francesco Barchiesi
- Clinica Malattie Infettive, Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, Azienda Ospedaliera Umberto I° Via Conca Torrette, Ancona, Italy
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Marchese V, Beltrame A, Angheben A, Monteiro GB, Giorli G, Perandin F, Buonfrate D, Bisoffi Z. Schistosomiasis in immigrants, refugees and travellers in an Italian referral centre for tropical diseases. Infect Dis Poverty 2018; 7:55. [PMID: 29907162 PMCID: PMC6004084 DOI: 10.1186/s40249-018-0440-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 05/16/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Schistosomiasis is one of the most important neglected tropical diseases. If unrecognised and untreated, the chronic infection can lead to irreversible complications. METHODS Retrospective observational study aimed at describing clinical history, laboratory findings and imaging presentation of imported schistosomiasis diagnosed at the Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital of Negrar, Verona, Italy from 2010 to 2014. The aim of our study was to assess differences in demographic characteristics, clinical presentation, laboratory data and ultrasound findings between immigrants/visiting friends and relatives (VFR) from endemic countries (endemic group) and expatriates/travellers (non-endemic group). RESULTS A total of 272 patients were retrieved: 234 in the endemic and 38 in the non-endemic group. Most of the patients acquired schistosomiasis in Africa (97.4%). Symptoms were reported by 52.9% of the patients; abdominal pain (36%), macroscopic hematuria (11.3%), and genito-urinary symptoms (7.4%) being the most frequently reported. Increased IgE and blood eosinophilia were observed in 169 (63.8%) and 130 (47.8%) patients, respectively. The proportion of positive serology was 250/272 (91.9%).The Circulating Cathodic Antigen CCA for Schistosoma mansoni was positive in 14/61 individuals (23%). At microscopy, infected subjects were 103/272 (37.9%). The species of Schistosoma found were S. haematobium (47.6%), S. mansoni (46.6%) or both (5.8%). Schistosomiasis was classified as confirmed in 103 (37.9%), probable in 165 (60.6%) and suspected in 4 (1.5%) cases using clinical presentation, laboratory data and ultrasound findings. The infection was further classified based on organ involvement: intestinal (17.9%), hepatosplenic (5.1%), urogenital (48.9%), and indeterminate (43.8%). The comparative analysis of endemic and non-endemic patients highlighted differences in sex and age. Endemic patients had more frequent ova identification (41.9% vs. 13.2%, P < 0.001) and increased IgE (70% vs. 26.3%, P < 0.001) when compared with non-endemic. Multivariate analyses showed that younger age, abnormal ultrasound findings and blood eosinophilia were significantly associated with positive microscopy (OR = 0.94, OR = 2.12, OR = 1.98, respectively). CONCLUSIONS Symptoms, eosinophilia and abnormal ultrasound findings were present in about half of patients, without differences between groups. Many patients had positive serology but negative microscopy, indicating that schistosomiasis might be misdiagnosed. A combination of diagnostic tools may facilitate the diagnosis.
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Affiliation(s)
- Valentina Marchese
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
- University Department of Infectious and Tropical Diseases & WHO Collaborating Centre for TB/HIV and TB elimination, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy
| | - Anna Beltrame
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Andrea Angheben
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Geraldo Badona Monteiro
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Giovanni Giorli
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesca Perandin
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Dora Buonfrate
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Zeno Bisoffi
- Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
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Buonfrate D, Requena-Mendez A, Angheben A, Cinquini M, Cruciani M, Fittipaldo A, Giorli G, Gobbi F, Piubelli C, Bisoffi Z. Accuracy of molecular biology techniques for the diagnosis of Strongyloides stercoralis infection-A systematic review and meta-analysis. PLoS Negl Trop Dis 2018; 12:e0006229. [PMID: 29425193 PMCID: PMC5823464 DOI: 10.1371/journal.pntd.0006229] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/22/2018] [Accepted: 01/10/2018] [Indexed: 12/11/2022] Open
Abstract
Background Strongyloides stercoralis infection is a neglected tropical disease which can lead to severe symptoms and even death in immunosuppressed people. Unfortunately, its diagnosis is hampered by the lack of a gold standard, as the sensitivity of traditional parasitological tests (including microscopic examination of stool samples and coproculture) is low. Hence, alternative diagnostic methods, such as molecular biology techniques (mostly polymerase chain reaction, PCR) have been implemented. However, there are discrepancies in the reported accuracy of PCR. Methodology A systematic review with meta-analysis was conducted in order to evaluate the accuracy of PCR for the diagnosis of S. stercoralis infection. The protocol was registered with PROSPERO International Prospective Register of Systematic Reviews (record: CRD42016054298). Fourteen studies, 12 of which evaluating real-time PCR, were included in the analysis. The specificity of the techniques resulted high (ranging from 93 to 95%, according to the reference test(s) used). When all molecular techniques were compared to parasitological methods, the sensitivity of PCR was assessed at 71.8% (95% CI 52.2–85.5), that decreased to 61.8% (95% CI 42.0–78.4) when serology was added among the reference tests. Similarly, sensitivity of real-time PCR resulted 64.4% (95% CI 46.2–77.7) when compared to parasitological methods only, 56.5% (95% CI 39.2–72.4) including serology. Conclusions PCR might not be suitable for screening purpose, whereas it might have a role as a confirmatory test. Strongyloides stercoralis is a worm that can potentially kill affected immunosuppressed individuals. The parasite is not easily detected with stool microscopy, hence novel tests have been implemented, such as polymerase chain reaction (PCR), that can detect the DNA of the parasite. This work aims at evaluating the performance of PCR for the diagnosis of S. stercoralis through a revision of diagnostic studies available in literature. According to the results of this work, PCR for S. stercoralis still misses a relevant proportion of infected people, while a positive result confirms the presence of the infection.
