Hyperuricemia in Psoriatic Arthritis: Epidemiology, Pathophysiology, and Clinical Implications

Psoriatic arthritis (PsA) represents the articular component of the systemic psoriatic disease and the extra-cutaneous disorder most frequently found in patients with psoriasis. Besides the articular involvement, PsA is associated with several metabolic abnormalities such as insulin resistance, hypertension, diabetes and hyperuricemia. Uric acid is the final product of purine metabolism and the etiological substrate of gout. Accumulating evidence highlights the emerging role of hyperuricemia as a major cardiovascular risk factor. Moreover, different studies evaluated the interplay between hyperuricemia and psoriatic disease, suggesting that individuals affected by psoriasis or PsA might present higher serum levels of uric acid and that hyperuricemia might affect severity of clinical manifestations and degree of inflammation in PsA patients. In this review, we focus on the bidirectional relationship between uric acid and PsA, analyzing how uric acid may be involved in the pathogenesis of psoriasis/PsA and how clinical manifestations of PsA and inflammatory mediators are affected by uric acid concentrations. Finally, the effects of anti-rheumatic drugs on uric acid levels and the potential benefit of urate-lowering therapies on psoriasis and PsA were summarized.

Impact of smoking habit on adult-onset Still's disease prognosis, findings from a multicentre observational study

The objective of this study is to describe the possible prognostic impact of smoking habit on adult-onset Still's disease (AOSD) patients, by the assessment of clinical characteristics, life-threatening complications occurrence, and mortality in smokers than non-smokers. A multicentre retrospective study of prospectively followed-up AOSD patients included in Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort was conducted. Out of 185 AOSD assessed patients, 45 smokers were identified. These showed a higher frequency of pericarditis (35.5% vs 16.4%, p = 0.011), pleuritis (33.3% vs 14.3%, p = 0.008), and abdominal pain (17.7% vs 6.4%, p = 0.035). Furthermore, smokers showed higher values of systemic score (6.4 ± 2.2 vs 5.4 ± 1.8, p = 0.004), an increased rate of macrophage activation syndrome (MAS) (28.9% vs 6.4%, p < 0.0001) and of parenchymal lung disease (17.7% vs 12.6%, p = 0.035). Although not significant, these patients more frequently experienced a poor prognosis (13.3% vs 4.3%, p = 0.074). Smoking habit predicted MAS occurrence in both univariate (HR: 5.98, 95% CI: 2.45-14.57, p < 0.0001) and multivariate regression models (HR: 6.21, 95% CI: 2.46-15.70, p < 0.0001). Smokers had a significant higher risk of parenchymal lung disease in both univariate (HR: 3.97, 95% CI: 1.43-11.02, p = 0.008) and multivariate regression models (HR: 3.90, 95% CI: 1.36-11.23, p = 0.012). Smoking habit also increased the risk of mortality in univariate regression model (HR: 4.25, 95% CI: 1.33-13.55, p = 0.015). Smoking habit resulted to be a negative prognostic factor on AOSD patients. Smokers were characterised by a higher frequency of serositis and higher values of systemic score. Additionally, these patients were more frequently burdened by MAS and parenchymal lung disease associated with a poor prognosis. Key points • Smoking habit resulted to be a negative prognostic factor on AOSD. • Smokers were characterised by an increased frequency of serositis and higher values of systemic score. • Cigarette exposure was associated with MAS and parenchymal lung disease in AOSD.

Covid-19 And Rheumatic Autoimmune Systemic Diseases: Role of Pre-Existing Lung Involvement and Ongoing Treatments

BACKGROUND

The Covid-19 pandemic may have a deleterious impact on patients with autoimmune systemic diseases (ASD) due to their deep immune-system alterations.

OBJECTIVE

To investigate the prevalence of symptomatic Covid-19 and its correlations with both organ involvement and ongoing treatments in a large series of Italian ASD patients during the first wave of pandemic.

METHOD

Our multicenter telephone 6-week survey included 3,029 unselected ASD patients enrolled at 36 tertiary referral centers of northern, central, and southern Italian macro-areas with different diffusion of pandemic. Symptomatic SARS-CoV-2 infection was classified as definite Covid-19 (presence of symptoms plus positive oral/nasopharyngeal swabs) or highly suspected Covid-19 (highly suggestive symptoms, in absence of a swab testing).

