AB0558 PREVALENCE OF LATENT TUBERCULOSIS INFECTION AND ITS ASSOCIATIONS WITH CLINICAL AND SEROLOGICAL PARAMETERS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic Lupus Erythematosus (SLE) and Tuberculosis are complicatedly related and studies have shown increased risk of TB in SLE. Studies of Latent TB and SLE are inadequate. This study intended to assess the prevalence of latent TB and its association with disease parameters in SLE.

Objectives

To assess the prevalence of latent TB in patients with SLE. To investigate the demographics and clinical characteristics in patients with SLE and concomitant latent TB compared to those without.

Methods

This is a single center cross sectional study. 124 adult patients with SLE without past h/o TB were recruited. SLE demography, disease activity indices, autoantibody profile and steroid use were noted. Presence of Latent TB infection was assessed in all patients based on the IFN-g release assay (TB-IGRA). Based on the results of IGRA, SLE cases were divided into 2 groups-IGRA positive and IGRA negative. The collected parameters were compared between the 2 groups.

Results

Among 124 patients, 19 had latent TB resulting in a point prevalence of 15.4 %. The average disease duration was 4.3 years in IGRA positive and 4.6 in IGRA negative group(p>0.05). Among antibody profile, though no statistical significance among the groups, proportion of antibodies like anti Ku, Ro 60, Ro 52 and La were numerically higher in the IGRA positive group (21.1%, 42.1%, 42.1% and 21.1% respectively) when compared to the IGRA negative group (11.5%, 28.8%, 28.1% and 7.7% respectively). Likewise, anti nucleosome, histone, U1RNP, PCNA, aCLA IgG and IgM, beta 2 GPI IgG and LAC were numerically higher in IGRA negative group (42.3%, 40.4%, 43.3%, 8.7%, 23%, 18.3%, 28.8%, 14.4%) when compared to IGRA positive group (31.6%, 21.1%, 31.6%, 0, 15.8%, 5.3%, 15.8%, 5.3%). Mean clinical SLEDAI was 2.37 ±5.1 in IGRA positive and 3.5 ±5.77 in IGRA negative group. Among clinical features, 1 person in IGRA positive and none in the IGRA negative group had current gastrointestinal involvement. Comparison of other organ manifestations yielded no statistically significant difference in the 2 groups at this point. Serology revealed greater proportion of C4 in IGRA negative as compared to the positive group(p<0.042).

Conclusion

Prevalence of latent TB in SLE cases was 15.4%. Although comparison of demographic, clinical and autoantibody profile did not yield any statistically significant differences, the early turnover from this pilot study mandates further evaluation with larger sample size.

Table 1.

Comparison of clinical and laboratory parameters between IGRA positive and IGRA negative SLE cases

IGRA POSITIVE(n=19)IGRA NEGATIVE(n=105)p VALUEAge(Mean± SD)31.79±9.729.26 ±10.80.199Female Sex n(%)19(100)101(97.1)0.312Anti P0 antibody n(%)3(15.8)14(13.5)0.827Anti Ribo P antibody n(%)2(10.5)13(12.5)0.761Age of disease onset(Mean± SD)25.58± 10.624.62± 10.570.285Disease duration(Mean± SD)4.33 ±4.024.6± 3.530.438Treatment duration(Mean± SD)3.84± 4.124.03± 3.420.439Clinical SLEDAI(Mean± SD)2.37 ±5.13.5 ±5.770.306SLICC ACR DI(Mean± SD)0.105±0.320.231± 0.660.666Current CNS involvement1(5.3)4(3.8)0.781Current renal involvement3(15.8)26(25)0.367Current hematological involvement1(5.3)14(13.5)0.272Current GI involvement1(5.3)00.052Current steroid dose(Mean± SD)11.32± 11.6513.03 ± 11.60.400Serum C3(Mean± SD)0.79 ±0.320.89± 0.470.477Serum C4(Mean± SD)0.19± 0.0720.1635± 0.130.413Anti dsDNA (Mean± SD)458± 400.8379.5± 400.50.454Low C3 n(%)9(52.9)37(38.9)0.108Low C4 n(%)2(11.8)35(36.8)0.042Elevated Antidsdna n(%)6(35.3)37(38.9)3.343

Disclosure of Interests

None declared

POS0773 AUTOANTIBODIES IN A MULTI-INSTITUTIONAL INDIAN COHORT (INSPIRE) OF SLE PATIENTS: PREVALENCE, CLUSTER ANALYSIS AND PHENOTYPE ASSOCIATION

Background

Systemic Lupus Erythematosus (SLE) is characterized by an array of autoantibodies. Different autoantibodies have been associated with different clinical features like anti-dsDNA antibodies with nephritis and anti-phospholipid antibodies with pregnancy loss. However, the prevalence of autoantibodies has been variable across different ethnic groups. Data on the Indian population is limited.

Objectives

To assess the prevalence of different autoantibodies in a multi-institutional cohort (INSPIRE) of Indian SLE patients and to test their association with various clinical features using cluster analysis

Methods

The patients (n=1053) enrolled in a multi-institutional cohort of Indian patients (Indian SLE inception cohort for Research [INSPIRE]) were included.1 Antibodies were assayed using Immunoline (Euroimmune, Germany) 17 antigen kit. Anti-phospholipid antibodies (IgG and IgM anti-cardiolipin antibodies (ACLs), IgG anti-Beta 2 GpI antibodies) were measured using ELISA (Euroimmune). Lupus anticoagulant was available in a subset of patients.

The prevalence data for autoantibodies were analyzed using an intensity of only ++ and above on Immunoline assay as significant. Univariate analysis by Chi-square test was done to identify associations between individual autoantibodies and their clusters with clinical manifestations.

Results

The clinical features were fever in 702, alopecia in 813, oral ulcers in 628, acute cutaneous lupus (ACLE) in 520, proteinuria in 400, pleural effusion in 181, thrombocytopenia in 250 and autoimmune hemolytic anemia in 137 patients.

The prevalence of various autoantibodies by ELISA was anti-dsDNA antibodies in 70.2% (551/784), IgG Anti- beta-2 GpI in 4.47% (42/938), IgG ACL in 6.14% (61/992) and IgM ACL in 7.1% (54/760). Lupus anticoagulant was present in 13.9% (112/ 805). By Immunoline assay, the prevalence for anti-Ro 52, anti-Ro 60, anti-La and anti-Ribosomal P was 28.49%, 33.14%, 10.07% and 24.03% respectively (Table 1).

Table 1.

Prevalence of different autoantibodies in the INSPIRE lupus cohort

S. No.AutoantibodyPrevalence (%) (n=1053)1.dsDNA28.112.Nucleosomes27.833.Histones24.884.Ro_52_SSA28.495.Ro_60_SSA33.146.SSB-La10.077.Ribosomal P24.038.nRNP36.759.Sm33.1410.Scl-703.2311.PM-Scl0.3812.Jo-10.0913.CENP-B0.3814.PCNA1.3315.AMA-M22.28

Cluster analysis (Figure 1) revealed association (Odds ratio with 95% confidence interval) of Cluster 1 (antibodies against dsDNA, histones and nucleosomes) with arthritis (1.51 [1.18-1.94]), proliferative nephritis (3.05[2.08-4.48]) and pleural effusion (1.49[1.08-2.05]), cluster 2 (antibodies against Sm, nRNP, Ro52, Ro60 and Ribosomal P) with ACLE (1.3[1.02-1.65]) and non-proliferative nephritis (1.64[1.09-2.46]) and cluster 3 (antiphospholipid antibodies) with thrombocytopenia (3.34[1.57-7.11]).

Figure 1.

Cluster analysis of autoantibodies (Cluster 1: dsDNA, histone and nucleosome; cluster 2: Sm, nRNP, Ro52, Ro60 and Ribosomal P; cluster 3: cardiolipin, β2GP1 and La and lupus anticoagulant; cluster 4: Scl-70, Jo-1, PCNA, AMA-M2, PM-SCL and CENP-B)

Conclusion

The prevalence of anti-Sm antibody and Anti-Ribosomal P antibody is higher whereas that of anti-La antibody is lesser in the Indian SLE patients as compared to other cohorts of SLE patients with different ethnicities.2 Cluster analysis reveals co-occurrence of different autoantibodies in our patients and their significant association with various clinical manifestations which suggests a possible pathogenic role of autoantibodies or a common genetic basis for it.

References

[1]Shobha V, Aggarwal A, Rajasekhar L, Jain A, Gupta R, Das B, et al. Indian SLE Inception cohort for Research (INSPIRE): the design of a multi-institutional cohort. Rheumatol Int. 2021 May;41(5):887-894.

[2]Yang J, Xu Z, Sui M, Han J, Sun L, Jia X, et al. Co-Positivity for Anti-dsDNA, -Nucleosome and -Histone Antibodies in Lupus Nephritis Is Indicative of High Serum Levels and Severe Nephropathy. PLoS One. 2015 Oct 14;10(10):e0140441.

Disclosure of Interests

Amita Aggarwal: None declared, Ranjan Gupta Grant/research support from: Dr. Ranjan Gupta has received 2 grants for educating patients and primary care physicians about rheumatoid arthritis managment., Rudrarpan Chatterjee: None declared, Vir Negi: None declared, Bidyut Kumar Das: None declared, Parasar Ghosh: None declared, Debashish Danda: None declared, Vineeta Shobha: None declared

POS0775 COMBINED MODEL OF RENAL HISTOPATHOLOGY AND CLINICAL PARAMETERS BETTER PREDICT ONE YEAR RENAL OUTCOMES IN LUPUS NEPHRITIS: ANALYSIS OF 334 KIDNEY BIOPSIES

Background

Diagnosis of Lupus Nephritis (LN) is currently based on laboratory tests and renal histopathology. Role of histopathological features in determining long term outcomes is unclear.