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Affiliation(s)
- Dora Buonfrate
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Ana Requena-Mendez
- Barcelona Institute for Global Health, ISGlobal-CRESIB, Universitat de Barcelona, Spain
| | - Andrea Angheben
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Michela Cinquini
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Mario Cruciani
- Centre of Community Medicine and Infectious Diseases Service, ULSS 9 Scaligera, Verona, Italy
| | | | - Giovanni Giorli
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Federico Gobbi
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Chiara Piubelli
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Zeno Bisoffi
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
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Verra F, Angheben A, Martello E, Giorli G, Perandin F, Bisoffi Z. A systematic review of transfusion-transmitted malaria in non-endemic areas. Malar J 2018; 17:36. [PMID: 29338786 PMCID: PMC5771189 DOI: 10.1186/s12936-018-2181-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transfusion-transmitted malaria (TTM) is an accidental Plasmodium infection caused by whole blood or a blood component transfusion from a malaria infected donor to a recipient. Infected blood transfusions directly release malaria parasites in the recipient's bloodstream triggering the development of high risk complications, and potentially leading to a fatal outcome especially in individuals with no previous exposure to malaria or in immuno-compromised patients. A systematic review was conducted on TTM case reports in non-endemic areas to describe the epidemiological characteristics of blood donors and recipients. METHODS Relevant articles were retrieved from Pubmed, EMBASE, Scopus, and LILACS. From each selected study the following data were extracted: study area, gender and age of blood donor and recipient, blood component associated with TTM, Plasmodium species, malaria diagnostic method employed, blood donor screening method, incubation period between the infected transfusion and the onset of clinical symptoms in the recipient, time elapsed between the clinical symptoms and the diagnosis of malaria, infection outcome, country of origin of the blood donor and time of the last potential malaria exposure. RESULTS Plasmodium species were detected in 100 TTM case reports with a different frequency: 45% Plasmodium falciparum, 30% Plasmodium malariae, 16% Plasmodium vivax, 4% Plasmodium ovale, 2% Plasmodium knowlesi, 1% mixed infection P. falciparum/P. malariae. The majority of fatal outcomes (11/45) was caused by P. falciparum whilst the other fatalities occurred in individuals infected by P. malariae (2/30) and P. ovale (1/4). However, non P. falciparum fatalities were not attributed directly to malaria. The incubation time for all Plasmodium species TTM case reports was longer than what expected in natural infections. This difference was statistically significant for P. malariae (p = 0.006). A longer incubation time in the recipient together with a chronic infection at low parasite density of the donor makes P. malariae a subtle but not negligible risk for blood safety aside from P. falciparum. CONCLUSIONS TTM risk needs to be taken into account in order to enhance the safety of the blood supply chain from donors to recipients by means of appropriate diagnostic tools.
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Affiliation(s)
- Federica Verra
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, 37024, Negrar, Verona, Italy.
| | - Andrea Angheben
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, 37024, Negrar, Verona, Italy
| | - Elisa Martello
- Department of Veterinary Sciences, University of Turin, Grugliasco, 10095, Turin, Italy
| | - Giovanni Giorli
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, 37024, Negrar, Verona, Italy
| | - Francesca Perandin
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, 37024, Negrar, Verona, Italy
| | - Zeno Bisoffi
- Centre for Tropical Diseases, Sacro Cuore-Don Calabria Hospital, 37024, Negrar, Verona, Italy
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