RESULTS

A significantly higher prevalence of definite plus highly suspected Covid-19 compared to Italian general population was detected in the whole ASD series (p=.000), as well as in patients from the three macro-areas (p=.000 in all). Statistically higher prevalence of Covid-19 was also found in connective tissue diseases compared to chronic arthritis subgroup (p=.000) and in ASD patients with pre-existing interstitial lung involvement (p=.000). Patients treated with either conventional disease modifying anti-rheumatic drugs (DMARDs) and/or biological DMARDs showed a significantly lower prevalence of Covid-19 (p=.000 in both). Finally, scleroderma patients undergoing low-dose aspirin showed significantly lower rate of Covid-19 compared to those without (p=0.003).

CONCLUSION

The higher prevalence of Covid-19 in ASD patients along with the significant correlations with important clinical features and therapeutic regimens suggests the need to develop targeted prevention/management strategies during the current pandemic wave.

Fibromyalgia: a new facet of the post-COVID-19 syndrome spectrum? Results from a web-based survey

Objective

Postacute COVID-19 syndrome (PACS) is an emerging entity characterised by a large array of manifestations, including musculoskeletal complaints, fatigue and cognitive or sleep disturbances. Since similar symptoms are present also in patients with fibromyalgia (FM), we decided to perform a web-based cross-sectional survey aimed at investigating the prevalence and predictors of FM in patients who recovered from COVID-19.

Methods

Data were anonymously collected between 5 and 18 April 2021. The collection form consisted of 28 questions gathering demographic information, features and duration of acute COVID-19, comorbid diseases, and other individual’s attributes such as height and weight. The American College of Rheumatology (ACR) Survey Criteria and the Italian version of the Fibromyalgia Impact Questionnaire completed the survey.

Results

A final sample of 616 individuals (77.4% women) filled the form 6±3 months after the COVID-19 diagnosis. Of these, 189 (30.7%) satisfied the ACR survey criteria for FM (56.6% women). A multivariate logistic regression model including demographic and clinical factors showed that male gender (OR: 9.95, 95% CI 6.02 to 16.43, p<0.0001) and obesity (OR: 41.20, 95% CI 18.00 to 98.88, p<0.0001) were the strongest predictors of being classified as having post-COVID-19 FM. Hospital admission rate was significantly higher in men (15.8% vs 9.2%, p=0.001) and obese (19.2 vs 10.8%, p=0.016) respondents.

Conclusion

Our data suggest that clinical features of FM are common in patients who recovered from COVID-19 and that obesity and male gender affect the risk of developing post-COVID-19 FM.

Incidence of venous thromboembolism in rheumatoid arthritis, results from a "real-life" cohort and an appraisal of available literature

Rheumatoid arthritis (RA) is associated with an increased risk of venous thromboembolism (VTE) occurrence. In this work, we assessed the incidence and predictive factors of VTE in our "real-life" cohort of RA patients. To contextualize our results, we reviewed the available literature about this topic.We performed a retrospective analysis of prospectively followed-up patients with RA attending our Rheumatologic Clinic between January 2010 and December 2020. Each patient was investigated for VTE occurrence. Incident cases were reported as incidence proportion and incidence rate per 1000 person-years at risk. Possible predictive factors were also exploited by regression analyses. Available literature about this topic was also assessed.In this evaluation, 347 consecutive patients without previous evidence of VTE, attending our Rheumatologic Clinic from 2010 to 2020, were studied. In our "real-life" cohort, the incidence proportion of VTE was 3.7% (2.7-4.7%) and considering over 1654 person-years, an incidence rate of 7.8 × 1000 (2.5-11.7). Exploratively assessing predictive factors in our cohort, older age (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.01-1.14, p = .015), higher body mass index (HR 1.37, 95% CI 1.04-1.80, P = .026), and longer disease duration (HR 1.11, 95% CI 1.03-1.20, P = .006) resulted to be significant predictors of VTE occurrence during the follow-up.In our "real-life" cohort, VTE burden has been suggested in patients with RA. Comparing our results with previous data derived from randomized controlled trials and administrative data, some different findings were retrieved about incidence of VTE. Assessing predictive factors, older age, higher body mass index, and longer disease duration resulted to be significant predictors of VTE occurrence during the follow-up. Taking together these observations, a further evaluation of this issue on specific designed studies is needed to provide more generalizable results to the daily clinical practice.