Objectives

1. To assess if clinical and biochemical parameters at baseline can identify renal histopathological class.

2. To assess the clinico-histopathological predictors of renal response.

Methods

This is a single centre retrospective study comprising 334 LN renal biopsies. Clinical and biochemical parameters at the time of biopsy were noted and their association with histopathological class, activity and chronicity scores (AS/CS) (ISN/RPS classification) were evaluated. Complete, partial or no response (CR, PR, NR) for renal outcome (EULAR/EDTA) at 1 year were assessed for 293 patients. Binary logistic regression was done to look for the predictors of NR.

Results

Class III/IV LN was seen in 240(71.8%). Hypertension was seen in (52.1%) of class III/IV and <25% each with class II, V and combined class(p<0.001). Class III/IV had lower eGFR [87.6(62.75-118.8)] (p<0.001) than the other classes. Nephrotic range proteinuria was seen in 32% of class V and 21% in class III/IV (p=0.004). Among class-III/IV, AS had weak correlation with baseline UPCR (r=0.31) and eGFR (r=-0.172) (p<0.01). CS had weak negative correlation with eGFR (r=-0.212, p<0.01). NR at 1 year was higher in males (OR-4.6,95%CI-1.9-10.8, p<0.001), those with abnormal serum creatinine (OR-3.3,95%:CI1.6-7.02, p-0.001), higher renal SLEDAI (p<0.05), higher AS, CS (p<0.001), interstitial inflammation and tubular atrophy(p<0.005) (Table 1). On binary logistic regression a combined clinico-histopathological model comprising of serum creatinine, UPCR, male sex and CS performed best in predicting NR (Figure 1).

Table 1.

Comparison of baseline characteristics among those who attained any response (CR/PR) versus others at 1 year

ParameterAny response Complete Response CR/PR (n=233)Others (No response/rescue) (n=60)OR (95% CI)P valueFemale/male, n (%)221(94.8)/12(5.2)48(80)/12(20)4.6(1.9-10.8)0.001Median age at nephritis onset28(11-65)25(13-67)0.079Median SLE duration12(0-232)18(0-144)0.770Hypertension, n (%)100(42.9)34(56.7)0.061Creatinine>1.3mg/dL (median, IQR)21(9.0)15(25)3.3(1.6-7.02)0.001eGFR categories, n (%)137(58.8)27(45)1.7(0.96-3.03)0.003>9057(24.5)15(25)61-9034(14.6)9(15)30-604(1.7)8(13.3)<30Active urinary sediments, n (%)132(56.7)44(73.3)0.019uPCR g/day (median with IQR)1.38(0.8-2.67)1.95(1.18-4.19)0.098Class III/IV, n (%)167(71.7)49(81.7)0.117Class V, n (%)17(7.3)5(8.3)0.788Combined class, n (%)7(3.0)3(5.0)0.469Activity score, median with IQR3(1-6)6(3-9)0.001Chronicity score, median with IQR0(0-1)1(0-2)5.06(1.49-17.21)0.001Presence of Crescents, no (%)43(18.5)17(28.3)0.104Fibrinoid necrosis, n (%)28(12.0)7(11.7)0.791Interstitial inflammation, n (%)86(36.9)33(55)2.08(1.17-3.70)0.003Interstitial fibrosis, n (%)23(10.7)9(15)0.273Tubular atrophy, n (%)64(27.5)27(45)0.003Blood vessel changes, n (%)2(0.9)1(1.7)0.606Fibrinoid necrosis206(88.4)50(83.3)0.339Other changes*Figure 1.

ROC curve and AUC for the three different models

Model 1: Baseline serum creatinine, urine PCR, male sex; AUC – 0.694(0.609-0.779), p <0.001

Model 2: Baseline serum creatinine, urine PCR, male sex, chronicity score; AUC – 0.740(0.660-0.820), p<0.001

Model 3: Baseline serum creatinine, urine PCR, male sex, chronicity score, crescents, interstitial inflammation; AUC – 0.744(0.664-0.824), p<0.001

Conclusion

Clinical and biochemical parameters can predict the renal histological class to a fair extent but has limited value in predicting the activity and chronicity parameters. Since a combination of clinical and histopathology parameters are better in predicting renal outcomes, performing renal biopsies should be encouraged in LN.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

POS0392 ROLE OF SEMIQUANTITATIVE THIGH MAGNETIC RESONANCE IMAGING (tMRI) IN DETERMINING SKELETAL MUSCLE OUTCOMES AT BASELINE AND ON FOLLOW UP IN IDIOPATHIC INFLAMMATORY MYOPATHIES (IIMs)

Background

Idiopathic Inflammatory Myopathies (IIMs) are characterized by muscle inflammation and associated muscle weakness. Semiquantitative scoring of thigh Magnetic Resonance Imaging (tMRI) has shown contradictory results in associating muscle inflammation, damage, and clinically assessed muscle weakness. Moreover, there are no studies assessing the role of tMRI detected muscle damage in determining long-term recovery of muscle strength and endurance.

Objectives

To correlate tMRI scores for muscle edema, fascial edema, muscle atrophy, and fatty infiltration with consecutively collected manual muscle testing 8 (MMT-8) scores and muscle enzymes. To determine the role of baseline tMRI changes in achieving maximum muscle power during follow-up.

Methods

This is a retrospective analysis of a single-center myositis cohort. IIM patients (n=55) who underwent baseline tMRI (STIR and T1 sequences) at the time of diagnosis were included. Baseline demographic, clinical, and serological parameters were noted. MRI T1 weighted sequence and STIR sequence axial and coronal images were assessed for intramuscular and fascial edema, atrophy and fatty replacement using a semiquantitative score and the percentage of muscle involvement for each parameter was calculated. MMT-8 values and muscle enzyme levels which remained unchanged at least for 6 months during follow-up were noted for 42 patients. MMT-8 ≥74 was taken as near normal muscle power based on the fact that 75% of IIM patients in remission for a long duration achieved MMT-8 of≥74 in our cohort. Spearman correlation was done between clinical parameters, muscle enzymes, and tMRI scores. Baseline parameters of patients who achieved and did not achieve MMT8≥74 were compared. Multiple linear regression was performed to assess the tMRI variables predicting a higher MMT-8 during follow-up

Results

The median age was 36 (27.25-44.75) years, median duration of disease at presentation was 4 months (2-10), median duration of follow up was 24 months (6.75-38.25). Dermatomyositis, Polymyositis and Antisynthetase syndrome comprised of 58.2%, 7.3% and 30.9% cases respectively. Baseline muscle enzymes CPK(r=0.531), AST(r=0.535) and ALT(r=0.442) showed significant positive correlation(p<0.01) with muscle edema. Baseline MMT-8 showed significant negative correlation with muscle edema(r=-0.657) and fascial edema(r=-0.522) (p<0.01). Follow up MMT-8 showed significant negative correlation with muscle edema(r=-0.359), muscle atrophy (r=-0.319) and fatty infiltration(r=-0.308) (p<0.05) (Figure 1). Baseline MMT-8 and MRI fatty infiltration were significantly different between patients who achieved and did not achieve MMT-8 of ≥74 on follow-up (Table 1). Multiple regression analysis revealed adjusted R2 value of 0.386. Baseline MMT-8(β=0.372) and muscle atrophy(β=-0.459) significantly predicted MMT-8 on follow-up

Table 1.

Comparison between those who achieved near-normal muscle power versus others

Follow up MMT-8<74 (n=8)Follow up MMT-8 ≥74 (n=34)P-valueAge (years) (median, IQR)36.5(27-47.5)36(28.75-44.25)1.000Duration of disease (months) (median, IQR)6(4-10.5)3.5(2.75-9.75)0.459Baseline muscle enzymes and MMT-8 (median, IQR)CPK (IU/L)1758(116-6160)680(57.5-3595)0.410LDH (IU/L)496(240-823)616.50(289.25-753)0.672AST (IU/L)112(76-201.5)69.5(40.5-226.25)0.352ALT (IU/L)74.50(65.5-139.75)69(36-142.25)0.560MMT-8 baseline (0-80)49.5(47.25-56)63(53.75-73.25)0.007MRI thigh scores (median, IQR)Muscle edema%22.41(5.65-63.33)10.37(0.00-28.70)0.070Fascial edema %43.33(18.61-78.06)33.89(11.49-50.56)0.478Muscle atrophy %2.22(0.28-20.83)0.00(0.00-2.50)0.081Fatty infiltration %6.67(2.78-18.61)0.56(0.00-3.61)0.010Figure 1.

Correlation between baseline and Follow up MMT-8 with tMRI scores.

Conclusion

Low baseline MMT-8 and presence of muscle atrophy at baseline are predictors of poor outcome. Hence performing a baseline MRI will help in the prognosis.

Disclosure of Interests

None declared

Tensile behavior of non-crosslinked networks of athermal fibers in the presence of entanglements and friction

Many biological and soft artificial materials contain a random network of non-crosslinked fibers as their main structural component. The excluded volume interactions (contact forces) at fiber contacts control the mechanical behavior of these systems. This physics has been studied extensively in compression, but little is known about the relation between network structure and its mechanical response in tension. In particular, although occasionally used conjecturally, the notion of fiber entanglements in athermal networks is not well defined, nor is it clear what role entanglements play in athermal network mechanics. The primary contribution of this work is the introduction of a measure of the degree of entanglement of a system of random athermal fibers, and the definition of its relationship with the mechanical behavior of the network. Entanglements confine the fibers during tensile loading, reduce the auxetic effect in mat-like networks, and maintain the inter-fiber contact density. In the absence of this contribution, reduction of the contact density during tensile loading due to auxeticity results in stress reduction. Entanglements stabilize the network via a tensegrity mechanism similar to that operating in woven materials and lead to network stiffening. The relation between the proposed measure of entanglements and the fiber volume fraction is defined. The effect of inter-fiber friction on the mechanics of entangled mat-like non-crosslinked fiber networks is also evaluated.