Blocking Jak/STAT signalling using tofacitinib inhibits angiogenesis in experimental arthritis

OBJECTIVE

During rheumatoid arthritis (RA), the angiogenic processes, occurring with pannus-formation, may be a therapeutic target. JAK/STAT-pathway may play a role and the aim of this work was to investigate the inhibiting role of a JAK-inhibitor, tofacitinib, on the angiogenic mechanisms occurring during RA.

METHODS

After ethical approval, JAK-1, JAK-3, STAT-1, STAT-3 and VEGF expression was evaluated on RA-synovial-tissues. In vitro, endothelial cells (ECs), stimulated with 20 ng/ml of VEGF and/or 1 μM of tofacitinib, were assessed for tube formation, migration and proliferation, by Matrigel, Boyden chamber assay and ki67 gene-expression. In vivo, 32 mice received collagen (collagen-induced arthritis (CIA)) and 32 mice PBS (control). At day 19, CIA and controls mice were divided: 16 mice receiving vehicle and 16 mice receiving tofacitinib. At day 35, the arthritis score, the thickness of paw joints and the serum levels of VEGF and Ang-2 were evaluated.

RESULTS

The expression of JAK-1, JAK-3, STAT-1, STAT-3 and VEGF in synovial tissue of RA-patients were significantly higher than healthy controls. In vitro, tofacitinib inhibited the ECs ability to form vessels, to proliferate and to migrate. In vivo, administration of tofacitinib prevented the increase of the arthritis score, the paw thickness, the synovial vessels and VEGF and Ang-2 serum-accumulation, when compared to CIA without tofacitinib.

CONCLUSIONS

We explored the anti-angiogenic role of tofacitinib, reporting its ability to inhibit in vitro the angiogenic mechanisms of ECs and in vivo the formation of new synovial vessels, occurring in CIA model. These findings suggest that the therapeutic effect of tofacitinib during RA may be also related to its anti-angiogenic activity.

Biotechnological Agents for Patients With Tumor Necrosis Factor Receptor Associated Periodic Syndrome-Therapeutic Outcome and Predictors of Response: Real-Life Data From the AIDA Network

Objective: To describe the role of biotechnological therapies in patients with tumor necrosis factor receptor associated periodic syndrome (TRAPS) and to identify any predictor of complete response. Methods: Clinical, laboratory, and therapeutic data from 44 Caucasian TRAPS patients treated with biologic agents were retrospectively collected in 16 Italian tertiary Centers. Results: A total of 55 biological courses with anakinra (n = 26), canakinumab (n = 16), anti-TNF-α agents (n = 10), and tocilizumab (n = 3) were analyzed. A complete response was observed in 41 (74.5%) cases, a partial response in 9 (16.4%) cases and a treatment failure in 5 (9.1%) cases. The frequency of TRAPS exacerbations was 458.2 flare/100 patients-year during the 12 months prior to the start of biologic treatment and 65.7 flare/100 patients-years during the first 12 months of therapy (p < 0.0001). The median duration of attacks was 5.00 (IQR = 10.50) days at the start of biologics and 1.00 (IQR = 0.00) days at the 12-month assessment (p < 0.0001). Likewise, a significant reduction was observed in the Autoinflammatory Disease Activity Index during the study period (p < 0.0001). A significant corticosteroid sparing effect was observed as early as the first 12 months of treatment both in the number of patients requiring corticosteroids (p = 0.025) and in the dosages employed (p < 0.0001). A significant reduction was identified in the erythrocyte sedimentation rate (p < 0.0001), C reactive protein (p < 0.0001), serum amyloid A (p < 0.0001), and in the 24-h proteinuria dosage during follow-up (p = 0.001). A relapsing-remitting disease course (OR = 0.027, C.I. 0.001-0.841, p = 0.040) and the frequency of relapses at the start of biologics (OR = 0.363, C.I. 0.301-0.953, p = 0.034) were significantly associated with a complete response. No serious adverse events were observed. Conclusions: Treatment with biologic agents is highly effective in controlling clinical and laboratory TRAPS manifestations. Patients with a relapsing-remitting course and a lower frequency of flares at the start of treatment show more likely a complete response to biologic agents.

Pathogenic implications, incidence, and outcomes of COVID-19 in autoimmune inflammatory joint diseases and autoinflammatory disorders

As the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread rapidly, there are still many unresolved questions of how this virus would impact on autoimmune inflammatory joint diseases and autoinflammatory disorders. The main aim of this paper is to describe the main studies focusing their attention on COVID-19 incidence and outcomes of rheumatoid arthritis (RA), spondylarthritis (SpA), and autoinflammatory disease cohorts. We also revised possible pathogenic mechanisms associated with. Available data suggest that, in patients with RA and SpA, the immunosuppressive therapy, older age, male sex, and the presence of comorbidities (hypertension, lung disease, diabetes, CVD, and chronic renal insufficiency/end-stage renal disease) could be associated with an increased risk of infections and high rate of hospitalization. Other studies have shown that lower odds of hospitalization were associated with bDMARD or tsDMARDs monotherapy, driven largely by anti-TNF therapies. For autoinflammatory diseases, considering the possibility that COVID-19 could be associated with a cytokine storm syndrome, the question of the susceptibility and severity of SARS-CoV-2 infection in patients displaying innate immunity disorders has been raised. In this context, data are very scarce and studies available did not clarify if having an autoinflammatory disorder could be or not a risk factor to develop a more severe COVID-19. Taking together these observations, further studies are likely to be needed to fully characterize these specific patient groups and associated SARS-CoV-2 infection.

Association Between Minor Salivary Gland Biopsy During Sjӧgren's Syndrome and Serologic Biomarkers: A Systematic Review and Meta-Analysis

Objective

Patients with primary Sjögren’s syndrome (pSS) may develop a potentially severe disease with extra-glandular involvement and lymphoma insurgence. Minor salivary gland biopsy is routinely used in the disease diagnosis, but its potential role as a biomarker for clinical disease presentation and prognosis is still poorly understood.

Methods

We performed a systematic review and meta-analysis on clinical presentation and prognosis in pSS patients who underwent minor salivary gland biopsy at diagnosis according to the PRISMA guidelines.

Results

We included five retrospective studies and 589 pSS patients. Ectopic GCs presence was not associated with a significant increase in the odds ratio for the clinical variables explored such as salivary gland swelling, arthritis, and Raynaud’s phenomenon. As far as serological features are concerned, ectopic GCs presence accounted for an increased ratio of antibodies anti-SSA (OR = 3.13, 95% CI: 1.25–7.85, p = 0.02, I² = 79%), anti-SSB (OR = 3.94, 95% CI: 1.50–10.37, p = 0.0005, I² = 80%), and RFs presence (OR = 3.12, 95% CI: 1.94–5.00, p < 0.00001, I² = 0%).

Conclusions

This study showed that the association between ectopic GC in salivary glands identifies a clinical subset characterized by autoantibodies presence, and probably pSS patients affected from a more severe disease.

POS1344 EVALUATING THE MULTIVISCERAL INVOLVEMENT ON ADULT-ONSET STILL’S DISEASE TO RETRIEVE IMAGING-BASED DIFFERENCES IN PATIENTS WITH AND WITHOUT MACROPHAGE ACTIVATION SYNDROME; RESULTS FROM A SINGLE-CENTRE OBSERVATIONAL STUDY

Background:

Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder usually affecting young adults, burdened by life-threatening complications, mainly macrophage activation syndrome (MAS), a secondary form of hemophagocytic lymphohistiocytosis [1]. In this context, the importance of an accurate assessment of AOSD is suggested to promptly recognise the multivisceral involvement of the disease which is associated with life-threatening complications. The assessment of the most aggressive subsets of the disease could guide the clinicians when to apply additional resources but avoiding unnecessary expenditures in patients with a less severe clinical picture.

Objectives:

In this study, we aimed at describing the multivisceral involvement of the disease to retrieve imaging-based differences in AOSD patients with and without MAS.

Methods:

The present evaluation has been designed as a cross-sectional study to descriptively compare the multivisceral involvement in AOSD patients with and without MAS. Patients admitted to our Institution, who underwent a total body CT scan, were selected from our historical cohort and assessed. Clinical and CT scan characteristics of AOSD patients with and without MAS were compared. Clinical and CT scan characteristics of AOSD patients with and without MAS were analysed by parametric or non-parametric t tests for all continuous variables, and chi squared test was used for categorical ones, as appropriate. Furthermore, possible correlations among radiological outcomes with laboratory markers and systemic score were estimated by using a point-biserial coefficient correlation.