POS0880 TWO-MINUTE WALK TEST AS A SIMPLE AND OBJECTIVE OUTCOME MEASURE IN IDIOPATHIC INFLAMMATORY MYOSITIS

Background:

Manual muscle testing (MMT) and Functional index 2(FI-2) are the usual methods in assessing disease activity in IIM1. Limitations of MMT8 include low sensitivity to change, floor/ceiling effect, and under-representation of certain important muscle groups1 while FI-2 takes a longer time to administer. Several Timed function tests (TFTs) like the 2-minute walk test (2MWT) or 30s raise from a chair test and 30s 1kg arm rise test may be better alternatives and less time taking2. Data looking at the performance of these tests are limited to small controlled studies.

Objectives:

To assess the performance of timed function tests against MMT8 and FI-2 in assessing muscle strength and endurance at baseline, 3 and 6 months of therapy.

Methods:

An observational cohort study, included 41 patients with polymyositis and dermato-myositis attending OPD and IPD service of tertiary centre. MMT8, FI-2 and Timed function tests were done at baseline, at 3 months and at 6 months. (Figure 1)

Figure 1.

Consort diagram showing the workflow in study population

Results:

Forty one patients included in the study had completed three month follow-up assessment, while 17 patients achieved a six-month evaluation. Out of 41 patients, 11 (27%) were polymyositis, and 30 (73%) were dermatomyositis. The mean MMT8 of the total study population at baseline was 57±15, at three months (n=41) was 66 ±10 and at six months (n=17) was 71 ± 10, while in active subgroup was 50 ± 18, 64 ± 9 (n=41), 67 ± 9.6 (n=17)at baseline, three months and six months respectively. The change in TFTs showed a moderate to strong correlation with the change in Fi-2 among the study population at three months and six months (Table 2). Among the TFTs 2MWT showed moderate correlation with both MMT8 and FI-2 in active disease.

Table 1.

Spearman Rho Correlation between change in timed function tests with change in MMT8, change in FI-2 at 3 months and 6 months

At 3 months (n=41)At 6 months (n=17)Active disease(n=18)Inactive disease(n=23)Active disease(n=7)Inactivedisease(n=10)Correlation of Δ MMT8 withΔ30s rise form chair0.1430.3460.2000.347Δ30s1kg arm lift0.0180.2840.3620.168Δ2MWD0.755*0.3130.482*0.334Correlation of ΔFI-2 withΔ30s rise form chair0.784*0.495*0.486*0.424*Δ30s1kg arm lift0.671*0.1070.704*0.301Δ2MWD0.834*0.623*0.808*0.506*

*p<0.05

Conclusion:

Using timed function tests can be an excellent alternative to FI-2 in assessing muscle endurance. 2-minute walk distance is a better alternative to conventional muscle testing as it measures both power and endurance, and this can overcome the ceiling effect of MMT-8.

References:

[1]Rider LG, Aggarwal R, Machado PM, Hogrel J-Y, Reed AM, Christopher-Stine L, et al. Update on outcome assessment in myositis. Nat. Rev. Rheumatol. 2018;14:303–18.

[2]Agarwal S, Kiely PD. Two simple, reliable and valid tests of proximal muscle function, and their application to the management of idiopathic inflammatory myositis. Rheumatology. 2006 Jul 1;45(7):874-9.

Acknowledgements:

I would like to acknowledge my patients, my teachers, colleagues, and paraclinical staff of the department of Clinical Immunology JIPMER

Disclosure of Interests:

None declared

POS0890 MACROVASCULAR DYSFUNCTION AND ITS CLINICAL IMPLICATION IN SYSTEMIC SCLEROSIS

Background:

Even though microvascular dysfunction has been implicated in pathogenesis of scleroderma (SSc), there is minimal evidence to suggest presence of macrovascular dysfunction. The clinical implication of macrovascular dysfunction in SSc is unknown. Moreover, data on the correlation between dysfunction in small and large blood vessel is inconclusive. [1-2]

Objectives:

To study the correlation between macrovascular dysfunction as assessed by percent change in flow mediated vasodilation (FMD) of brachial artery and microvascular dysfunction as assessed by nail fold capillaroscopy (NFC) findings in SSc. To assess the clinical impact of macrovascular dysfunction.

Methods:

This cross-sectional comparative study enrolled patients with SSc and age and gender matched healthy controls. FMD change was calculated using standard USG probe of 5 to 6 MHz in right brachial diameter from the average of 3 consecutive end diastolic frames. NFC was performed using portable nail fold capillary microscope at 800X magnification. Clinical features of SSc were compared between SSc patients with and without macrovascular dysfunction.

Results:

This study enrolled 59 SSc patients including 29 (49.2%) diffuse, 20 (20.4%) limited, 08 (10.2%) sine SSc and 2 patients (3.4%) with myositis overlap. SSc patients had significantly (p-<0.0001) lower % FMD change compared to healthy controls. NFC showed significantly higher architecture distortion (p-<0.0001), loss of capillaries (p-<0.0001) and abnormal capillaries (p-<0.0001). There was no correlation between FMD change and capillary density (p-0.381), avascular area (p-0.266) and abnormal capillaries (p-0.899). None of the clinical features like pulmonary hypertension, digital ulcer burden, acro-osteolysis and auto amputation were different between SSc with and without macrovascular dysfunction.

Conclusion:

Macrovascular dysfunction in SSc is substantial and it seems to be independent of the microvascular dysfunction. The clinical implications of macrovascular dysfunction are yet to be identified.

References:

[1]Schioppo T, Orenti A, Boracchi P, De Lucia O, Murgo A, Ingegnoli F. Evidence of macro- and micro-angiopathy in scleroderma: An integrated approach combining 22-MHz power Doppler ultrasonography and video-capillaroscopy. Microvasc Res. 2019 Mar;122:125–30.

[2]Rollando D, Bezante GP, Sulli A, Balbi M, Panico N, Pizzorni C, et al. Brachial Artery Endothelial-dependent Flow-mediated Dilation Identifies Early-stage Endothelial Dysfunction in Systemic Sclerosis and Correlates with Nailfold Microvascular Impairment. J Rheumatol. 2010 Jun 1;37(6):1168–73.

Table 1.

Comparison of various parameters between the SSc patients with healthy controls.

ParameterFrequency (percentage)/median (interquartile range)SSc patients (n=59)Healthy controls (n=64)Demographic detailsAge in years38 (27-46)36.5 (28.25-42)Gender Male03 (5.1%)03 (4.7%) Female56 (95.1%)61 (95.3%)FMD findings FMD % change*4.54 (3.13-8.82)10.30 (8.33-13.16)NFC findings Number of capillaries*51 (38-63)121 (113-128) Average capillary density*3.19 (2.38-3.94)7.56 (7.06-8) Disorganized architecture (%)*37.5 (12.5-37.5)0 U shape (%)*50 (36.59-68.09)85.51 (82.97 – 88.53) Abnormal (%)*36.11 (14.03-55.26)0 Enlarged (%)*10.63 (2.94-23.68)0 Giant (%)*21.05 (0-45.45)0 Microhemorrhages (%)*6.25 (0-12.5)0 Neoangiogenesis (%)*3.85 (0-20)0 Avascular area (%)*50 (31.25- 75)0

*parameters with statistically significant (p value< 0.0001) difference among two groups. SSc; Systemic Sclerosis, FMD; flow mediated vasodilatation, NFC; nail fold capillaroscopy

Figure 1.

Scatter plot showing correlation between FMD percentage change and average capillary density. (r= 0.116) (P-value - 0.381)

Disclosure of Interests:

None declared

Autoimmune polyendocrine syndrome type 1 (APECED) in the Indian population: case report and review of a series of 45 patients

BACKGROUND

Autoimmune polyendocrinopathy-candidiasis-ectodermal-dystrophy (APECED) or autoimmune polyglandular syndrome type 1 (APS-1) is a rare autosomal recessive genetic disease due to mutations in the AIRE (AutoImmune REgulator) gene. The clinical diagnosis is classically based on the presence of at least two of the three main components: chronic mucocutaneous candidiasis, hypoparathyroidism and primary adrenal insufficiency. Patients often suffer from other endocrine or non-endocrine autoimmune conditions throughout life. APECED etiopathogenesis is mediated by T lymphocytes. Autoantibodies against proteins of the affected organs are found in the serum of APECED patients as well as neutralizing antibodies against cytokines. We report here the clinical and genetic characteristics of 45 Indian APECED patients in comparison to Finnish, Sardinian, Turkish and North/South American cohorts from their published results. We also report a new case of APECED of Indian origin, a 2-year old child suffering from chronic mucocutaneous candidiasis since the age of 8 months, with confirmatory AIRE homozygous mutation c.274C > T (p.R92W).

CONCLUSION

With the inherent limitations of a retrospective study, analysis of Indian APECED patients suggested that compared to classic criteria, application of Ferre/Lionakis criteria validated in North/South American patients could help in earlier diagnosis in 3 of 8 (37.5%) patients for whom adequate information for evaluation was available.