Results:

This study evaluated 39 AOSD patients (men 64.1%), mean age of 48.8±16.6 years). Out of those, 14 patients (35.9%) were complicated by MAS. These patients showed higher values of ferritin [AOSD: 770.0 (1306.5) ng/mL vs MAS: 2926.3 (4918.5) ng/mL p=0.003] and systemic score (AOSD: 4.6±1.4 vs MAS: 6.9±1.7, p<0.0001). AOSD patients with MAS presented a higher prevalence of lung disease than others (AOSD: 56.0% vs MAS 85.7% p=0.048). Lung disease correlated with the systemic score (coefficient 0.491, p=0.003). AOSD patients with MAS were more frequently characterised by hepatomegaly (AOSD: 12.0% vs MAS: 50.0% p=0.019) and splenomegaly (AOSD: 16.0% vs MAS 50.0% p=0.033), respectively, than others. Hepatomegaly correlated with CRP (coefficient 0.421, p=0.016), ferritin (coefficient 0.397, p=0.020), and systemic score (coefficient 0.391, p=0.022). Furthermore, the presence of splenomegaly correlated with the systemic score (coefficient 0.439, p=0.009). CT scan features of abdominal effusions were more frequently observed in AOSD patients with MAS than those without this complication (AOSD: 12.0% vs 57.1% p=0.007). Finally, a higher percentage of AOSD patients with MAS showed a significant lymph node enlargement, either mediastinal or abdominal, than others on CT scan (AOSD: 36.0% vs MAS 71.4% p=0.048). The presence of lymphadenomegaly correlated with the systemic score (coefficient 0.368, p=0.032).

Conclusion:

Our findings showed a higher prevalence of multiorgan involvement in AOSD patients with MAS, suggesting imaging-based differences, although other studies are needed to fully assess this issue. Pulmonary disease, hepatomegaly, splenomegaly, lymph nodes enlargement, and abdominal effusions were associated with these more aggressive patients.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018 Sep;93:24-36.

Disclosure of Interests:

None declared

AB0156 INCIDENCE OF CERVICAL SPINE INVOLVEMENT IN RHEUMATOID ARTHRITIS, RESULTS FROM A SINGLE CENTRE OBSERVATIONAL STUDY

Background:

Rheumatoid arthritis (RA) manifests as a chronic, symmetrical articular disease; any synovial joint may be involved and the cervical spine is another possible affected site [1,2]. Although the cervical spine involvement is a very severe complication of RA, the exact incidence of cervical spine abnormalities in RA is not fully elucidated yet.

Objectives:

In this work, we aimed at evaluating the incidence of a cervical spine involvement and associated clinical characteristics in patients with RA in a single centre observational study.

Methods:

In this study, we performed a retrospective analysis of prospectively followed-up patients with RA attending our Rheumatologic Clinic, University of L’Aquila, L’Aquila, Italy, between January 2010 and December 2020. Patients who met the diagnostic criteria of 1987 ACR and/or ACR/EULAR 2010 criteria were assessed. Each patient was investigated for cervical spine involvement occurrence, particularly the atlas-axis cervical involvement. Instrumental imaging evaluation of the cervical spine was performed in all patients with clinical suspicion of involvement, by both MRI and CT examinations. MRI examinations were performed on a 1.5 Tesla scanner, acquiring T1, T2, and STIR sequences on sagittal, coronal and axial planes. CT examinations were performed on a multidetector 320-row CT scanner (Aquilion One,Toshiba) acquired with a thin collimation; soft tissue or bone algorithms were applied for image data reconstruction and analysis.

Incident cases of cervical spine involvement were reported as incidence proportion and incidence rate per 1000 person-years at risk.

Results:

In this evaluation, 347 consecutive patients, (mostly female 87.6%, mean age of 66.1 ± 11.3 years) attending our Rheumatologic Clinic, were studied. The incidence proportion of cervical spine involvement was 2.0% [0.6 – 3.4%], occurring in 7 out of 347 patients, and identified by both MRI and CT scan. Considering over 1623 person-years, an incidence rate of 4.0 × 1000 [3.0 – 5.0] person-years was also estimated. All our patients with cervical spine involvement were characterised by female gender, rheumatoid factor, ACPA, fulfilment of ACR 1987 classificative criteria, and poorly controlled disease activity. Smoking habit and extra-articular manifestations were also frequently reported. Glucocorticoids, methotrexate, and infliximab were mainly administered in these patients. This therapeutic strategy resulted in a complete resolution of the inflammatory synovitis in all but one patient. The latter developed a cervical spinal instability resulting in neurological progression and required a subsequent surgical management.