Clinical features, severity and outcome of acute pancreatitis in systemic lupus erythematosus

Acute pancreatitis (AP) is a rare but life threatening manifestation of Systemic Lupus Erythematosus (SLE). The current study aims to study the clinical characteristics, severity, mortality, and outcome of SLE-related AP in Indian population. We retrospectively reviewed medical records of patients with SLE who had AP in the past. Data from 13 rheumatology centers across India were compiled. All patients satisfied SLICC criteria for SLE and ATLANTA criteria for AP. AP was classified in to mild, moderate and severe using revised Atlanta classification. Patients with known risk factors like gall stone and alcohol were excluded.Sixty-six patients (six, children) were studied. Majority of patients were females (82%). The median age of presentation was 24 (11-63) years and most patients (57.5%) presented within first year of diagnosis of lupus. AP occurred mostly in the setting of active lupus (89%). Active nephritis was seen in 39% while a fourth had CNS disease. Patients with severe AP had lower C3. Ascites and sepsis were most common local and systemic complications, respectively. Mortality was 17%. Hypocalcemia, presence of sepsis and shock predicted mortality. In the multivariate analysis, only presence of shock remained as independent predictor of death (OR 63.0, 95% CI: 5.2-760.3). Pancreatitis is an early manifestation of SLE and is associated with active disease. Significant mortality is seen particularly with severe pancreatitis.

Deficiency of Adenosine Deaminase 2 in Adults and Children: Experience From India

OBJECTIVE

Deficiency of adenosine deaminase 2 (DADA2) is a potentially fatal monogenic syndrome characterized by variable manifestations of systemic vasculitis, bone marrow failure, and immunodeficiency. Most cases are diagnosed by pediatric care providers, given the typical early age of disease onset. This study was undertaken to describe the clinical phenotypes and treatment response both in adults and in children with DADA2 in India.

METHODS

A retrospective analysis of pediatric and adult patients with DADA2 diagnosed at various rheumatology centers across India was conducted. Clinical characteristics, diagnostic findings, and treatment responses were analyzed in all subjects.

RESULTS

In total, 33 cases of DADA2 were confirmed in this cohort between April 2017 and March 2020. Unlike previous studies, nearly one-half of the confirmed cases presented during adulthood. All symptomatic patients exhibited features of vasculitis, whereas constitutional symptoms and anemia were more common in pediatric patients. Cutaneous and neurologic involvement were common, and 18 subjects had experienced at least one stroke. In addition, the clinical spectrum of DADA2 was expanded by recognition of novel features in these patients, including pancreatic infarction, focal myocarditis, and diffuse alveolar hemorrhage. Treatment with tumor necrosis factor inhibitors (TNFi) was initiated in 25 patients. All of the identified disease manifestations showed marked improvement after initiation of TNFi, and disease remission was achieved in 19 patients. Two cases were complicated by tuberculosis infection, and 2 deaths were reported.

CONCLUSION

This report presents the first case series of patients with DADA2 from India, diagnosed by adult and pediatric care providers. The findings raise awareness of this syndrome, particularly with regard to its presentation in adults.

AB0094 FUNCTIONAL TREG CELLS MAY BE CONVERTED INTO T EFFECTOR PHENOTYPE ON EXPOSURE TO INFLAMMATORY MILIEU IN RHEUMATOID ARTHRITIS (RA) SYNOVIAL FLUID: IN-VITRO STUDY

Background:

The debate on functional versus numerical difference in T regulatory cell population among patients with Rheumatoid arthritis (RA) is not clear. Tregs expressing Inflammatory subset phenotype markers, such as Th1(cxcr3, Tbet) and Th17(ccr6,Rorϒ) are reported. (1) Though the reported numbers of synovial fluid tregs are higher in RA, (2) the fate of Tregs on entering the synovial inflammatory milieu from peripheral blood (PB) has not yet been investigated.

Objectives:

To compare Treg frequencies in PB and synovial fluid between osteoarthritis (OA) and RA

To compare cytokine levels in PB and SF between OA and RA

To study the effect of autologous synovial fluid on RA and OA Treg isolated form peripheral blood

Methods:

The Peripheral Blood (PB) and synovial fluid (SF) of RA (n=80) and OA (n=30) patients were analyzed for CD4+T-cell subset frequencies and phenotypes by flow cytometry. Cytokine concentrations in plasma and SF were measured by cytometric bead array. Tregs from 5 RA-PB and 5 OA-PB were isolated and cultured in autologous synovial fluid for 24 hrs. Phenotypic expression of Th1 and Th17 chemokines on the cell surface were analyzed by flow cytometry and expression levels of T-bet, RORγ and FOXP3 in those Treg cells were measured with quantitative real-time PCR (RT-qPCR).

Results:

The PB and SF frequencies of Th1, Th17 and Tregs are shown in Table 1. The pro-inflammatory cytokines were high in the plasma and SF of RA but the anti-Inflammatory cytokines were similar (Fig 1.A&B). Treg cells were isolated from RA and OA PB and cultured in autologous SF for 24 hrs. RA Treg showed increased cell surface expression of CXCR3+ and CCR6+ (Fig 1C) and there was no difference in OA Treg. Gene expression studies showed an increased expression of T-bet, RORγ and decreased expression of Foxp3 in RA Tregs while there was no difference in OA Tregs before and after in-vitro culture (Fig 1D).

Table 1.

Tcell subsets in Rheumatoid Arthritis and Osteoarthritis.

CD4 subtypeRAOAPBSFPBSFN=80N=30N=30N=30Th126.65 ± 5.5934.99 ± 1.3025.97 ± 7.2426.45 ± 1.87*Th25.19 ± 1.916.36 ± 1.735.24 ± 2.151.44 ± 0.10*Th1714.05 ± 3.2921.18 ± 2.0410.81 ± 2.78*2.45 ± 0.23*Treg10.68 ± 2.4712.53 ± 2.1011.162.9513.04 ± 2.57

*P<0.05

Conclusion:

Tregs in RA may be converted to Th1 and Th17 phenotype on exposure to inflammatory cytokine in the synovial fluid, thus losing their regulatory functions. Understanding factors influencing stability of Treg cells may help improve future therapeutics.

References:

[1]Jinlin Miao & Ping Zhu. Functional Defects of Treg Cells: New Targets in Rheumatic Diseases, Including Ankylosing Spondylitis. Current Rheumatology Reports 2018; 20: 30

[2]Penatti et al. Differences in serum and synovial CD4+ T cells and cytokine profiles to stratify patients with inflammatory osteoarthritis and rheumatoid arthritis. Arthritis Research & Therapy.2017; 19:103

Acknowledgments:

Department of Science and technology, India for the research grant.

Disclosure of Interests:

None declared

SAT0314 TIMED FUNCTION TESTS ARE AN ALTERNATIVE TO MMT8 AND FI-2 IN INFLAMMATORY MYOSITIS - AN OBSERVATIONAL COHORT STUDY

Background:

Inflammatory myositis are heterogenous group of diseases affecting skeletal muscles and multiple different organs1. Manual muscle testing (MMT) is the common tool used for assessment of muscle strength. Its limitations include poor sensitivity to change, floor/ceiling effect, and under representation of certain important muscle groups2. Functional index 2(FI-2) is an objective measure of dynamic repetitive muscle function at 11 proximal and distal muscle groups which correlates well with patient-reported physical function3. Since MMT8 is inadequate and FI-2 takes longer time to administer, several timed tests to assess muscle function, endurance and fatiguability like the 2- minute walk test (2MWT) or 30s raise from a chair test and 30s arm rise test are viable alternatives to be tested. Data looking at the performance of these tests are limited to small controlled studies.

Objectives:

To study correlation of timed tests with MMT8 and FI-2 in assessing muscle strength, endurance at baseline and at 3 months of therapy.

Methods:

An observational cohort study, included 19 patients with polymyositis and dermatomyositis attending OPD and IPD service of tertiary center. Patients with nclusion body myositis, overlap myositis, chronic kidney disease, coexisting myocarditis, sepsis, malignancy, pregnancy were excluded. MMT8, FI-2 and Timed function tests were done at baseline and after 3 months.

Results:

The study had 19 patients of which 6 were polymyositis and 13 were dermatomyositis. Male to female ratio was 1:2.1. Anti-cell antibody was positive in 16 patients. The mean MMT8 of the study group at baseline was 60.84±16.77 and after 3 months was 67.05±11.7. Out of 19 patients, all received prednisolone as induction agent followed by Methotrexate in 13, cyclophosphamide in 9, azathioprine in 5, Rituximab by one patient. Mean scores of 30s arm lift, 30s rise from chair test and 2 min walk test were 11.7±6.39,14±7.29,101.5± 46.48 respectively at baseline and 13.05±6.5,15.6±7.1,117.84±38.4 after 3 months.

Table 1.

Spearman Rho Correlation between timed function tests and MMT8, FI-2, patient and physician VAS

Δ 30s rise from chair testΔ 30s arm lift testΔ 2 min walk testΔ MMT80.3820.3370.724**Δ FI-2Hip flexion right0.3880.4130.314Hip flexion Left0.503*0.4160.422Neck flexion0.600**0.590**0.610**Shoulder flexion right0.1830.3000.239Shoulder flexion left0.3930.2220.207Shoulder abduction right0.2360.2220.348Shoulder abduction left0.1820.2360.273Step test right0.744**0.489*0.326Step test left0.8400.500*0.378Heel rise0.4420.2940.388Toe rise0.4460.2910.419Δ Physician VAS-0.508*-0.506**-0.215Δ Patient VAS-0.600**-0.597**-0.249

Δ → change from baseline to 3 months *→ Correlation is significant at the 0.05 level **→ Correlation is significant at the 0.01 level

Conclusion:

Timed function tests correlated well with MMT 8 and parameters with in FI-2. Thus these tests are good alternatives in assessing disease activity and response assessment in inflammatory myositis.

References:

[1]Selva-O’Callaghan A, Pinal-Fernandez I, Trallero-Araguás E, Milisenda JC, Grau-Junyent JM, Mammen AL. Classification and management of adult inflammatory myopathies. Lancet Neurol. 2018; 17:816–28.

[2]Rider LG, Aggarwal R, Machado PM, Hogrel J-Y, Reed AM, Christopher-Stine L, et al. Update on outcome assessment in myositis. Nat. Rev. Rheumatol. 2018;14:303–18.

[3]Alexanderson H, Broman L, TollbÄck A, Josefson A, Lundberg IE, StenstrÖm CH. Functional index-2: Validity and reliability of a disease-specific measure of impairment in patients with polymyositis and dermatomyositis. Arthritis Rheum. 2006;55:114–22.

Disclosure of Interests: :

None declared

Immunological biomarkers in neuropsychiatric systemic lupus erythematosus: a comparative cross-sectional study from a tertiary care center in South India

INTRODUCTION

The prevalence of various immunological biomarkers in neuropsychiatric systemic lupus erythematosus (NPSLE) differs among various patients with varied neuropsychiatric manifestations and different populations. We studied the prevalence of these biomarkers; especially the neuron specific autoantibodies in patients with systemic lupus erythematosus (SLE) and compared them among patients with and without neuropsychiatric involvement.

METHODOLOGY

This is a comparative cross-sectional study conducted in a tertiary care hospital in South India. The prevalence of immunological biomarkers including complement levels, systemic and brain specific autoantibodies (anti-myelin antibody, anti-myelin oligodendrocyte glycoprotein and anti-myelin-associated glycoprotein antibody) were assessed and compared among those with and without NPSLE and with different NPSLE manifestations.

RESULTS

A total of 522 SLE patients were enrolled in the study. The mean age of the study participants was 28.5 ± 8.8 years and 93.5% were women. Neuropsychiatric manifestations were seen in 167 (32%) patients. Seizure was the most common neuropsychiatric manifestation seen in 41.3%, followed by psychosis (18.6%), mood disorder (16.8%), stroke (10.8%), mononeuropathy (10.2%), headache (9.6%), acute confusional state (6.6%) and aseptic meningitis (5.4%). Patients with NPSLE had a higher SLE disease activity index score. Most of the autoantibodies, that is anticardiolipin antibody (aCL), anti-β2 glycoprotein 1 antibody (β2GP1), lupus anticoagulant (LA), anti-nucleosome, anti-ribosomal P, anti-Ro52, anti-Ro60 and anti-La, were seen in higher proportion in the NPSLE group, although the difference failed to reach statistical significance. On subgroup analysis, psychosis was significantly higher in patients with anti-ribosomal P positivity than without (11.8% versus 4.1%, p.0.007; odds ratio (OR) 3.1, confidence interval (CI) 1.4-6.8), while stroke had a higher proportion among those with positive b2GP1 IgG (6.3% versus 1.8%, p.0.03; OR 3.6, CI 1.2-11.0). A higher proportion of demyelination was seen among the LA positive than the negative (10.3% versus 0.2%, p.0.03; OR 5.39, CI 1.15-24.17) and anti-myelin oligodendrocyte glycoprotein in mood disorder (14.3% versus 3.4%, p = 0.03; OR 4.66, CI 1.13-19.13).

CONCLUSION

No single biomarker correlated with NPSLE. Among different NPSLE manifestations, the prevalence of IgG β2GP1 in stroke, LA in demyelination, anti-ribosomal P in psychosis and anti-myelin oligodendrocyte glycoprotein in mood disorder were higher. Further studies on the pathogenic mechanisms underlying NPSLE and its different manifestations may help us to identify better biomarkers.

Mechanical behavior of nonwoven non-crosslinked fibrous mats with adhesion and friction

We present a study of the mechanical behavior of planar fibrous mats stabilized by inter-fiber adhesion. Fibers of various degrees of tortuosity and of infinite and finite length are considered in separate models. Fibers are randomly distributed, are not cross-linked, and interact through adhesion and friction. The variation of structural parameters such as the mat thickness and the mean segment length between contacts along given fibers with the strength of adhesion is determined. These systems are largely dissipative in that most of the work performed during deformation is dissipated frictionally and only a small fraction is stored as strain energy. The response of the mats to tensile loading has three regimes: a short elastic regime in which no sliding at contacts is observed, a well-defined sliding regime characterized by strain hardening, and a rapid stiffening regime at larger strains. The third regime is due to the formation of stress paths after the fiber tortuosity is pulled out and is absent in mats of finite length fibers. Networks of finite length fibers lose stability during the second regime of deformation. The scaling of the yield stress, which characterizes the transition between the first and the second regimes, and of the second regime's strain hardening modulus, with system parameters such as the strength of adhesion and friction and the degree of fiber tortuosity are determined. The strength of mats of finite length fibers is also determined as a function of network parameters. These results are expected to become useful in the design of electrospun mats and other planar fibrous non-cross-linked networks.

Strength of filament bundles - The role of bundle structure stochasticity

Most biological fibrous materials are hierarchical, in the sense that fibers of finite length assemble in bundles, which then form networks with structural role. Examples include collagen, silk, fibrin and microtubules. Some artificial fiber-based materials share this characteristic, examples including carbon nanotube (CNT) yarns and unidirectional composites. Here we study bundles in which filaments do not break, while bundle rupture happens by the failure of inter-filament crosslinks, followed by pull-out. In all cases, the crosslinks are randomly distributed along interfaces. The strength of such bundles depends on material parameters of the filaments and crosslinks, such as their stiffness and strength, and on the cross-link density. We focus on the dependence of the bundle strength on two parameters: filament waviness and filament staggering. Bundles with regular staggering are stronger than those with stochastic staggering. We identify the optimal regular staggering that maximizes the strength. Filament waviness increases the strength of stochastically staggered bundles at constant crosslink density but decreases the strength of regularly staggered bundles. Results for bundles with permanent crosslinks, which never reform once they break, as well as transient crosslinks capable of reforming during deformation are presented, and it is shown that the general trends are independent of the nature of the crosslinks. The results are discussed in the context of collagen and carbon nanotube bundles.

Reduction in polyamine catabolism leads to spermine-mediated airway epithelial injury and induces asthma features

BACKGROUND

Airway epithelial injury is a crucial component of acute and severe asthma pathogenesis and a promising target for treatment of refractory asthma. However, the underlying mechanism of epithelial injury remains poorly explored. Although high levels of polyamines, mainly spermine, have been found in asthma and comorbidity, their role in airway epithelial injury and the cause of their altered levels in asthma have not been explored.

METHODS

We measured key polyamine metabolic enzymes in lung samples from normal and asthmatic subjects and in mice with OVA-induced allergic airway inflammation (AAI). Polyamine metabolism was modulated using pharmacologic/genetic modulators. Epithelial stress and apoptosis were measured by TSLP levels and TUNEL assay, respectively.

RESULTS

We found loss of the polyamine catabolic enzymes spermidine/spermine-N (1)-acetyltransferase-1 (SAT1) and spermine oxidase (SMOX) predominantly in bronchial epithelial cells (BECs) of human asthmatic lung samples and mice with AAI. In naïve mice, SAT1 or SMOX knockdown led to airway hyper-responsiveness, remodeling, and BEC apoptosis. Conversely, in mice with AAI, overexpression of either SAT1 or SMOX alleviated asthmatic features and reduced TSLP levels and BEC apoptosis. Similarly, while pharmacological induction of SAT1 and SMOX using the polyamine analogue bis(ethyl)norspermine (BENSPM) alleviated asthmatic features with reduced TSLP levels and BEC apoptosis, pharmacological inhibition of these enzymes using BERENIL or MDL72527, respectively, worsened them. Spermine accumulation in lungs correlated with BEC apoptosis, and spermine treatment caused apoptosis of human BEAS-2B cells in vitro.

CONCLUSIONS

Spermine induces BEC injury. Induction of polyamine catabolism may represent a novel therapeutic approach for asthma via reversing BEC stress.

Urinary haptoglobin, alpha-1 anti-chymotrypsin and retinol binding protein identified by proteomics as potential biomarkers for lupus nephritis

The study was aimed at identification by proteomics and validation by enzyme-linked immunosorbent assay (ELISA) of potential urinary biomarkers for lupus nephritis. Study subjects comprised 88 systemic lupus erythematosus (SLE) patients and 60 controls (rheumatoid arthritis, diabetes mellitus and healthy individuals). Based on the SLE disease activity index (SLEDAI), patients were classified as active renal (AR), active non-renal (ANR) or inactive disease (ID). Urinary proteins from a group of patients with AR or ID were resolved by two-dimensional gel electrophoresis and identified by matrix-assisted laser desorption ionization-time of flight-mass spectrometry (MALDI-TOF-MS/MS). The selected biomarkers were validated by ELISA using samples from all patients and controls. AR patients were followed-up for 12 months after start of therapy. Three urinary proteins, alpha-1 anti-chymotrypsin (ACT), haptoglobin (HAP) and retinol binding protein (RBP), were detected in patients with AR and not ID. Upon validation, ACT levels were higher in AR patients than the other groups (P < 0·001) and showed good correlation with renal SLEDAI (r = 0·577, P < 0·001) as well as SLEDAI (r = 0·461, P < 0·001). Similarly, HAP levels were > 10-fold higher in AR than other groups (P < 0·001) and correlated well with renal SLEDAI (r = 0·594, P < 0·001) and SLEDAI (r = 0·371, P < 0·01). RBP levels were also higher in AR patients than in other groups (P < 0·05), except diabetes, and showed moderate correlation with renal SLEDAI (r = 0·284, P < 0·008) and SLEDAI (r = 0·316, P < 0·003). Upon follow-up with treatment, levels of all three proteins declined at 6 and 12 months (P < 0·01). Multiple logistic regression identified ACT as the best marker to differentiate AR from ANR. Urinary HAP, ACT and RBP are potential biomarkers for lupus nephritis activity.