Conclusion:

The cervical spine involvement is an uncommon but serious manifestation of RA, since possibly causing severe neurologic damage. A poorly controlled inflammatory process would be an important risk factor for developing a cervical spine involvement in RA, thus, a proper management is required, from an early accurate recognition to a timely therapeutic strategy. MRI could provide a useful clinical tool to early evaluate the cervical spine involvement in RA. Finally, considering the low incidence, further studies are needed to fully estimate the exact incidence of this manifestation, mostly in poorly symptomatic patients.

References:

[1]Shlobin NA, Dahdaleh NS. Cervical spine manifestations of rheumatoid arthritis: a review. Neurosurg Rev. 2020 Oct 10. Neurosurg Rev. 2020 Oct 10. doi: 10.1007/s10143-020-01412-1.

[2]Kothe, R.Rheumatoid instability in the cervical spine: Diagnostic and therapeutic strategies. Orthopade. 2018 Jun;47(6):489-495.

Disclosure of Interests:

None declared

POS1349 THE JOINT INVOLVEMENT IN ADULT ONSET STILL’S DISEASE IS CHARACTERISED BY A PECULIAR MAGNETIC RESONANCE IMAGING AND A SPECIFIC TRANSCRIPTOMIC PROFILE

Background:

Adult onset Still’s disease (AOSD) is a rare systemic autoinflammatory disease and joint involvement is one of its clinical manifestations [1]. Arthritis, either oligoarthritis or bilateral symmetrical rheumatoid arthritis-like polyarthritis, is another common clinical feature of AOSD, with a migrating pattern at the beginning and becoming stable over the time [1].

Objectives:

The aims of the study were to assess joint involvement in AOSD by using magnetic resonance imaging (MRI), to describe main patterns of involvement, and associated clinical characteristics, and to evaluate the global transcriptomic profile of synovial tissues in AOSD to elucidate possible pathogenic pathways involved with.

Methods:

AOSD patients, who underwent to magnetic resonance imaging (MRI) exam on joints, were assessed to describe patterns of joint involvement and associated clinical characteristics. Some synovial tissues were collected for RNA-sequencing purposes.

Results:

In this study, 31 patients with AOSD (mean age 42.3 ± 15.2 years, 54.8% male gender), who underwent to at least one MRI exam on joints, were assessed. The most common MRI finding was the presence of synovitis on 60.5%, mainly in peripheral affected joints. MRI revealed a mild to moderate proliferative synovitis, as thickening of the synovial membrane, with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-fat saturated weighted and STIR images, suggesting the presence of a hyperplastic than of a hypertrophied synovial tissue. Bone oedema and bone erosions were reported on 34.9% and 25.6% MRI exams, respectively. In all patients but one, bone erosions were synchronous with bone oedema, overlapping completely the locations. Assessing clinical characteristics in patients with MRI-erosions, a higher prevalence of splenomegaly, a more frequent chronic disease course, lower levels of erythrocyte sedimentation rate and ferritin was observed.

Assessing the synovial tissues of some AOSD patients, a moderate perivascular mononuclear infiltrate in the sub-lining stroma of hip synovial tissues was observed, whereas the lining cells were relatively unremarkable. In addition, interleukin (IL)-1β, IL-6, TNF, and heavy ferritin subunit (FeH) were found on AOSD synovial tissues.

An RNA-sequencing analysis assessed the global transcriptomic profile of synovial tissues on AOSD patients and matched-controls. Assessing IL-1 pathway, we found an increased expression of il1a, il1b, il1rap, il1r1, il18r1, and Il18bp on AOSD tissues when compared with controls. In IL-6 pathway, we found an increased expression of il6 and il6st/gp130 on AOSD synovial tissues whereas an increased expression of il6r was shown on the controls. Among genes involved in TNF pathway, tnf, traf1, traf2, tnfaip3 and tnfrsf1a resulted to be more expressed in AOSD synovial tissues than in controls. Finally, fth1 and ftl were more expressed in AOSD patients than controls, when we explored the iron uptake and transport pathway.