An exploratory study of immune markers in acute and transient psychosis

The aim of this study was to look into the balance of pro-inflammatory (TNF-α, IL-6) and anti-inflammatory (TGF-β) cytokines and their association with stress, alterations in HPA axis activity and the disease severity in acute psychosis. Socio-demographic and clinical details were collected from 41 in-patients with a diagnosis of Acute and Transient Psychotic Disorder. Holmes and Rahe Stress Scale for stress in the preceding year, and Brief Psychiatric Rating Scale at baseline and follow up (4-12 weeks) for psychopathology were applied. IL-6, TNF-α (pro-inflammatory), TGF-β (anti-inflammatory) and Cortisol (morning and afternoon values) were measured at baseline and follow up. A total of 30 out of 41 cases recruited had follow up data available. The levels of IL-6 (p<0.001), TNF-α (p<0.001) and TGF-β (p<0.001) at baseline were all found to be significantly elevated compared to 42 age and gender matched healthy controls. There was a significant increase in the levels of TNF-α (p=0.020) and morning levels of cortisol (p=0.009) and a significant decrease in the levels of TGF-β (p=0.004) and afternoon levels of cortisol (p=0.043) from baseline to follow up. This study showed that there was an increased level of both pro and anti-inflammatory cytokines at baseline and a prolonged pro - inflammatory compared to anti - inflammatory response which warrants larger prospective studies and comparative studies to patients with schizophrenia and bipolar disorders.

An outbreak of hepatitis A virus among children in a flood rescue camp: A post-disaster catastrophe

We report an outbreak of acute viral hepatitis among children in a flood rescue camp at Rudraprayag district of Uttarakhand State, India. In May 2013, there was a disastrous natural calamity, The Himalayan Tsunami in Himalayan and Sub-Himalayan region of Uttarakhand. More than 5700 people were feared dead, and thousands were sheltered in different rescue camps. A linkage was hypothesised between the infected individuals and the common water sources feared of being contaminated faecally. Aetiological agent of the present outbreak was HAV that is emerging in an outbreak form in India, emphasizing a definite need for formulating mandatory vaccination and proper control strategies. The report exemplifies the basic problems encountered after a natural calamity.

Association of NKG2D gene variants with susceptibility and severity of rheumatoid arthritis

NKG2D (KLRK1) is a C-type lectin receptor present on natural killer (NK) cells, γδ, CD8⁺ and CD4⁺ T cells. Upon ligand binding, NKG2D mediates activatory and co-stimulatory signals to NK cells and activated CD4⁺ T cells, respectively. Polymorphisms in NKG2D predispose to infectious diseases, cancer, transplantation and autoimmune disorders. We studied the influence of this NK receptor polymorphism on predisposition to and modification of the disease phenotype in patients with rheumatoid arthritis (RA). Eight different single nucleotide polymorphisms (SNP) in the NKG2 gene were genotyped in 236 patients with RA and 187 controls using Taqman 5' nuclease assays. NKG2D genotype/allele frequency did not differ between patients and controls. Subgroup analysis showed that the frequency of A allele of NKG2D9 and T allele of NKG2D10 was significantly higher in patients with deformities (a marker of severe disease) [11 versus 5%, Pc = 0·03, odds ratio (OR) = 2·44, 95% confidence interval (CI) = 1·09-5·98 and 10 versus 4%, Pc = 0·04, OR = 2·45, 95% CI = 1·05-6·39, respectively], while the frequency of alleles G of NKG2D9 and A of NKG2D10 was greater in patients without deformities (Pc = 0·03, OR = 0·41, 95% CI = 0·17-0·91 and Pc = 0·04, OR = 0·41, 95% CI = 0·16-0·96). Similar trends of association were observed with deforming phenotype of RA in female patients and deforming young onset RA subgroups. Haplotype analysis revealed that the frequency of haplotype G-C-A-G-A-T-C-C was higher in patients than in controls (12 versus 8%, P = 0·04, OR = 1·61, 95% CI = 1·01-2·55), suggesting that it may predispose to RA. Our study suggests that the NKG2D gene polymorphisms may modify the risk of development and severity of RA.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

TNFAIP3 and TNIP1 polymorphisms confer psoriasis risk in South Indian Tamils

Psoriasis is a chronic inflammatory skin disease with genetic and environmental factors having an important role in its aetiology. Several genome-wide association studies have reported the association of the genes of the TNFα signalling, tumour necrosis factor alpha-induced protein 3 (TNFAIP3), TNFAIP3-interacting protein 1 (TNIP1) with psoriasis in Western and Chinese populations. The aim of this study is to demonstrate whether the TNFAIP3 and TNIP1 genes contribute to the risk of psoriasis in the ethnically distinct South Indian population. 360 psoriatic subjects and 360 healthy controls were recruited in this case control study. TNFAIP3 (rs610604) and TNIP1 (rs17728338) polymorphisms were typed by using TaqMan 5 allele discrimination assay. The results demonstrated that the SNPs rs610604 and rs17728338 of the TNFAIP3 and TNIP1 genes, respectively, were associated with psoriasis in our population at both allelic and genotypic levels. Thus, our results suggest that TNFAIP3 (rs610604) and TNIP1 (rs17728338) polymorphisms confer increased risk of psoriasis and may play a vital role in its pathogenesis in our ethnic South Indian Tamils.

Urinary osteoprotegerin: a potential biomarker of lupus nephritis disease activity

OBJECTIVES

Urinary biomarkers may help in identification, treatment and assessment of response in patients with lupus nephritis (LN). Osteoprotegerin (OPG) is produced by the kidneys and lymphoid cells and may reflect renal disease activity better. The data on its utility are sparse.

METHODS

Fifty-eight patients with active LN (AN), 24 with active non-renal disease (ANR) and 39 with inactive disease (ID) were included. Median disease duration was 32 (1-204) months and median age was 27 (12-50) years. AN patients were followed up every three months for one year. Urine and serum samples were collected for OPG measurement by ELISA (pg/ml) and urinary values were normalised for creatinine excretion (pg/mg). Urine samples from 24 healthy individuals (HCs) and 20 patients each of rheumatoid arthritis (RA) and diabetic nephropathy (DM) served as controls. Variables were expressed as median (range).

RESULTS

At baseline, normalised urinary OPG (uOPG) was significantly higher (p < 0.001) in AN (1229 (0-8577)) than ANR (236 (0-14713)), ID (463 (7-4253)), HCs (366 (120-2849)) and DM (350 (127-1577)) but it was not different from RA (1511 (122-8849)). uOPG correlated modestly with rSLEDAI (r = 0.4, p < 0.001) and SLEDAI (r = 0.31, p < 0.001) but not with serum OPG (sOPG). uOPG but not sOPG could differentiate between AN and ANR groups. In the longitudinal study, uOPG and sOPG decreased significantly with treatment at all follow-up visits but the trend of fall in sOPG was erratic. uOPG values at baseline, 3, 6, 9 and 12 months were 1229 (0-8577), 466 (3-4874), 104 (0-1598), 325 (0-4025) and 555 (6-6771) pg/mg, respectively. uOPG but not sOPG rose before conventional markers in three patients who had a relapse of LN. In two patients who developed chronic kidney disease, uOPG remained persistently high. For differentiating AN from ANR patients, uOPG performed the best on receiver operator characteristics analysis (AUC = 0.72) when compared with anti-dsDNA antibodies, C3, C4 and sOPG.

CONCLUSION

uOPG is derived from kidneys and helps differentiate active SLE patients with and without LN. It shows modest correlation with disease activity and has a potential to predict poor response to therapy and relapse of LN.

The HLA-C*06 allele as a possible genetic predisposing factor to psoriasis in South Indian Tamils

Psoriasis is a multi-factorial heritable prototypical immune-mediated inflammatory disease, characterized by hyperproliferation of keratinocytes in the affected skin. There are no studies till date, to the best of our knowledge, about the association of HLA-C*06, the risk variant in the PSORS 1 susceptibility locus that confers the greatest risk for early onset of psoriasis, with the disease in South Indian Tamil patients with psoriasis. The present study was performed to determine the association of HLA-C*06 with psoriasis in the South Indian Tamil ethnic population. Three hundred and fifty-five cases of psoriasis and 360 healthy controls were included in this case-control study. Severity grading according to psoriasis area severity index (PASI) scoring was done in patients with psoriasis. PCR assays with sequence-specific primers (PCR-SSP) were used for specific detection of HLA-C*06. PCR with analysis of restriction fragment length polymorphism was used to distinguish between patients homozygous and heterozygous for HLA-C*06. We observed that those with the HLA-C*06-positive allele had a 3.5 times higher odds of having psoriasis compared to those without, [p < 0.0001, OR 3.5, 95 % CI (2.59-4.79)]. Among cases of psoriasis, it was noted that there was a significant association of HLA-C*06 positivity with female psoriatics [p = 0.006; OR 2.49 (1.28-4.87)] and early age of onset of psoriasis [p = 0.002; OR 2.04 (1.29-3.20)]. Our results suggest that the HLA-C*06 allele is positively associated with susceptibility to psoriasis, female gender and early onset of psoriasis in South Indian Tamils.

Investigation of association of the IL-12B and IL-23R genetic variations with psoriatic risk in a South Indian Tamil cohort

BACKGROUND

Psoriasis is a T-cell mediated chronic systemic inflammatory skin disease. Emerging evidences suggest the interleukin (IL)-12B and IL-23R genes encoding the common p40 subunit of IL-12 and IL-23 are the key cytokines in T-helper (Th)1 and Th17 differentiation and function. Certain allelic variants of these genes significantly influence the risk of psoriasis. Hence we undertook to study the association of IL-12B and IL-23R gene polymorphisms with disease susceptibility in South Indian Tamil patients with psoriasis.

METHODS

360 psoriatics and 360 healthy controls were included in this case control study. IL-12B gene (rs3212227) and IL-23R gene (rs2201841, rs10889677 and rs11805303) polymorphisms were typed by using TaqMan 5'allele discrimination assay and cytokine levels were assayed by ELISA.