Conclusion:

A peculiar MRI pattern of joint involvement in AOSD was reported; the most common finding was the presence of synovitis, characterised by intermediate to high signal intensity on T2-fat-saturated weighted and STIR images. Bone erosions and bone oedema were also observed. This MRI pattern was associated with a hyper-activation of IL-1, IL-6, and TNF pathways together with a hyper-expression of ferritin genes on AOSD synovial tissues.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

Disclosure of Interests:

None declared

POS0177 POTENTIAL INVOLVEMENT OF IL-40 AND IL-40-PRODUCING CELLS IN PRIMARY SJOGREN’S SYNDROME (pSS) AND pSS-ASSOCIATED LYMPHOMA

Background:

The pathogenesis of pSS relies on a complex interplay between both innate and adaptive immune responses in which B cells play a pivotal role. Their chronic aberrant hyperactivation may drive clonal escape and consequent lymphomagenesis [1]. In the last few years, B cells have emerged as potential effector cells, able to release a wide range of cytokines that actively contribute to shape the microenvironment they act in. Recently, IL-40, a novel B cell associated cytokine encoded by an uncharacterized gene (C17orf99; chromosome 17 open reading frame 99) was described. Naïve B cells can express IL-40 at both tissue and peripheral level and the stimulation of B cells with IL-4 and TGF-β significantly increases IL-40 release. In addition, human B cells lymphomas are able to constitutively produce IL-40 [2]. Taking into account this emerging evidence and considering the well-known role of IL-4 and TGF-β in pSS pathogenesis, as well as the association with lymphomas, we decided to focus our attention on IL-40 in pSS patients.

Objectives:

The aim of the present study was to investigate IL-40 expression in the salivary glands of patients affected by pSS and pSS-associated non-Hodgkin’s lymphoma (NHL).

Methods:

Minor salivary gland biopsies were obtained from 22 patients with pSS and 12 patients with non-specific chronic sialoadenitis (nSCS), included as controls. Paraffine-embedded samples of parotid glands from patients with a previous diagnosis of pSS-associated NHL (n=10) were selected from the biopsy bank of the Pathology Unit of the Ospedale Cervello (Palermo, Italy). Quantitative gene expression analysis by TaqMan real-time PCR and immunohistochemistry (IHC) for IL-40, IL-4, TGF-β1 was performed on salivary glands from patients and controls. The cellular sources of IL-40 among infiltrating inflammatory cells were determined by fluorescence-activated cell sorting (FACS) analysis and immunofluorescence (IF). Serum IL-40 levels were measured by ELISA in both patients (n=10) and controls (n=9).

Results:

IL-40 was significantly increased at both protein and mRNA level in the inflamed salivary glands of patients with pSS where a positive strong correlation between the IL-40 mRNA levels and the focus score (FS) was evidenced. The expression of IL-40 in parotid glands of pSS-associated NHL was also markedly increased (Figure 1). IL-40 expression correlated with the presence of IL-4 and TGF-β; both cytokines were significantly increased in pSS at mRNA and protein level. Among infiltrating immune cells, CD19+ B cells resulted the major source of IL-40. However, we identified CD4+, CD8+ T cells and CD68+ macrophages as additional producers of IL-40 in both FACS and IF analysis. The ELISA test also showed a significant increase of serum IL-40 concentration in pSS patients (p value = 0.0190), compared to controls.

Conclusion:

Our preliminary results suggest that IL-40 may play a role in the pathogenesis of pSS and pSS-associated NHL. To the best of our knowledge, this is the first demonstration of the overexpression of this cytokine in salivary gland tissue and sera in pSS. Moreover, we demonstrated that IL-40 is produced by several cellular types, such as T cells and macrophages, and is not exclusively released by B cells. Further studies are necessary to clarify IL-40 pathways and functions in order to unravel IL-40 possible role in pSS development.

References:

[1]Mariette X, Criswell LA. Primary Sjogren’s Syndrome. N Engl J Med. 2018;379(1):97.

[2]Catalan-Dibene J, Vazquez MI, Luu VP, Nuccio SP, Karimzadeh A, Kastenschmidt JM, et al. Identification of IL-40, a Novel B Cell-Associated Cytokine. J Immunol. 2017;199(9):3326-35.

Figure 1.

IL-40 overexpression in pSS and pSS-associated lymphoma A, Salivary gland biopsies stained for IL-40 showing a marked increase in IL-40 expression in presence of higher focus score. B, Parotid gland specimens of pSS-associated lymphoma showing intense staining for IL-40.