RESULTS

We observed that the patients carrying the risk genotypes of IL-12B (rs3212227) and IL-23R (rs2201841) conferred an increased susceptibility to psoriasis. We did not find any significant association between IL-23R (rs10889677 and rs11805303) gene polymorphisms and psoriasis risk in South Indian Tamil population. We did not observe any significant difference in haplotypes between the psoriasis cases and controls. We observed a significant increase in the mean IL-23 levels in psoriatics and the higher levels of IL-23 were found in the minor variant genotype CC when compared with that of heterozygous CT and major variant TT genotypes of rs2201841. Individual genotypes of rs10889677 and rs11805303 and IL-12 (rs3212227) were not significantly associated with their plasma levels.

CONCLUSION

Our results suggest that IL-12B (rs3212227) and IL-23R (rs2201841) polymorphisms confer increased risk of psoriasis in our ethnic South Indian Tamils.

Inflammatory mediators as predictors of outcome in perinatal asphyxia

OBJECTIVES

To identify biomarkers for neuronal injury and outcome in perinatal asphyxia.

METHODS

This prospective cohort study was done in authors' level III NICU involving 80 neonates - 40 babies with perinatal asphyxia and 40 weight and gender matched normal neonates. Levels of cytokines IL-6, IL -1β, IL-2 and TNF -α in cord blood of these neonates were estimated and correlated with the severity of asphyxia and developmental outcome at 6 mo using Baroda Developmental Score.

RESULTS

The baseline parameters revealed that there was no statistically significant difference between the two groups in terms of maternal age, parity, gestational age, gender and birth weight. The levels of cytokines IL-6 (p < 0.001) and IL-1beta (p < 0.03) were significantly higher in babies with perinatal asphyxia and correlated with the severity of asphyxia. The levels of IL-6 and IL-1β had significant negative correlation with developmental score at 6 mo. A cut off level of 14.18 pg/ml for IL-6 had 92.3 % sensitivity and 57.7 % specificity [Area under the curve = 0.80 (0.62-0.84)] for adverse neuro-developmental outcome while it was 11.17 pg/ml for IL-1β with a sensitivity of 69.2 % and specificity of 71.2 % [Area under the curve = 0.67 (0.57-0.80)].

CONCLUSIONS

IL-6 and IL-1 β are good predictive markers of severity of asphyxia and adverse neurological outcome.

Human leukocyte antigen-G polymorphism influences the age of onset and autoantibody status in rheumatoid arthritis

The study was conducted to investigate the frequency of three gene polymorphisms in the 3'-untranslated region (3'-UTR) of human leucocyte antigen-G (HLA-G) gene in south Indian patients with rheumatoid arthritis (RA) and analyze their influence on disease susceptibility, phenotype and treatment response. HLA-G 14 bp insertion (Ins)/deletion (del) (rs66554220), HLA-G +3142G>C (rs1063320) and +3187A>G (rs9380142) polymorphism was analyzed in 221 RA patients and 200 healthy controls. Frequency of HLA-G genotypes or alleles did not differ between patients and controls. Analysis based on rheumatoid factor (RF) status revealed that the frequency of allele 'A' (rs9380142) was significantly higher in RF-positive than in RF-negative patients [84% vs 74%, Yates-corrected P value (Pc) = 0.04, odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.0-3.2]. A similar difference was maintained in RF-positive female patients than their RF-negative counterparts (83% vs 71%, Pc = 0.02, OR = 1.9, 95% CI = 1.0 to 3.4) and between RF-positive and RF-negative young onset RA (YORA) patients (84% vs 73%, Pc = 0.03, OR = 1.9, 95% CI = 1.0-3.2), suggesting that rs9380142 polymorphism influenced RF status. The 14 bp Ins allele of rs66554220 was significantly more prevalent in RF-positive YORA than in RF-positive late onset RA (LORA) patients (51% vs 25%, P = 0.03, OR = 3.1, 95% CI = 1.1-9.8). Frequency of the four major haplotypes [InsGA (48%), DelGA (22%), DelCG (18%), DelCA (9.7%)] observed did not differ between cases and controls. HLA-G does not appear to be a risk factor for development of RA in south Indian Tamils but may act as a genetic modifier of clinical phenotype in terms of autoantibody production, gender preference and age at disease onset.

IRF5rs2004640 single nucleotide polymorphism is associated with susceptibility to rheumatoid arthritis in South Indian Tamils

Polymorphism of interferon regulatory factor 5 (IRF5), a latent transcription factor gene has been associated with various auto-immune diseases. Our aim was to study the IRF5rs2004640 gene polymorphism and its association with disease susceptibility, disease phenotype and treatment response in South Indian Tamil patients with rheumatoid arthritis (RA).The study was conducted on 217 RA patients fulfilling the American College of Rheumatology (ACR) 2010 criteria and 482 healthy controls (HCs) without family history of autoimmune disease. The IRF5rs2004640 genotyping was performed using a TaqMan 5' allelic discrimination assay. We found that the IRF5rs2004640T allele [P < 0.0001, odds ratio (OR) 3.25, 95% confidence interval (CI) 2.55-4.12] and TT genotype (P < 0.0001, OR 4.60, 95% CI 3.23-6.57) were significantly more frequent in RA patients as compared with HCs. No association was found between IRF5rs2004640 polymorphism, clinical manifestations, autoantibody profile and treatment response. IRF5rs2004640 T (mutant) allele may be a susceptibility factor conferring risk for RA in South Indian Tamils, whereas G allele (wild type) may be protective.

Immunoglobulin-like transcripts 6 (ILT6) polymorphism influences the anti-Ro60/52 autoantibody status in south Indian SLE patients

Introduction

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder with complex etiology. Loss of immune tolerance against self-antigens results in activation of the immune system to produce autoantibodies, which in turn contribute to the clinical manifestations of the disease. Immune cells harbor a plethora of regulatory receptors. Immunoglobulin-like transcripts (ILTs) exhibit both immune activation and inhibitory properties. Genetic defects in genes encoding these receptors may predispose to development of autoimmune diseases secondary to loss of their function. The aim of our study was to analyze the presence or absence of the 6.7 kb segment in the ILT6 gene and its association with susceptibility to SLE and its different manifestations.

Method

A total of 188 SLE patients and 192 age-, sex similar-, ethnicity-matched controls were recruited. They were genotyped to test the presence or absence of the 6.7 kb segment of the ILT6 gene by polymerase chain reaction.

Results

The mutant allele lacking the 6.7 kb gene segment had an equal frequency in patients as well as controls (20% and 18%, respectively). The mutant allele was not associated with SLE or its clinical manifestations. However, the mutant allele was associated with the presence of anti-Ro60 ( p = 0.0005, OR 3.5, 95% CI 1.8–7.1) and anti-Ro52 ( p = 0.0027, OR 2.99, 95% CI 1.5–6.06) autoantibodies.

Conclusion

ILT6 deletion polymorphism does not appear to be a lupus susceptibility gene in South Indian Tamils, but may behave as a genetic modifier of autoantibody phenotype by influencing the production of anti-Ro60 and anti-Ro52 autoantibodies and thus indirectly contribute to autoimmune responses in SLE.

Q222R polymorphism in DNAse I gene is a risk factor for nephritis in South Indian SLE patients

OBJECTIVE

Systemic lupus erythematosus (SLE) is a multisystem disorder in which defective apoptotic clearance is considered to be an important factor in pathogenesis. DNAse I is associated with disposal of apoptotic nuclear debris. The defective enzyme production due to +2373 A to G (Q222R) in exon 8 is reported to be a genetic risk factor for SLE. SLE in Indians is reported to be severe. There are no genetic studies reported from India which have explored this aspect of DNAseI gene. This study aimed to analyze whether Q222R is a susceptibility factor for SLE and to study its influence on clinical manifestations and autoantibody production in South Indian Tamils.

METHOD

Three hundred SLE cases (based on ACR 1982 criteria) and 530 age, sex similar and ethnicity matched controls were recruited. All the cases and controls were genotyped for DNAse I Q222R polymorphism using PCR-RFLP method.

RESULTS

DNAse I Q222R polymorphism is prevalent in our population. We observed higher frequency of Q/R in patients compared with controls (60% vs. 53%). This was found to be a genetic risk for SLE susceptibility (p = 0.04, odds ratio 1.5, 95% confidence interval 1-2.1). It also conferred a significant risk for development of nephritis (p = 0.007, odds ratio 1.93, 95% confidence interval 1.2-3.2).

CONCLUSION

DNAse I Q222R polymorphism is a potential genetic risk factor for SLE in South Indian Tamils. In addition, the mutant allele confers a significant risk for lupus nephritis.

The CTLA4 +49 A/G (rs231775) polymorphism influences susceptibility to SLE in South Indian Tamils

Systemic lupus erythematosus (SLE) is a prototype autoimmune disease with complex etiology. Loss of immune tolerance and synthesis of autoantibodies against nuclear antigens contributes to the disease. Genetic aberrations disrupting the functions of immune regulatory receptors may facilitate the development of autoimmune diseases. Cytotoxic T-lymphocyte antigen 4 (CTLA4) is an inhibitory receptor for T cells and this study was carried out to analyze the influence of CTLA4 +49A/G (rs231775) polymorphism on susceptibility to SLE in ethnic Tamils. Three hundred SLE patients and 460 age and sex similar, ethnicity-matched controls were screened for the +49 A/G polymorphism by real time polymerase chain reaction (PCR). The wild allele (A) frequency in controls and cases was 63% and 47%, respectively. The presence of heterozygous (AG) and homozygous mutant (GG) genotype was associated with a significant risk to develop SLE (P = 0.0001, OR-2.29, 95% confidence interval (CI), 1.6-3.3) and (P = 0.0001, OR-4.3, 95% CI, 2.8-6.99). The frequency of mutant allele (G) in patients was also significantly associated with SLE (P = 0.0001, OR-1.9, 95% CI, 1.5-2.4). However, this polymorphism did not influence the clinical or serological phenotypes in our study. Therefore the CTLA4 +49 A/G polymorphism is a potential genetic risk factor for lupus susceptibility in South Indian Tamils, but does not appear to influence either the clinical or serological phenotype.