Disclosure of Interests:

Chiara Rizzo: None declared, Marianna Lo Pizzo: None declared, Leila Mohammadnezhad: None declared, Vincenzo Luca Lentini: None declared, Diana Di Liberto: None declared, Giulia Grasso: None declared, Piero Ruscitti Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, Rorberto Giacomelli Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, francesco ciccia Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, Giuliana Guggino Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly

POS0326 ROLE OF THE IL-25 / IL-17RB AXIS IN TH9 POLARIZATION IN PATIENTS WITH PROGRESSIVE SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is an inflammatory connective tissue disease leading to chronic and progressive fibrosis, typically affecting the skin and internal organs. The alteration of both innate and adaptive immune responses plays a pivotal role in SSc pathophysiology, although it has not yet been fully elucidated [1].

Recent findings have demonstrated interleukin (IL)-9 overexpression and significant group 2 innate lymphoid cells (ILC2) expansion in patients with SSc. Th9-ILC2-mast cells axis seems to be involved in SSc tissue damage and in the induction of fibrosis [2]. Activation and production of IL-9 by Th9 cells are promoted by transforming growth factor (TGF)-β, thymic stromal lymphopoietin (TSLP), IL-25 and IL-33. Thus, the IL-25 / IL-17RB pathway would act as a key player in SSc.

Objectives:

The purpose of this study was to evaluate the role of the IL-25 / IL-17RB axis as a driver in Th9 polarization and ILC2 expansion and polarization in SSc patients.

Methods:

26 patients were enrolled in this study. Peripheral blood and skin biopsy specimens were obtained from SSc patients. PBMCs were isolated and incubated with and without recombinant (r)IL-25 for 24-48-72 hours and the frequencies of Th9 cells, Th17 cells and ILC2 were assessed by flow cytometry analysis. Moreover, the ex vivo expression of IL-17RB in ILC2 was also assessed. Immunofluorescence analysis was performed on biopsy skin samples to evaluate IL-17RB expression in ILC2.

Results:

In SSc samples, Th9 cells frequency progressively increased after stimulation with rIL-25, compared to healthy controls in which IL-9 frequency decreased over time regardless of rIL-25.

Simultaneously, we evaluated the role of the IL-25 / IL-17RB axis in Th17 cells.

In the SSc pool, the initially low rate of IL-17 increased at 72 hours after stimulation with rIL-25. In unstimulated SSc samples, the initially higher IL-17 rate decreased at 72 hours; conversely, it was consistently low in healthy controls, at both baseline and stimulated conditions.

Our results confirmed the presence of IL-25-dependent clonal ILC2 expansion, suggesting a greater and progressive expansion over time in patients with SSc, compared to controls.

Interestingly, increased IL-17RB expression was found in circulating ILC2 from SSc patients supporting the characterization of ILC2 inflammatory phenotype.

Consistently, immunofluorescence on the skin of SSc patients showed a marked infiltrate of CD3-GATA3+ IL-17RB+ cells, confirming the presence of the activated inflammatory phenotype ILC2, absent in skin biopsies of healthy controls (Figure 1).

Conclusion:

These preliminary data suggest an active role of the IL-25/IL-17RB axis in SSc. It results in Th9 polarization and Th17 clonal expansion, inducing the production of IL-9 and, to a lesser extent, IL-17. Moreover, in addition to promoting Th9-mediated ILC2 differentiation, IL-25 directs the polarization of ILC2 towards the inflammatory phenotype.

References:

[1]Denton CP, & Khanna D. (2017). Systemic sclerosis. Lancet (London, England), 390(10103), 1685–1699.

[2]Guggino G, Ciccia F, Di Liberto D, Lo Pizzo M, Ruscitti P, Cipriani P, Ferrante A, Sireci G, Dieli F, Fourniè JJ, Giacomelli R, Triolo G. s.l. Interleukin-9 over-expression and T helper 9 polarization in systemic sclerosis patients. Clin Exp Immunol, 2016 Dec.

Figure 1.

Immunofluorescence on biopsy skin samples of SSc patients (top) and healthy control (bottom).

Disclosure of Interests:

Lidia La Barbera: None declared, Marianna Lo Pizzo: None declared, Diana Di Liberto: None declared, Claudia Schinocca: None declared, Piero Ruscitti Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie, Rorberto Giacomelli Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie, Francesco Dieli: None declared, francesco ciccia Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie, Giuliana Guggino Consultant of: Pfizer, Novartis, Roche, Lilly, Celgene, Abbvie

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