A Rare Case of Idiopathic Congenital Complete Heart Block in a Neonate

Congenital complete heart block in utero has become diagnosed more frequently with the clinical use of fetal echocardiography. Autoimmune-associated congenital complete heart block (CHB) is a rare but important disease that can now be diagnosed in utero using fetal echocardiography1,2,3,4. The overall incidence of isolated CHB has been reported to be approximately 1:15,000 to 20,000 live births5. Several reviews have shown that children diagnosed prenatally have an increased mortality compared to those diagnosed immediately after birth or later in childhood1,2,3,4. At birth, some neonate with complete heart block may remain asymptomatic and may not require a pacemaker but majority require pacemaker to increase the heart rate. We report a rare case of idiopathic congenital complete heart block in a newborn male. J Nepal Paediatr Soc 2012;32(2):163-165 doi: http://dx.doi.org/10.3126/jnps.v32i2.5992

A Rare Association of Hydrops of Gall Bladder with Hepatitis E Infection

Gall bladder distension with acute viral acalculous cholecystitis is an extremely rare event especially with Hepatitis E infection in paediatric cases with a high incidence of perforation, gallbladder necrosis and mortality. We report a four year old male child presenting with fever, vomiting, pain abdomen, mild hepatosplenomegaly and tenderness in right hypochondrium. Laboratory investigations revealed hyperbilirubinemia and elevated liver enzymes, but there was no evidence of bacterial or parasitic infection. Serology for viral hepatitis suggested acute Hepatitis E infection. Ultrasonographically distended inflamed gallbladder without calculous was observed. Finally acute acalculous cholecystitis due to Hepatitis E virus was diagnosed and the child responded to the conservative management. Key words: Acalculous cholecystitis; Hepatitis E; Pericholecystic fluid; Gallbladder thickening.DOI: http://dx.doi.org/10.3126/jnps.v31i3.5362 J Nep Paedtr Soc 2011;31(3): 216-222-223

Congenital segmental dilatation of jejunoileal region in a newborn: Unusual clinical and radiologic presentation

Segmental dilatation of the ileum is one of the uncommon causes of intestinal obstruction in neonates. We present a case of slow transit of bowel contents leading to suspicion of functional bowel obstruction in a new born, which on exploration turned out to be a case of segmental dilatation of the jejuno-ileal region. The clinical and radiological evaluation was suggestive of hypomotility disorder of gut, resulting in diagnostic dilemma and delayed surgical intervention.

Activation of NF-kappaB in lymphocytes and increase in serum immunoglobulin in hyperthyroidism: possible role of oxidative stress

This study evaluated oxidative stress, serum IgM and IgG, and nuclear factor (NF)-kappaB signaling in lymphocytes of hyperthyroidism patients. GSH content in lymphocytes was significantly lower and serum malondialdehyde, IgM and IgG levels were significantly higher in hyperthyroidism as compared to controls. In lymphocytes, the NF-kappaB signaling pathway was studied by western blot analysis of p65 and p-IkappaBalpha. Density of p-IkappaBalpha and p65 (in nuclear fraction) was significantly higher in hyperthyroidism as compared to controls. The density of p-IkappaBalpha and p65 had significant positive correlation with serum malondialdehyde level and negative correlation with lymphocyte GSH level in hyperthyroid cases. The serum IgG and IgM levels were correlated significantly with density of p-IkappaBalpha and p65. As immunoglobulin production is regulated by the NF-kappaB pathway, we conclude that the oxidative stress-induced activation of the NF-kappaB pathway might play a role in the rise of serum immunoglobulin level in hyperthyroidism.

Reverse passive haemagglutination (RPHA) test for detection of mycobacterial antigen in the cerebrospinal fluid for diagnosis of tubercular meningitis

BACKGROUND

Various serological techniques have been developed to detect antibodies and antigens in the cerebrospinal fluid (CSF) for diagnosis of tubercular meningitis. Most of the serological assays are ELISA based. Attempts have been made to use much simpler antigen detection techniques like the reverse passive haemagglutination (RPHA)which is simple and cost-effective.

AIMS

To evaluate the reverse passive haemagglutination (RPHA) test for detection of mycobacterial antigens in the CSF for diagnosis of tubercular meningitis.

METHODS

In the present study, we have made the use of polyclonal antiserum against heat killed whole Mycobacterium tuberculosis bacilli to sensitize the RBCs in RPHA to detect antigens in clinically suspected cases. A total of 46 cases (clinically suspected TBM 24, culture proven TBM 2, non- TBM cases 20) were included in the present study for detecting M. tuberculosis antigen in the CSF specimens.

RESULTS

Of the 26 test CSF specimens, 13 CSF specimens were positive by RPHA while 4 of the 20 control CSF specimens were also reactive. Two culture positive specimens included in the study were positive by RPHA. Of the 4 control CSF specimens positive by RPHA, 3 were culture proven cases of pneumococcal meningitis and 1 was a case of cryptococcal meningitis. The RPHA is found to be 50% sensitive and 80% specific; and showed a 76.4 % positive predictive value and a 55.2 % negative predictive value.

CONCLUSION

The RPHA is a simple test that could be used as an adjunct in diagnosing TBM. It does not require any special equipment or technically trained or skilled manpower. It is economical and can be afforded for use in community where TBM is more prevalent. Even though the present study showed a poor sensitivity and specificity, further identification, characterization and evaluation of better immuno-dominant and specific antigens or epitopes, and the usage of antibodies developed against such mycobacterial antigens might improve the sensitivity and specificity of this test.

Complement degradation product C3d in urine: marker of lupus nephritis

OBJECTIVE

To examine whether serum and urine C3d, a degradation product of C3, correlate with renal and extrarenal lupus activity.

METHODS

Serum and urinary C3d levels were measured by ELISA in 15 healthy individuals and 24 patients with systemic lupus erythematosus (SLE) (8 with inactive disease, 7 with active but nonrenal disease, 9 with active lupus nephritis). Disease activity variables like serum C3, C4, and anti-dsDNA antibodies were also measured.

RESULTS

The median serum C3d levels were significantly higher (p < 0.01) in patients with active (26 arbitrary units/ml; AU/ml) and inactive SLE (27 AU/ml) compared to healthy controls (11.25 AU/ml); levels were comparable in patients with active renal and extrarenal SLE. On the other hand, urine C3d was elevated only in patients with active SLE; its level was highest in patients with active lupus nephritis (0.87 AU/ml) compared to patients with active extrarenal diseases (0.31 AU/ml; p < 0.05), to patients with inactive lupus nephritis (0.06 AU/ml; p < 0.001), or to levels in healthy individuals (0.06; p < 0.001). Urine C3d showed stronger correlation with disease activity score (SLE Disease Activity Index) than serum C3, C4, anti-dsDNA antibodies, and serum C3d.

CONCLUSION

Urine C3d is a good index of active lupus, particularly lupus nephritis.

Antiendothelial cell antibodies in scleroderma correlate with severe digital ischemia and pulmonary arterial hypertension

OBJECTIVE

To determine the prevalence of IgG antiendothelial cell antibodies (AECA) in patients with scleroderma (systemic sclerosis, SSc) and to correlate it with clinical spectrum and autoantibody profile.

METHODS

Seventy-six patients with SSc and 50 matched healthy controls were studied. Immunological variables were antinuclear antibody (ANA), rheumatoid factor (RF), and Scl-70. IgG-AECA was measured by cellular ELISA.

RESULTS

The prevalence of IgG-AECA was 27.6% in patients with SSc compared to 6% in controls (p < 0.01). Forty percent of patients with diffuse disease had this antibody, versus 13.5% of those with limited cutaneous involvement (p < 0.05). Patients with AECA had significantly higher incidence of digital infarcts and gangrene (p < 0.01) and pulmonary arterial hypertension (p < 0.001) than those without. In the AECA positive group, mean IgG-AECA levels (measured by absorbance values) were significantly higher in patients with digital infarcts (0.91+/-0.31 vs 0.60+/-0.05; p < 0.01) and pulmonary arterial hypertension (1.14+/-0.37 vs 0.68+/-0.13; p < 0.001) compared to those without these features.

CONCLUSION

IgG-AECA appears to be an important marker for disease severity in scleroderma.

High familial prevalence of gallstones in the first-degree relatives of gallstone patients

Limited information is available on the prevalence of gallstones in the first-degree relatives of gallstone patients. Three groups of subjects were studied by real-time ultrasound examination: group A, 105 index gallstone patients (male/female; 20:85); group B, 330 first-degree relatives of index patients; group C, matched controls for group A (n = 105) and group B (n = 330) subjects. Dietary, anthropometric, and biochemical investigations were carried out. In 39 of 105 (37%) index cases, one or more additional family members had gallstones (positive-index case). The positive-index cases were younger than the remaining index cases (mean age, 33.1 +/- 14 vs. 44.5 +/- 13.1 years; P < .05). Fifty-one of 330 (15.5%) first-degree relatives had gallstones, nearly four and a half times (95% confidence interval [CI], 2.4 to 8.5) more often than in the matched control population (12 of 330 [3.6%]). Thirty-three of 51 (65%) positive relatives were women; mother (37.3%), sister (17.6%) or daughters (10%) to the index patients. There was no difference in the diet, physical activity, and serum lipid profile between the positive index patients and the remaining gallstone patients and positive relatives and their controls. Our results show that there is a strong familial predisposition for gallstone formation. Female relatives of young gallstone patients should be routinely screened for gallstones.